Abstract
Staphylococcus aureus is the most common endogenous infection in patients with end-stage renal disease (ESRD), and the anterior nares are the most common endogenous S. aureus carrier sites. Eliminating nasal S. aureus will greatly benefit ESRD patients. However, prophylactic topical nasal usage of mupirocin or any kind of antibiotic is against the principles of antibiotic usage. Nasal irrigation has been demonstrated to significantly increase ciliary clearance and decrease mucous inflammation, and has been proven to be an inexpensive, effective, simple, and safe treatment method in nasal health care. We propose that nasal irrigation might be the appropriate nasal hygiene intervention for ESRD patients and should be routinely applied in ESRD patients, especially those with risk factors.
Key words
ESRD patients, dialysis, nasal S.aureus, nasal irrigation
Introduction
Infection is one of the most common causes of hospitalization, morbidity, and mortality among patients with End-Stage Renal Disease (ESRD) who are undergoing hemodialysis (HD), Peritoneal Dialysis (PD), Continuous Ambulatory Peritoneal Dialysis (CAPD), or kidney transplantations [1-3]. Endogenous gram-positive cocci, especially Staphylococcus aureus (S. aureus), are the most frequently associated microorganism in long-term dialysis patients, and anterior nares are the most common endogenous SA carrier sites [4].
Nasal S. aureus is the most common endogenous infective resource of ESRD patients
Based on sensitivity to methicillin, S. aureus is usually divided into two subclasses, namely methicillin-resistant S. aureus (MRSA) and methicillin-sensitive S. aureus (MSSA). 15.1%-73.9% ESRD patients carried nasal MSSA while 1.1%-27.4% ESRD patients carried MRSA in their noses (Table 1).
Sample Size
|
Total
S. aureus
|
MRSA
|
Dialysis types
|
Experiment Year
|
Country
|
Reference
|
n
|
%
|
n
|
%
|
87
|
20
|
23.0
|
-
|
-
|
CAPD
|
1984
|
UK
|
[18]
|
140
|
63
|
45.0
|
-
|
-
|
CAPD
|
1987
|
Belgium
|
[19]
|
146
|
41
|
28.1
|
-
|
-
|
CAPD
|
1989
|
Singapore
|
[20]
|
167
|
-
|
-
|
28
|
16.8
|
CAPD
|
1989
|
Singapore.
|
[21]
|
129
|
66
|
51.2
|
-
|
-
|
CAPD
|
1992
|
Denmark
|
[22]
|
129
|
60
|
46.5
|
-
|
-
|
CAPD
|
1992
|
Denmark
|
[22]
|
168
|
100
|
59.5
|
-
|
-
|
HD
|
1992
|
Denmark
|
[22]
|
168
|
96
|
57.1
|
-
|
-
|
HD
|
1992
|
Denmark
|
[22]
|
172
|
67
|
39.0
|
-
|
-
|
HD
|
1992
|
Netherland
|
[6]
|
54
|
31
|
57.4
|
-
|
-
|
CAPD
|
1993
|
Netherland
|
[23]
|
138
|
69
|
50.0
|
-
|
-
|
PD
|
1993
|
USA
|
[24]
|
32
|
12
|
37.5
|
-
|
-
|
CAPD
|
1995
|
Denmark
|
[25]
|
24
|
9
|
37.5
|
-
|
-
|
CAPD
|
1996
|
USA
|
[26]
|
205
|
78
|
38.0
|
22
|
10.7
|
HD
|
1997
|
Saudi Arabia
|
[15]
|
28
|
16
|
57.1
|
-
|
-
|
HD
|
1998
|
Poland
|
[27]
|
52
|
30
|
57.7
|
-
|
-
|
PD
|
1998
|
Netherland
|
[28]
|
144
|
50
|
34.7
|
-
|
-
|
HD,CAPD
|
1999
|
UK
|
[29]
|
71
|
39
|
54.9
|
-
|
-
|
HD
|
2000
|
Spain
|
[30]
|
83
|
-
|
-
|
2
|
2.4
|
PD
|
2002
|
TAIWAN
|
[31]
|
198
|
-
|
-
|
11
|
5.6
|
HD
|
2002
|
USA
|
[32]
|
509
|
-
|
-
|
12
|
2.4
|
HD
|
2002
|
TAIWAN
|
[31]
|
69
|
28
|
40.6
|
-
|
-
|
HD
|
2003
|
Iran
|
[33]
|
43
|
12
|
27.9
|
-
|
-
|
HD
|
2004
|
Poland
|
[34]
|
43
|
12
|
27.9
|
1
|
2.3
|
HD
|
2004
|
Poland
|
[35]
|
136
|
72
|
52.9
|
16
|
11.8
|
HD
|
2004
|
GERMAN
|
[4]
|
261
|
148
|
56.7
|
-
|
-
|
HD
|
2004
|
Turkey
|
[36]
|
289
|
-
|
-
|
34
|
11.8
|
HD
|
2004
|
Germany
|
[5]
|
84
|
31
|
36.9
|
23
|
27.4
|
HD
|
2006
|
Iran
|
[37]
|
157
|
26
|
16.6
|
10
|
6.4
|
HD
|
2006
|
USA
|
[38]
|
103
|
-
|
-
|
12
|
11.7
|
HD
|
2007
|
USA
|
[39]
|
120
|
40
|
33.3
|
26
|
21.7
|
DIALYSIS
|
2007
|
USA
|
[17]
|
130
|
32
|
24.6
|
-
|
-
|
HD
|
2007
|
Iran
|
[40]
|
306
|
-
|
-
|
29
|
9.5
|
HD
|
2007
|
TAIWAN
|
[1]
|
541
|
121
|
22.4
|
32
|
5.9
|
HD
|
2007
|
TAIWAN
|
[16]
|
54
|
24
|
44.4
|
3
|
5.6
|
HD,CAPD
|
2008
|
Maroc
|
[41]
|
54
|
24
|
44.4
|
3
|
5.6
|
HD
|
2008
|
Morocco
|
[41]
|
46
|
34
|
73.9
|
-
|
-
|
TRANSP.
|
2009
|
Brazil
|
[42]
|
48
|
36
|
75.0
|
-
|
-
|
TRANSP.
|
2009
|
Brazil
|
[42]
|
70
|
37
|
52.9
|
-
|
-
|
DIALY.
|
2009
|
Brazil
|
[43]
|
111
|
55
|
49.0
|
-
|
-
|
DIALY.
|
2009
|
Brazil
|
[43]
|
112
|
-
|
-
|
10
|
8.9
|
HD
|
2009
|
JAPAN
|
[44]
|
264
|
48
|
18.2
|
14
|
5.3
|
DIALYSIS
|
2009
|
TAIWAN
|
[2]
|
70
|
30
|
42.9
|
1
|
1.4
|
HD
|
2010
|
Morocco.
|
[45]
|
103
|
-
|
-
|
4
|
3.9
|
HD
|
2010
|
JAPAN
|
[44]
|
184
|
52
|
28.3
|
-
|
-
|
HD
|
2011
|
Turkey
|
[46]
|
296
|
48
|
16.2
|
20
|
6.8
|
HD
|
2011
|
TAIWAN
|
[47]
|
185
|
28
|
15.1
|
2
|
1.1
|
HD
|
2012
|
Turkey
|
[48]
|
28
|
16
|
57.1
|
-
|
-
|
HD
|
-
|
Poland
|
[27]
|
91
|
34
|
37.4
|
-
|
-
|
HD
|
-
|
Netherland
|
[23]
|
114
|
34
|
29.8
|
-
|
-
|
HD
|
-
|
Marseille
|
[50]
|
Table 1. Nasal carriage of S. aureus and MRSA in ESRD patients
Nasal S. aureus will spread to the skin and catheter exits via touching, or to the bronchus and lung via airflow. Hence, the nose is the main original source of endogenous S. aureus. Besides, most S. aureus nasal carriers are asymptomatic but have greater potential risk of bacteremia than non-carriers. In particular, dialysis patients who are S. aureus nasal carriers usually have poor clinical outcomes, especially elderly patients [1,2]. Thus, eliminating nasal S. aureus will benefit ESRD patients and reduce the economic burden of both the patients and the government [1,2].
Prophylactic antibiotic is no longer the first choice to eliminate nasal S. aureus
Topical mupirocin application has been proven to be effective in eradicating S. aureus in the nose and catheter exits [5], and has been applied for years [6]. Topical application of mupirocin near catheter exits is rational and necessary because catheterization is an invasive treatment. However, there is no adequate reason for prophylactic nasal application of mupirocin because most S. aureus carriers are asymptomatic. Prophylactic antibiotic usage will induce antibiotic resistance and break the balance of nasal flora between S. aureus and other microorganisms such as Staphylococcus epidermidis. Therefore, prophylactic topical usage of mupirocin or any kind of antibiotic in ESRD patients is against the principles of antibiotic usage. Meanwhile, screening for nasal S. aureus is a time-consuming and economically inefficient process.
Nasal irrigation in patients with end-stage renal disease
Nasal hygiene of ESRD patients is essential but long-ignored. From otolaryngologists’ perspective, we propose that topical nasal irrigation might be the appropriate nasal hygiene intervention for ESRD patients.
Nasal irrigation, also called nasal wash, rinse, douche, and lavage, is a series of adjunctive treatments for patients with chronic sinusitis and a postoperative treatment of other nasal diseases. Abundant data provide evidence that nasal irrigation is an inexpensive, effective, simple, and safe treatment [7-10]. Treatment guidelines in many countries, including China, Europe, and North America, now advocate the use of nasal irrigation for all causes of rhinosinusitis and for postoperative cleaning of the nasal cavities [11].
Nasal irrigation is performed by injecting saline in one nostril and allowing it to drain out of the other nostril, bathing the nasal cavity. In the past century, many trials have been conducted about the irrigating solution components and devices [10]. Currently, a consensus seemed to have been reached that the combination of high-volume and low-pressure devices with hypertonic solutions show optimal outcomes [11,12] . Nasal irrigation has no longer been considered as merely an adjunctive treatment and is now becoming increasingly popular in nasal healthcare [12].
The beneficial mechanisms of nasal irrigation is to increase mucociliary clearance and decrease mucous inflammations, which might include the following aspects: 1) activation of the cilia motility and decreasing the bacterial adhesion, and therefore reducing nasal bacterial attachment; 2) physically flushing away inflammatory mediators, the crust, and other nasal discharges that act as the culture media of bacteria, hence inhibiting bacterial growth [7].
Only low-level evidence support the efficacy of nasal irrigation with antibiotics, suggesting that irrigation itself plays a more important role than the additive antibiotics. Nasal irrigation has been proven to decrease antibiotic usage and thereafter reduce antibiotic resistance [9]. Unfortunately, direct data are lacking that show the elimination effect of nasal irrigation on S. aureus.
Given that it is an inexpensive and convenient procedure, nasal irrigation is recommended to all dialysis patients and health-care staff. Moreover, it should be routinely used among patients with risk factors, which at least include the following: 1) antibiotic usage within 3 months before admission[13]; 2) hospitalization during the past 12 months [13]; 3) diagnosis of skin or soft tissue infection at admission [13,14]; 4) human immunodeficiency virus infection [13]; 5) elderly patient (≥75 years) [1,15]; 6) prolonged hospitalization[1,2]; 7) congestive heart failure [1,2]; and 8) nursing home admission and nasogastric tube feeding in the last 3 months [16,17].
Conflict of interest
No conflict of interest relevant to this paper is declared.
Disclosure of grants or other funding
None
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