W. G. M. Rivero, MD ← All Guides
Dialysis · Patient Guide

When the Access Gets Infected
Know the signs. Act fast. Protect your lifeline.

Your dialysis access — whether a fistula, graft, catheter, or PD tube — is your lifeline. An infection in or around it is a medical emergency. This guide will show you exactly what to watch for every day, how to care for your access, and when to call your dialysis team versus go straight to the emergency room.

Author: W. G. M. Rivero, MD, FPCP, DPSN Specialty: Internal Medicine · Nephrology Last Reviewed:
Section 1

What Is a Dialysis Access?

Dialysis needs a way to reach your blood. Your access is the connection that makes this possible — every session, blood leaves through it, passes through the dialysis machine, and returns cleaned. There are four main types.

Four types of dialysis access: AV fistula, AV graft, tunneled catheter, and PD catheter

AV Fistula

A surgeon connects an artery and a vein in your arm, usually at the wrist or elbow. Blood flowing through this connection creates a buzzing sensation called the "thrill." It is the best long-term access and takes 6–8 weeks to mature before it can be used. It has the lowest risk of infection of all access types.

AV Graft

A soft plastic tube connects an artery and a vein in the arm. It is ready for use sooner than a fistula (2–4 weeks) but carries a slightly higher infection risk because the plastic material can harbor bacteria more easily than your own blood vessel.

Tunneled Catheter (Permcath)

A two-lumen tube is placed under the skin of the chest and into a large vein near the heart. It is used when a fistula or graft is not yet ready or not possible. It carries the highest infection risk of all access types because it provides a direct path from the skin surface to the bloodstream.

PD Catheter

A soft silicone tube passes through the abdominal wall into the belly cavity (peritoneal space). It is used for peritoneal dialysis, which is often done at home. Infection at the exit site, along the tunnel, or inside the belly (peritonitis) is the most serious complication of PD.

Why infection is an emergency

Bacteria entering through a dialysis access go directly into your bloodstream during every dialysis session. What starts as a local redness can become a life-threatening bloodstream infection (sepsis) or endocarditis within hours. Do not wait to see if it gets better on its own.

Section 2

Daily Care

Most access infections begin with small breaks in care. The habits below are your strongest defense.

Three-step daily care routine: wash hands, inspect access, clean exit site

Fistula and Graft

  • Inspect your access every morning — run your finger gently along it. You should feel the thrill (a buzzing or vibration). If the thrill is gone, call your dialysis center immediately.
  • Wash the access site with soap and water daily.
  • Never allow blood pressure cuffs, blood draws, or IV lines on your access arm — this is an absolute rule, no exceptions.
  • Do not wear tight clothing, wristwatches, or jewelry over or near the access site.
  • Avoid sleeping directly on the access arm — this can compress blood flow and increase clot and infection risk.
  • Keep fingernails short and avoid scratching over needle puncture sites.
  • After each dialysis session: check that needle sites have stopped bleeding completely before leaving the center. Apply a gentle clean dressing if advised by your nurse.

Tunneled Catheter (Permcath)

  • Keep the catheter exit site covered with a clean, dry dressing at all times between sessions.
  • Do not shower without a proper waterproof cover applied over the site — ask your dialysis nurse which cover to use and how to apply it.
  • Never submerge the catheter site in baths, swimming pools, or the sea — ever.
  • Never disconnect or reconnect the catheter caps yourself unless you have been formally trained and specifically instructed by your medical team.
  • Report to your center immediately if the dressing falls off, the catheter appears to have shifted position, or you see any redness or discharge at the exit site.
  • Dressing changes are done by trained dialysis staff only — do not attempt this at home.
  • If your catheter has clamps, never leave them open (unclamped) when not in use.

PD Catheter (Exit Site)

  • Clean your exit site daily using soap and water (or chlorhexidine if your doctor prescribed it). Always wash your hands thoroughly with soap and water first.
  • After cleaning, dry the site completely with clean gauze — moisture under the dressing is a key infection trigger.
  • Apply mupirocin or gentamicin cream (if prescribed) directly to the exit site with a clean cotton swab after drying.
  • Secure your catheter with tape so it does not move or pull — the catheter moving in and out of the tunnel is one of the most important risk factors for infection.
  • Wear loose clothing that does not press on or rub against the catheter.
  • Brief showering is acceptable, but never take baths or swim in pools or open water.
  • Never pull or rotate the catheter unless your nurse specifically instructed you to do so.
Section 3

Prevention Best Practices

Four prevention pillars: hand hygiene, no swimming, good nutrition, protect access arm

Hand Hygiene — Most Important

Hand Hygiene Checklist

  • Wash hands with soap and water for at least 20 seconds before and after touching any part of your access or its dressing.
  • Use alcohol-based hand sanitizer if soap is not immediately available — but soap and water is better when your hands are visibly dirty.
  • You have the right to ask any dialysis staff member to wash or sanitize their hands in front of you before touching your access. This is your right and your safety.

Showering and Water Exposure

  • Fistula/graft: Showering is fine. Avoid submerging the access arm in baths or pools. No open-water swimming until needle puncture sites are fully healed.
  • Tunneled catheter: No showering without waterproof protection properly applied. No baths, pools, or sea — ever, without exception.
  • PD catheter: Brief showering is acceptable. No baths or swimming pools.

Mupirocin / Gentamicin Exit-Site Cream

  • If your doctor prescribed exit-site cream, apply it every day after cleaning and drying the site — do not skip even a single day.
  • This is one of the strongest proven steps for preventing PD exit-site and tunnel infections.
  • Apply a small amount with a clean cotton swab; do not use your fingers directly on the site.

Nutrition and Blood Sugar

  • Patients who are malnourished or who have poorly controlled diabetes develop access infections at much higher rates — your immune system depends on good nutrition.
  • Aim for adequate protein intake. Your dietitian will advise specific targets based on your dialysis type.
  • Keep blood sugar as well-controlled as possible — high glucose directly impairs your immune response and wound healing.

Other Important Prevention Points

  • Tell your dialysis team immediately about any skin breaks, boils, pimples, cuts, or dental procedures — even bacteria from dental work can travel in the blood and seed your access.
  • If your doctor prescribed mupirocin nasal ointment for MRSA, apply it exactly as instructed (usually 3 times daily for 5 days, repeated monthly).
  • Never allow anyone to access your catheter or PD port outside your dialysis center without proper training and sterile equipment.
  • Avoid picking at or scratching needle puncture sites after dialysis — even a small scratch can introduce bacteria.
Section 4

Warning Signs — When to Act

Warning signs: red panel for ER emergencies, amber panel for call-clinic situations
⛔

Go to the Emergency Room immediately if you have ANY of these:

  • Fever at or above 38°C (100.4°F) — especially with chills or shaking
  • Fever with confusion, extreme weakness, or a very fast heartbeat — this may be sepsis
  • Pus or thick discharge coming from your catheter exit site or PD exit site
  • Severe pain, swelling, or red streaking spreading up the arm from your fistula or graft
  • Your catheter cracked, broke, or came apart at any point
  • Your PD dialysis fluid (dialysate) appears cloudy — this is peritonitis until proven otherwise
⚠

Call your dialysis clinic today — do not wait until your next scheduled session:

  • New redness, warmth, or mild swelling around fistula needle sites or any exit site
  • Crust or dried discharge at the PD exit site that was not there before
  • Dressing fell off and the site looks different from how it normally appears
  • A pimple or boil developing anywhere near the access site
  • You had a fever that went away on its own
  • You feel generally unwell or unusually tired in the days after dialysis

When in doubt — call

Infections caught early are treated with antibiotics. Infections caught late may require surgery, catheter removal, or weeks in hospital. A single phone call could prevent all of that.

Be prepared

Save your dialysis center's phone number in your mobile phone right now. Know the location of the nearest emergency room that has dialysis capability.

Section 5

At Your Dialysis Center

At the dialysis center: nurse using proper sterile technique and patient checklist for each session

What Good Technique Looks Like

Every time staff connect you to dialysis, they should wash or sanitize their hands, put on gloves, and clean your access site with an antiseptic solution before touching the needles or catheter. This is a standard requirement — not an optional courtesy.

If you observe a break in technique — for example, a staff member touches something non-sterile and then goes to connect you without re-gloving — you have the right to politely but firmly say: "Could you please change your gloves before connecting me?" Your safety depends on it.

What to Tell the Nurse at the Start of Every Session

  • Any fever, chills, or unusual symptoms since your last dialysis session
  • Any new skin sores, cuts, wounds, or infections anywhere on your body
  • Any recent dental procedures, medical procedures, or hospital visits
  • Any antibiotic use since your last session

Buttonhole Cannulation (Fistula)

Some dialysis centers use a "buttonhole" technique where the same needle path is used at each session. If your center uses this method, the nurse must remove the scab from the track cleanly before inserting the needle. If you see blood or pus in the track, alert your nurse before the needle goes in. Never try to remove the scab yourself at home.

Dr. W. G. M. Rivero, MD

W. G. M. Rivero, MD, FPCP, DPSN

Nephrology and Internal Medicine specialist. This guide is written to help patients and families recognize access infections early, take the right steps, and work confidently with their dialysis team. When in doubt, always reach out to your healthcare provider.

Diplomate, Philippine Society of Nephrology · Fellow, Philippine College of Physicians

Section 6

Common Questions

My exit site is slightly pink — is that normal?

Pink skin without any discharge, crust, or pain can be normal immediately after cleaning, especially when the site is new. However, if the pinkness persists for more than a day or two, spreads, or is accompanied by any crust, pus, or swelling, call your dialysis team. Do not dismiss it.

Can I shower with my Permcath?

Only if a waterproof dressing cover is properly applied and secured before you shower. The cover must protect the exit site completely. When in doubt, take a sponge bath around the site instead. Never submerge the catheter in any water.

I have a fever but my access looks completely normal — should I still worry?

Yes. Catheter-related infections very often present with fever alone before any redness or discharge appears at the exit site. Fever in a dialysis patient with any type of catheter must be taken seriously. Call your dialysis center or go to the emergency room — do not wait.

My PD fluid looks a bit cloudy — can I wait until tomorrow's session to mention it?

No. Cloudy PD dialysate means peritonitis until proven otherwise. Go to your dialysis center or the emergency room now. Peritonitis that is not treated the same day can become life-threatening and may result in permanent loss of PD as a treatment option.

Can I use my access arm for blood pressure checks at a pharmacy?

No. Never put a blood pressure cuff on your fistula or graft arm — at any location, for any reason. Always inform the person checking your blood pressure and remind them to use the other arm.

The dialysis nurse did not wash her hands before connecting me — what should I do?

Politely say: "Excuse me, could you please wash or sanitize your hands before connecting me?" This is your right as a patient and a standard infection-control requirement. A professional nurse will understand and comply without offense.

Disclaimer: This guide is for patient education only and does not replace the individualized advice of your nephrologist or dialysis care team. Always consult your physician regarding your specific situation, medications, and treatment plan. Clinical recommendations are based on IDSA, ISPD, and KDOQI guidelines as interpreted for a Philippine clinical context.
⚕ Clinician Reference
Nephrology · Infectious Disease · Philippines Context

When the Access Gets Infected
Diagnostic workup, empiric antibiotics, catheter salvage decisions, and prevention protocols

Practical clinical protocols for dialysis access infections — covering AVF/AVG soft-tissue infection, tunneled catheter-related bacteremia (CRBSI), non-tunneled CVC infection, and PD exit-site/tunnel/peritonitis. Antibiotic selections reflect local Philippine pathogen context.

IDSA 2016 ISPD 2022 Philippines Context
Clinician Section 1

Access Types and Infection Spectrum

⚠

Philippine MRSA Context

In the Philippines, MRSA prevalence in HD-related bacteremia is estimated at 30–40% in tertiary referral centers. Vancomycin remains empiric first-line for any catheter-related bacteremia. Cefazolin is first-line for MSSA and soft-tissue cellulitis without systemic signs. AUC-guided vancomycin monitoring is preferred over trough-only in HD patients.

Access Type Infection Type Typical Organisms 30-Day Mortality Key Feature
AVF Exit site / soft-tissue cellulitis S. aureus (60%), CoNS, GNR Low if treated early Rarely leads to bacteremia; bacteremia occurs when needle site is infected and not the access itself
AVG (prosthetic graft) Graft infection: cellulitis → abscess → graft involvement S. aureus, MRSA, Pseudomonas, Candida Moderate-high; graft excision often required Prosthetic material cannot clear deep infection medically; early vascular surgery consultation essential
Tunneled HD catheter (TCC/Permcath) CRBSI; exit-site infection; tunnel infection S. aureus (MRSA 30–40% in PH), CoNS, Candida, GNR CRBSI: 10–25% at 12 weeks Most common bacteremia source in HD patients; differential time to positivity (DTP) ≥2 h confirms CRBSI
Non-tunneled CVC (temporary) CRBSI Same as TCC; higher Candida risk High; remove promptly Should not remain in situ >14 days; remove and replace at new site if bacteremia occurs
PD catheter Exit-site infection; tunnel infection; peritonitis CoNS (30%), S. aureus (15%), Pseudomonas, Candida, polymicrobial Peritonitis: 10–15% technique failure per episode PD peritonitis is the leading cause of technique failure and a significant cause of mortality in PD patients
Clinician Section 2

Diagnostic Workup

Initiate workup simultaneously with empiric antibiotic therapy — do not delay treatment to await results.

1

Blood Cultures — Paired Sets

Draw one set from the catheter lumen and one set from a peripheral vein before starting antibiotics. Differential time to positivity (DTP) ≥2 hours (catheter set positive ≥2 h earlier than peripheral) is diagnostic of CRBSI. If peripheral access is unavailable, draw both sets from different catheter lumens; interpretation is less specific. In AVF/AVG infection without systemic signs, peripheral blood cultures suffice.

2

Exit-Site Swab

Swab any discharge or crust before cleaning. Send for culture and sensitivity. Swab even in the absence of visible pus — colonization with MRSA or Pseudomonas guides definitive therapy and decolonization planning. For PD exit sites, swab routinely at every clinic visit in patients with recurrent infections.

3

PD Fluid Cell Count and Culture

For PD patients: drain PD fluid and send for WBC count with differential and culture and sensitivity. Peritonitis is defined as WBC >100 cells/μL with >50% neutrophils on differential, OR clinical symptoms plus a positive culture. Use blood culture bottles (10 mL per bottle) for PD fluid — this significantly increases culture yield compared to standard culture tubes.

4

Echocardiography

Obtain transthoracic echocardiography (TTE) in any of the following: S. aureus bacteremia (any source); bacteremia persisting ≥72 h despite adequate antibiotic therapy; new cardiac murmur; known structural heart disease or prosthetic valve; history of intravenous drug use. Proceed to TEE if TTE is non-diagnostic and clinical suspicion for endocarditis remains high.

5

Imaging

Ultrasound of the access site if abscess, fluid collection, tunnel infection, or graft involvement is suspected clinically. CT of the chest and neck for deep soft-tissue infection or when mediastinal involvement from an internal jugular tunneled catheter is considered. MRI is preferred for suspected spinal osteomyelitis in the setting of S. aureus bacteremia with back pain.

Clinician Section 3

Empiric Antibiotic Selection

⛔

Start empiric antibiotics before culture results

Do not delay antibiotics in any suspected CRBSI, peritonitis, or systemic access infection. De-escalate once organism and susceptibilities are known — typically at 48–72 hours. Every hour of delay in bacteremia worsens outcome.

Scenario First-Line Empiric Alternative Notes
AVF/AVG cellulitis — no systemic signs, no MRSA risk factors Cefazolin 1 g IV/IM per HD session (dialysis dose) OR amoxicillin-clavulanate 625 mg PO q12h Cloxacillin 500 mg PO QID Add gram-negative coverage (ciprofloxacin or ceftriaxone) if wet/weeping wound or diabetic foot-like presentation
AVF/AVG cellulitis — MRSA risk (prior MRSA, recent hospitalization, mupirocin non-adherence) Vancomycin 15–20 mg/kg IV loading dose (cap 3 g); redose per HD trough/AUC TMP-SMX DS 2 tabs BID (oral step-down only, if MRSA susceptibility confirmed) AUC-guided vancomycin preferred; target AUC/MIC 400–600
CRBSI — tunneled or non-tunneled catheter Vancomycin (as above) + ceftazidime 1 g IV per HD session (gram-negative cover) Vancomycin + piperacillin-tazobactam 2.25 g IV per HD if Pseudomonas risk (ICU, prior Pseudomonas, bronchiectasis) Cover gram-negatives empirically in all CRBSI — GNR bacteremia carries high 30-day mortality
PD peritonitis — empiric IP cefazolin 500 mg/L loading + 125 mg/L maintenance PLUS IP ceftazidime 500 mg/L loading + 125 mg/L maintenance per exchange IV vancomycin + IV ceftazidime if IP administration is not immediately possible ISPD 2022 recommends IP route for peritonitis; use the longest PD exchange available (at least 6 h dwell) for antibiotic exchanges
Exit-site infection — no systemic signs, no tunnel involvement Mupirocin 2% cream topically PLUS cefalexin 500 mg PO QID x 7 days if surrounding cellulitis TMP-SMX DS BID if gram-negative or PD exit site Most PD exit-site infections can be managed without catheter removal if no tunnel involvement is confirmed on clinical assessment or ultrasound
Clinician Section 4

Definitive Therapy — Culture-Directed

Organism Recommended Regimen Duration Notes
MSSA (methicillin-sensitive S. aureus) Cefazolin 2 g IV 3x/week post-HD (dialysis dose) OR cloxacillin 2 g IV q4h in non-dialysis patients 4 weeks (uncomplicated bacteremia); 6 weeks if endocarditis confirmed Cefazolin is strongly preferred over vancomycin for MSSA — superior clinical outcomes. Step down to oral cloxacillin 500 mg QID when clinically stable for soft-tissue-only infection
MRSA Vancomycin AUC-guided (target AUC/MIC 400–600) post-HD dosing 2 weeks minimum (uncomplicated); 4–6 weeks if endocarditis Do not transition to oral therapy for MRSA bacteremia. Request infectious disease consultation for all MRSA bacteremia cases
CoNS (coagulase-negative Staphylococcus) Vancomycin (HD dose as above) 7–14 days with catheter removal; 4–6 weeks if catheter salvage attempted High relapse rate with catheter salvage — removal and replacement is generally preferred. Salvage may be considered in clinically stable patients without tunnel infection (see Section 5)
Enterococcus Ampicillin 2 g IV q4–6h if susceptible; vancomycin if resistant; linezolid or daptomycin for VRE 14 days (uncomplicated); 6 weeks if endocarditis Screen for VRE if prior vancomycin exposure, healthcare-associated acquisition, or prior VRE history
Gram-negative rods (susceptible, non-Pseudomonas) Ceftriaxone 2 g IV q24h (non-dialysis) OR cefazolin dialysis dose 7–14 days Step down to oral ciprofloxacin 500 mg BID x 7–14 days once susceptibilities confirmed and patient clinically improving
Pseudomonas aeruginosa Piperacillin-tazobactam 2.25 g IV per HD session OR meropenem 1 g IV per HD 14 days minimum High relapse risk — catheter removal strongly recommended. Cefepime 1 g IV per HD: dose-adjust carefully (encephalopathy risk in HD). Do not step down to oral fluoroquinolone unless definitive susceptibility is confirmed
Candida spp. Anidulafungin 200 mg loading then 100 mg/day IV OR fluconazole 200 mg loading then 100–200 mg per HD post-session (if Candida susceptible) Minimum 14 days after the last positive blood culture Catheter MUST be removed for Candida CRBSI — no salvage. Ophthalmology referral for dilated fundoscopy. C. krusei and C. glabrata: use echinocandin (fluconazole-resistant)
PD peritonitis — culture-directed Per organism susceptibility (see ISPD 2022 antibiotic dosing tables) 14–21 days IP, organism-dependent See Section 7 for PD-specific management
Clinician Section 5

Catheter Salvage vs. Removal

⛔

Absolute indications for catheter removal — do not attempt salvage:

  • S. aureus bacteremia (MRSA or MSSA) — relapse rate with salvage 20–35%; removal is standard of care
  • Candida or any fungal bacteremia — always remove immediately
  • Gram-negative bacteremia with clinical instability (septic shock, hypotension)
  • Tunnel infection (pus or swelling tracking along the subcutaneous tunnel)
  • Pocket abscess
  • Endocarditis or septic thrombophlebitis confirmed on imaging
  • Bacteremia persisting >72 hours despite appropriate antibiotics
⚠

Catheter salvage MAY be attempted (CoNS or susceptible GNR, clinically stable, no tunnel infection):

  • Antibiotic lock therapy (ALT): vancomycin 5 mg/mL + heparin 2500 U/mL in each lumen, dwell 12–16 h, removed and discarded before next HD session, continued x 14 days concurrent with systemic antibiotics
  • Success rate with CoNS: approximately 70%. Success rate with S. aureus: less than 50% — salvage is not recommended for S. aureus
  • If bacteremia persists at 72 h or recurs after completing the ALT course, remove the catheter without delay

Decision Algorithm

1
CoNS, clinically stable, no tunnel infection

Salvage with antibiotic lock therapy (ALT) + systemic vancomycin x 14 days. Reassess at 72 h. If persistent bacteremia at 72 h: remove catheter.

2
S. aureus (MRSA or MSSA)

Remove catheter — do not attempt salvage. Duration of systemic antibiotics 4 weeks minimum.

3
Candida / any fungal organism

Remove catheter immediately. Start echinocandin empirically. Ophthalmology review within 24 h.

4
GNR (non-Pseudomonas), clinically stable

Salvage may be attempted with ALT + systemic antibiotics. Reassess at 72 h. If persistent: remove catheter.

5
GNR Pseudomonas aeruginosa

Remove catheter. Anti-pseudomonal systemic therapy x 14 days minimum.

6
Any organism + tunnel infection, abscess, or endocarditis

Remove catheter regardless of organism. Surgical consultation for tunnel abscess. ID consultation for endocarditis.

Clinician Section 6

AVF/AVG Infection Algorithm

⚠

Preserve access function when possible

Do NOT ligate or surgically close a functioning fistula without vascular surgery consultation. Even in the setting of infection, the fistula may be salvageable with adequate drainage and antibiotic therapy if properly assessed by a vascular surgeon. Access loss has severe long-term consequences for the patient.

Presentation Management Surgical Threshold
AVF cellulitis — superficial, no abscess, no systemic signs Cefazolin (MSSA) or vancomycin (MRSA risk) systemically. Continue using fistula if no sepsis and no local abscess. Monitor closely q48–72 h Surgical consultation if not improving at 48–72 h
AVF abscess — localized Surgical drainage + systemic antibiotics. Avoid cannulating infected area. Vascular surgery consultation for drainage planning Urgent surgical drainage; preserve fistula if possible
AVG infection — limited, soft tissue only, no graft involvement Systemic antibiotics. Early vascular surgery consultation — do not delay, as prosthetic graft infection can progress rapidly Early vascular surgery; may attempt partial excision for localized anastomotic infection
AVG infection — systemic signs, abscess, or graft involvement confirmed Systemic antibiotics + urgent vascular surgery referral for graft excision. Partial excision may be possible for localized anastomotic involvement if graft is not diffusely seeded Urgent: graft excision required for cure in most cases
Bacteremia from AVF/AVG infection Full CRBSI workup: paired blood cultures, echocardiography, imaging as appropriate. Duration of antibiotics by organism as per Section 4. ID consultation recommended for all bacteremia Vascular surgery to assess need for ligation vs. access salvage
Clinician Section 7

PD Exit-Site, Tunnel, and Peritonitis

Cross-reference: See Module 12 of the CKD Prescriber's Playbook for IP antibiotic dosing tables and the full ISPD 2022 peritonitis protocol.

Syndrome Definition / Diagnosis Initial Management Catheter Removal Threshold
Exit-site infection Redness and/or purulent discharge at catheter exit; no tunnel tenderness, no peritoneal signs Topical mupirocin + oral antibiotics (cefalexin or ciprofloxacin based on organism); do NOT remove catheter initially; reassess at 2 weeks Persistent infection at 3 weeks, tunnel involvement confirmed, or S. aureus exit-site infection not responding to oral antibiotics
Tunnel infection Tenderness, swelling, or erythema along the subcutaneous catheter track; ultrasound confirms fluid collection or abscess in tunnel Systemic antibiotics based on exit-site culture or empiric coverage; ultrasound guided if fluid collection present; reassess at 2 weeks Catheter removal often required if no clinical response at 14 days; simultaneous reinsertion not recommended — wait ≥2 weeks
Peritonitis WBC >100/μL in PD effluent with >50% neutrophils, OR clinical symptoms + positive culture. Cloudy effluent is peritonitis until proven otherwise IP cefazolin + IP ceftazidime empirically (ISPD 2022). Culture-directed step-down at 48–72 h. Treat 14–21 days depending on organism Refractory peritonitis (no improvement by day 5); fungal peritonitis (remove immediately); fecal peritonitis; same-organism relapse within 4 weeks of completing a course
Catheter re-insertion after removal Requires resolution of peritonitis and negative effluent cultures Wait ≥2 weeks after catheter removal before re-insertion (bacterial peritonitis). Fungal peritonitis: wait ≥4 weeks Simultaneous removal and reinsertion is not recommended; allow adequate time for resolution
Clinician Section 8

Prevention Protocols

Intervention Target Population Protocol Evidence
Mupirocin nasal ointment HD catheter patients with confirmed nasal S. aureus carriage (anterior nares swab positive) 2% mupirocin ointment, both nares, 3 times daily x 5 days; repeat monthly Reduces CRBSI by approximately 60% in MRSA carriers. Level A evidence (IDSA)
Mupirocin exit-site cream All HD catheter patients and PD catheter patients Apply to exit site daily after cleaning and drying; standard of care Reduces catheter infection rates; supported by multiple RCTs
Polysporin Triple cream (exit site) Alternative to mupirocin at PD exit site Daily application; evidence comparable to mupirocin; some centers alternate monthly to reduce mupirocin resistance selection pressure ISPD-supported alternative; avoids mupirocin resistance
Citrate 4% catheter lock All tunneled HD catheters, especially high-risk patients (prior CRBSI, diabetes, MRSA carrier) Instill 4% citrate lock solution in each lumen post-HD; remove and discard before next session. Use 4% concentration only — avoid 30% citrate (cardiac toxicity risk) Preferred over heparin + antibiotic lock for infection prevention; reduces biofilm formation
Povidone-iodine exit-site scrub PD catheter patients Clean exit site with PVP-I solution for 30–60 seconds before gauze dressing application Evidence supports superiority over chlorhexidine for PD exit-site infection prevention
Buttonhole vs. rope-ladder cannulation AVF patients Rope-ladder (rotating sites) is preferred for infection prevention. Buttonhole carries higher exit-site infection risk — consider abandoning buttonhole in patients with recurrent needle-site infections KDOQI recommendation; buttonhole infection risk is real and institution-dependent on technique standardization
MRSA surveillance swabs All HD unit patients Regular MRSA surveillance swabs (nares, groin, exit site) per institutional infection control protocol; decolonization as above for carriers Local hospital infection control guidance; particularly important in centers with high MRSA prevalence
Clinician Section 9

Monitoring and Follow-up

Parameter When to Check Threshold for Action
Repeat blood cultures 48–72 h after initiating appropriate antibiotics in any bacteremia Persistent positivity at 72 h: reassess source, consider catheter removal or source change, escalate antibiotics if susceptibility issue
Clinical response (fever, CRP, WBC, systemic signs) Daily for inpatients; at 48–72 h for outpatient oral antibiotic therapy No improvement at 48–72 h: reassess access as ongoing source, broaden antibiotics if culture pending, reconsider catheter removal
Echocardiogram (TTE) S. aureus bacteremia: at 5–7 days from onset (or sooner if clinical deterioration) Vegetations identified: extend IV antibiotics to 6 weeks; cardiology co-management; consideration of valve surgery in selected cases
Catheter exit-site assessment Every HD session (nursing assessment) New erythema, crust, or discharge: swab, escalate to physician, initiate or adjust topical and systemic therapy
Antibiotic lock solution Each HD session during lock therapy course Prepare fresh lock solution for each session — do not reuse. Discard residual solution remaining in lumen before next connection
Vancomycin AUC / trough Pre-4th dose (steady state) or per pharmacokinetics service protocol Target AUC/MIC 400–600. Trough-only monitoring: target 15–20 mg/L (less preferred but acceptable). Adjust dose or interval based on results
Clinician Section 10

Quick Reference Card

Dialysis Access Infection — Clinical Snapshot

  • CRBSI empiric: Vancomycin (MRSA cover) + ceftazidime (GNR cover) — start before cultures
  • MSSA bacteremia: Switch to cefazolin or cloxacillin — superior to vancomycin for MSSA
  • S. aureus CRBSI: Always remove catheter — do not attempt salvage
  • Candida CRBSI: Always remove catheter + anidulafungin; ophthalmology review within 24 h
  • Peritonitis empiric: IP cefazolin + IP ceftazidime (ISPD 2022); do not wait for cultures
  • PD cloudy fluid: Start IP antibiotics same day — peritonitis until proven otherwise
  • Salvage: Only for CoNS, clinically stable, no tunnel infection — not for S. aureus
  • Vancomycin in HD: Loading 15–20 mg/kg; target AUC 400–600; redose when trough <15
  • AVG infection: Early vascular surgery — prosthetic graft may require excision
  • MRSA prevention: Mupirocin nasal ointment monthly in carriers; exit-site cream daily
  • Echo indications: S. aureus bacteremia; bacteremia >72 h; new murmur
  • PD catheter removal: Fungal peritonitis (immediate); refractory day 5; same-organism relapse within 4 weeks
Dr. W. G. M. Rivero, MD

W. G. M. Rivero, MD, FPCP, DPSN

This clinician reference reflects IDSA 2016, ISPD 2022, and KDOQI guidelines as applied to a Philippine tertiary nephrology context. Local MRSA prevalence data are incorporated where available. Always integrate with current institutional antibiogram and infection control protocols. For complex or refractory cases, infectious disease co-management is strongly recommended.

Diplomate, Philippine Society of Nephrology · Fellow, Philippine College of Physicians · Internal Medicine · Nephrology

Related Guides

Nephrology Living With Dialysis Practical guidance for patients on hemodialysis or peritoneal dialysis — diet, fluid, schedule, and daily adjustments. → Nephrology Hemodialysis Complications Recognition and management of common and serious complications during and after hemodialysis sessions. → Nephrology Dialysis Access Care How to protect and maintain your fistula, graft, or catheter for long-term dialysis success. → Clinician Reference The CKD Prescriber's Playbook Complete prescribing protocols for CKD and dialysis — includes IP antibiotic dosing tables and ISPD peritonitis protocol. → Nephrology Preventing UTI in Kidney Disease Why CKD patients are at higher risk for urinary tract infections and how to reduce that risk. →