Our PD unit is reviewing our policy and procedure on wet and dry contamination. What are the ISPD guidelines around contamination? We have the majority of our patients living in rural communities, most are fly in only. We would like to make new policies and procedures to follow the ISPD guidelines.

Questions About PD

Jessica C. , Nurse from Thunder Bay asked
Our PD unit is reviewing our policy and procedure on wet and dry contamination. What are the ISPD guidelines around contamination? We have the majority of our patients living in rural communities, most are fly in only. We would like to make new policies and procedures to follow the ISPD guidelines.

1 answer

Nurse Canada with members of the ISPD Nursing Liaison Committee February 17, 2020

We thank you for your question. The latest ISPD peritonitis recommendations (2016) list “wet contamination” as a modifiable risk factor for peritonitis. Prophylactic antibiotics are usually recommended after wet contamination, i.e. if the dialysis solution is infused after contamination, or if the catheter administration set was open for an extended period. The authors of these latest ISPD guidelines note that there is no widely accepted standard regimen (1).
Our local practice is, as follows:
     Wet Contamination:
     Defined as an open or unclamped system with the potential for organisms to enter the peritoneal cavity.
     For pts <50 kg: cefazolin 1 g IP for 6-hr dwell x 1 dose.
     For pts >50 kg: cefazolin 1.5 g IP for 6-hour dwell x 1 dose.
     If allergic to cefazolin, use vancomycin 1 g IP for 6 hr dwell x 1 dose.
     Dry Contamination:
     Dry contamination is defined as a clamped system with no risk of bacterial entry into the peritoneal cavity. This can occur when the clamp is   closed on the transfer set but the end of the transfer set is touched.
     The Minicap (with povidone-iodine solution) should be replaced for at least five minutes prior to continuing with the procedure.
     Antibiotics are not required (2, page 123).
 
From an informal poll of nursing members of the ISPD Nursing Liaison Committee, as we have found before, procedures differ within countries and between countries. We appreciate that the procedure for wet contamination above, while also recommended by some other centers in Canada, is problematic for you for patients on PD living in remote communities (2, 3). Our suggestion is to try and involve rural community nurses in these remote locations (or nurses on the nursing stations for First Nations communities), and have these nurses taught how to administer the one-time dose of IP prophylactic antibiotic for wet contamination.
 
For dry contamination, some other home dialysis centers in Canada also follow the procedure above (2, 3). As well, some centers in the U.K. and New Zealand follow a similar procedure with varying times for the Minicap to be in place before PD is resumed. It should be noted here that some centers in the U.S. and the U.K. would also have the patient clamp the PD catheter and come to the PD center immediately for a transfer set change for both wet and dry contamination with prophylactic antibiotics for wet contamination. Some centers have patients who are suitable taught to administer their own one-time dose of prophylactic IP antibiotic – always calling the home PD nurse on call first and following the nurse’s instruction; some centers use a short course of PO antibiotics. However, there is very limited research that we are aware of showing that one method of managing either wet or dry contamination for patients on PD has better outcomes than another.
 
1. Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, Fish DN, Goffin E, Kim YL, Salzer W, Struijk DG. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Peritoneal Dialysis International. 2016 Sep 1;36(5):481-508.
 
2. Gozdzil A (Editor). UHN Division of Nephrology House Staff/NP Guidebook. January 2020 page 123. Available at : http://www.ukidney.com/nephrology-publications/nephrology-manuals/university-health-network-nephrology-manual
 
3. British Columbia Provincial Renal Agency. PD Procedures – Wet Contamination (January 2019). Available at:
http://www.bcrenalagency.ca/resource-gallery/Documents/PD_Procedures-Wet_Contamination_Procedure.pdf
 
4. British Columbia Provincial Renal Agency. PD procedures – Dry Contamination (January 2019). Available at:
http://www.bcrenalagency.ca/resource-gallery/Documents/PD_Procedures-Dry_Contamination_Procedure.pdf
 

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