Home About us Current issue Ahead of Print Back issues Submission Instructions Advertise Contact Login   

Search Article 
Advanced search 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 2242 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 

ORIGINAL ARTICLE Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 5  |  Page : 737-745
Prevention of Staphylococcal Peritonitis in CAPD Patients Combining Ablution and Mupirocin

Department of Internal Medicine, Nephrology Division, King Fahd University Hospital, King Faisal University, Al-Khobar, Saudi Arabia

Click here for correspondence address and email


Although there has been a dramatic decrease in the incidence of peritonitis in continuous ambulatory peritoneal dialysis (CAPD), rates > 0.5 episodes per patient per year are still common, with a very high rate of relapse. The nasal, pharyngeal, and skin carriage of Staphylococcus aureus (S. aureus) has been reported to be one of the most important of predisposing factors for peritonitis. Mupirocin application has been introduced to combat S. aureus carriage state with some degree of success. To evaluate the benefits of combining ablution for prayers with mupirocin in eliminating the carrier state of S. aureus and thus preventing peritonitis in CAPD patients, we randomized prospectively 65 patients on CAPD into two groups; group (1) used mupirocin intranasal application alone, and group (2) were instructed, in addition to application of mupirocin, to perform the proper ablution technique. The main outcome measures were the state of nasal, skin and pharyngeal S. aureus carriage state, the incidence of peritonitis, and mal-function-free PD catheter survival. After 3 months of CAPD initiation, S. aureus carrier state was detected in 11 (33.3%) patients in group (1), and in 2 (6.25%) patients in group (2) (p< 0.005), and at the end of the study 10 (30.3%) patients from group (1) and none in group (2) remained S. aureus carriers (p< 0.001). S. aureus peritonitis occurred in 19 occasions in 10 patients of group (1) versus 4 occasions in 3 patients of group (2) (p< 0.001). Malfunction-free catheter survival at 12 months was 72.7% in group (1) versus 90.6% in group (2) patients (p< 0.05). We conclude that combined with mupirocin intranasal application, performing proper ablution is an effective measure against S aureus carriage and hence it decreases the incidence of continuous ambulatory peritoneal dialysis-associated S. aureus peritonitis.

Keywords: CAPD, Staphylococcus aureus,Ablution, Mupirocin, S. aureus carriage

How to cite this article:
Al-Hwiesh AK, Abdul Rahman IS. Prevention of Staphylococcal Peritonitis in CAPD Patients Combining Ablution and Mupirocin. Saudi J Kidney Dis Transpl 2008;19:737-45

How to cite this URL:
Al-Hwiesh AK, Abdul Rahman IS. Prevention of Staphylococcal Peritonitis in CAPD Patients Combining Ablution and Mupirocin. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2022 Sep 26];19:737-45. Available from: https://www.sjkdt.org/text.asp?2008/19/5/737/42444

   Introduction Top

Peritonitis and exit-site infections have been the most frequent complications of continuous ambulatory peritoneal dialysis (CAPD) since the introduction of this modality as a viable treatment for patients with end-stage renal disease (ESRD). [1],[2] Active or persistent infec­tions may result in technique failure. [2],[3],[4],[5],[6] Despite the widespread use of modern disconnect sys­tems for PD, S. aureus and Staphylococcus epidermidis are still a frequent cause of dia­lysis-related infections.

S. aureus nasal and/or skin carriers are con­sidered to be at greater risk for developing peritonitis. [7],[8],[9],[10],[11] Treatment of S. aureus nasal carriers with topical intranasal mupirocin is useful to reduce the number of exit-site infec­tions caused by S. aureus, but not peritonitis. [12]

Resistance of bacteria to antimicrobial agents has become increasingly common during the last decade. [13],[14] This increasing prevalence of antimicrobial resistance is due to the two pri­mary factors: indifferent antimicrobial use and transmission of resistant strains from patient to patient. [15] strategies that limit the spread of antimicrobial resistance in patients with ESRD have been reviewed, [16] and clinical practice guidelines have been laid down. [17]

Hands hygiene is stated as the single most important infection-control measure, and should be performed after touching blood, body fluids, secretions, excretions, and contaminated items re-gardless of whether gloves are worn. Hand washing should be performed as frequent as possible to avoid the transfer of microorga­nisms. [16],[17]

Fourteen centuries ago, our Prophet Mohammed (Peace be upon him) gave us a prescription of 26 washing movements (ablu­tion) to be carried out 5 times a day. The holy Quraan stated "O ye who believe! When ye prepare for prayer, wash your faces, and your hands (and arms) to the elbows; Rub your hands (with water); and wash your feet to the ankles. If ye are in a state of ceremonial impurity, bathe your whole body". [18]

Since ablution may solve the problem of nasal, pharyngeal and skin carrier state of microorganisms that is responsible for CAPD­related peritonitis, we combined the usage of mupirocin with instructions to our patients about adopting the correct ablution techniques to evaluate the outcome of such strategy on the incidence of peritonitis in our CAPD patients.

   Patients and Methods Top

We prospectively studied 65 incident patients started on CAPD in a single center (King Fahd University Hospital Al-Khobar, Saudi Arabia), from 2005–2007 (a period of 2 years). They were divided into two groups: (1) incident CAPD patients from February 2005 to January 2006 inclusive (Group (1)–33 patients), in whom only topical mupirocin ointment was used as prophylaxis against Staphylococcus aureus Scientific Name Search  infection, and (2) incident patients from Feb­ruary 2006 to March 2007 inclusive (Group (2)–32 patients), in whom topical mupirocin was combined with the proper ablution tech­nique. Each patient was assessed and coun­seled by the dialysis coordinator to determine the suitability of the treatment before the elective insertion of a coiled, double-cuff Ten­ckoff catheter (Accurate Surgical Instruments Corporation, Toronto, Ontario). Antibiotic pro­phylaxis with intravenous cephazolin was ad­ministered prior to surgery. A break-in period of at least 2 weeks was required during which the exit site was visually inspected on days 5 and 10 after catheter placement. Patients and their caregiver(s), if any, were then trained for 1 week on the use of CAPD by a PD nurse. Patients and their caregiver(s) of group 2 were given extra-training of the proper ablution technique for an additional week. The training was delivered by a nephrologist. The double­bag (Ultrabag) system was used for all PD patients. Mupirocin was regularly applied on the exit sites in all incident patients as part of their exit site care. Mupirocin in the form of 2% ointment was applied three to five times per week, after cleaning the area around the site with iodine (single-use swabs sterile packs). An amount of ointment equivalent to the size of match head was applied to each nostril twice daily for 5 days each month. Standard cotton swabs were collected bi-monthly from every patient (and their caregiver(s), if any), one each from the anterior nares, pharynx, the skin folds between the toes, and from the subungual sulci of all fingers of the dominant hand.

All cultures were incubated aerobically at 35° C. The plates were reviewed at 24 hours and again after 48 hours if no growth was observed. Putative S. aureus colonies were identified on the basis of positive Gram stain, catalase test, coagulation tube test, and Pastorex Staph Plus rapid agglutination slide test (Bio-Rad, Montreal, Quebec, Canada). All strains of S. aureus isolated were tested for methicillin and mupirocin resistance. Methicillin resistance was tested using methicillin scree­ning plates containing oxacillin 6 mg/ml and 4% NaCl. Mupirocin resistance was tested using E-test strips (AB Biodisk, Slona, Sweden). Clinical data were collected from patients at the time of swab collection [Table 1]. Peritonitis was diagnosed if at least two of the following were present:

  1. abdominal pain or tenderness,
  2. presence of white cells in the peritoneal effluent in excess of 100 cells/ml, com­prising at least 50% polymorphs and,
  3. positive dialysate culture results. The dia­lysate samples were cultured in Bact-Alert blood culture bottles media (Organon Tech­nika, Durham, NC) and subcultured in 5% sheep blood agar, chocolate, and McConkey agar 24 hours later.

Ablution technique:

The usual technique of ablution was used with special emphasis on the following items:

  1. To wash the hands and in between the fingers carefully three times.
  2. Shift the ring (if any) when washing the hands.
  3. During mouth washing, rinse it vigorously with water and gurgle the throat, three times.
  4. Wash the nostrils three times with the right hand, draw the water as deep as possible, and then blow it out with the left hand.
  5. Swab the ears carefully with water. Clean the inside and outside of the ear.
  6. When washing the face, arms, and feet, use a little more of water than the com­pulsory amount. During washing the arms fill the palm with water and then pour it towards the elbow. Repeat this three times in each ablution.
  7. Wash every limb three times. Every part of the limb must be washed and rubbed with water.
  8. Swab the head with water using the hand in backwards and forwards movement.
  9. When washing the feet, wash in between the toes from under them in succession, beginning with the little the of the right foot, and then after finishing with the right foot carry on with the big toe of the left foot towards the little one.
  10. To perform ablution before each prayer, and at least 5 times per day.

   Statistical analysis Top

Statistical analysis was done using the soft­ware of SPSS Inc. for windows to identify the different predictors of the occurrence of peri­tonitis. Data are expressed as means with SD or median with range. Continuous variables were compared with t-test. Times to the first peritonitis were analyzed using Cox regression analysis. P value < 0.05 was considered to be statistically significant. All the reported p-values were two-tailed.

   Results Top

The demographics of 65 CAPD patients are presented in [Table 1]. Both groups were similar in terms of co morbidities, serum albumin before the initiation of CAPD, and age at the start of PD. A high proportion of our patients had diabetes or ischemic heart disease, and serum albumin below 30 g/L at entry into the PD program. Isolation of S. aureus from the nostrils was also similar at baseline 15 (45.5%) in group (1) and in 13 (40.6%) in group (2) (p> 0.05). After 3 months and at end of study, S. aureus carrier state was detected in 11 (33.3%) and 2 (6.25%) patients (p< 0.005), and 10 (30.3%) patients versus none (p< 0.001), respectively. None of the S .aureus isolates were MRSA. Mupirocin resistance was found in 12 (18.5%) patients; 10 (15.4%) in group (1), and 2 (3.1%) in group (2) (p< 0.005). S. aureus peritonitis occurred in 19 occasions in 10 patients of group (1) versus 4 occasions in 3 patients of group (2) (p< 0.001). Most of the peritonitis episodes in group (2) patients occurred within 3 months of entry into the trial, whereas those in group (1) continued throughout the trial [Figure 1]. By Cox reg­ression analysis, time to first infection was significantly shorter in group (1) than in group (2) patients (hazard ratio, 2.4; 95% confidence interval 1.0-5.3; p= 0.04). Cumulative evidence of peritonitis was 1 per 9.5 patient months in group (1) and 1 per 24 patient months in group (2) (odds ratio 3.4; 95% CI 1.5 to 8.5; p= 0.004). Six (18.2%) patients in group (1) ver­sus 1 (3.1%) patient in group (2) had PD catheter malfunction necessitating catheter change (p< 0.01). Malfunction-free catheter survival at 12 months was 72.7% in group (1) versus 90.6% in group (2) patients (p< 0.05), [Table 2].

   Discussion Top

As many as 15% of end stage kidney disease patients in the U.S. are on PD. In other coun­tries such as Canada and the United Kingdom (35%), New Zealand (55%), and Mexico (90%), the rates are higher, but the major limitation to the broader uptake of PD is still an unacceptable rate of peritonitis, which in turn promotes technique failure, more hospita­lizations [19] and increased mortality. [20],[21],[22], Several PD catheter-related interventions (catheter de­signs, surgical insertion approaches, and co­nnection methods) have been purported to reduce the risk of peritonitis in PD. Although there has been a dramatic decrease in peri­tonitis from the inception of CAPD, rates > 0.5 episodes per patient per year are still co­mmon, [23],[24],[25] and peritonitis tends to be recu­rrent, with a very high rate of relapse (~0.5 episodes/patient/year). [26] The incidence of peri­tonitis has been reported to vary depending on age, [24],[25] coexisting disease (e.g., diabetes), nasal carriage of S. aureus, [27],[28] and race. [29],[30],[31] S. aureus colonizes the skin and mucosa of human beings and several animal species. [32] Although multiple body sites can be colonized in the human beings, the anterior nares of the nose are the most frequent carriage site for S aureus. [32] Extra-nasal sites that typically har­bour the organism include the skin, perineum, and pharynx. [32],[33],[34],[35] Most studies on S. aureus nasal carriage have used a cross-sectional design with a single nasal culture to classify an individual as a carrier. However, longitudinal studies distinguish at least three S. aureus nasal carriage patterns in healthy individuals: persistent carriage, intermittent carriage, and non-carriage. [32],[33],[36],[37],[38] Some studies make a fur­ther distinction between occasional and inter­mittent carriers. [37],[39] Therefore, a patient classi­fied as a carrier in cross-sectional studies could be a persistent or an intermittent carrier. This distinction is important because persistent car­riers have higher S. aureus loads and a higher risk of acquiring S aureus infection. [40],[41] Like­ wise, non-carriers in a cross-sectional study may actually be intermittent carriers. Longitu­dinal studies show that about 20% (range 12&ndash30%) of individuals are persistent S. aureus nasal carriers and approximately 30% are intermittent carriers (range 16–70%). [36],[37],[42],[43] The very wide ranges found in the proportions of intermittent carriers are the result of the use of different culture techniques, different popu­lations being studied, and the use of different interpretation guidelines. [38] The mechanisms leading to S. aureus nasal carriage are multi­factorial. A recent study in which volunteers (non-carriers and persistent carriers) were artificially inoculated with a mixture of S. aureus strains showed that non-carriers quick­ly eliminated the inoculated S. aureus strains, whereas most persistent carriers selected their original resident S. aureus strain from the inoculation mixture. [44] The investigators con­cluded that host characteristics substantially co-determine the S. aureus carrier state and that an optimal fit between host and bacteria seems to be essential. [44] This view is further supported by the fact that S. aureus carriage rates vary between different ethnic groups, with higher rates in white people, [32],[45] and in men, [32],[37],[46] and depends on age. [33],[47],[48] Patients with diabetes mellitus (both insulin-dependent and non-insulin dependent) [49] , patients with end­stage liver disease, [50],[51] and patients undergoing hemodialysis, [52],[53] or CAPD for end-stage renal disease [54] have higher S. aureus carriage rates. Nasal secretions with antimicrobial peptides may have a role in the innate host defence, [55] however, several studies have found that these antimicrobial peptides have no or little activity against S. aureus or that other peptides are needed to enhance their activity. [56],[57] The inabi­lity of nasal antimicrobial peptides to clear S. aureus from the nose may be explained by

  1. the anatomy of nose in relation to S. aureus nasal carriage and
  2. resistance of S. aureus to many antimicro­bial peptides. [45],[58]

S. aureus predominantly colonizes an area in the vestibulum nasi that is devoid of cilia and relatively free from nasal mucous secretions that containing antimicrobial peptides and immu­noglobulins. [45] Mechanical removal of the orga­nisms by the proper act of ablution seems to be a perfect solution for this problem as shown by our study. S. aureus, in addition, has several other mechanisms of resistance including: sta­phylokinase [59] , membrane lipid modification [60] ,cationic antimicrobial peptides, including de­fensins and cathelicidins, present in the nasal mucosa. Furthermore, all S. aureus strains are also lysozyme resistant since they possess the peptidoglycan-specific O-acetyltransferase. [61]

In hemodialysis patients, S. aureus is a fre­quently found pathogen involving vascular access related infections and bacteremia. The infection rate is higher in nasal and pharyngeal carriers on hemodialysis, with relative risks varying from 1.8 to 4.7. [36],[52],[62],[63][64] S. aureus iso­lates from different sites are usually identical to the one previously isolated from the patient's nose or pharynx. [65] Multiple studies have de­monstrated that long-term eradication of S. aureus nasal and pharyngeal carriage effec­tively reduces S. aureus infections among patients on maintenance dialysis, thereby dec­reasing complications and costs. [66],[67],[68],[69] In patients on CAPD, S. aureus is the leading cause of peritoneal often resulting in catheter loss. S. aureus nasal and pharyngeal carriage was found to be a major risk factor for infections in PD patients mainly associated with exit site and tunnel infections. [41],[54],[70],[71],[72],[73],[74] Intervention stu­dies consistently demonstrated a substantial re­duction in the incidence of exit-site infections, but not a consistent reduction in the incidence of peritonitis. [52],[74],[75],[76],[77],[78] In a recent study it was demonstrated that PD patients with persistent or intermittent S. aureus nasal carriage were at similar increased risk of acquiring dialysis­related S. aureus infections. [41] Interventions to prevent continuous peritoneal dialysis-related infections include eliminating the carrier state by personal hygiene, nasal and throat cleansing and prophylactic antibiotic local use since the nasal strains and the infectious strain were found to be the same [36],[41],[54] In our patients, daily application of mupirocin with ablution was more effective in preventing S aureus peritonitis. The act of ablution performed pro­perly not only cleanses the vital parts of the body from dust and dirt but also softens and refreshes them. Especially the germs trapped in the nostrils are mechanically removed. According to a study conducted in Alexandria University, ablution positively affected the inner coating of the nostrils. [79] Rinsing of the mouth also proved to protect from the infections. [80]

We conclude that in addition to mupirocin performing ablution properly is an effective measure against Staphylococcus aureus nasal carriage resulting in lesser incidence of CAPD associated peritonitis Further studies at other centers with larger number of patients are needed to confirm this finding.

   Acknowledgement Top

The authors thank the staff nurses and the health educator in the peritoneal dialysis unit at King Fahd University Hospital for their valuable efforts in the completion of the study.

   References Top

1.Saklayen MG. CAPD peritonitis: incidence, pathogens, diagnosis, and management. Med Clin North Am 1990;74(4):997-1010.  Back to cited text no. 1    
2.Maiorca R, Vonesh EF, Cavalli PL, et al. A multicenter, selection-adjusted comparison of patient and technique survivals on CAPD and hemodialysis. Perit Dial Int 1991;11(2):118-27.  Back to cited text no. 2    
3.Selgas R, Fernandez-Reyes JR, Bosque Y, et al. Functional longevity of the human peritoneum: how long is peritoneal dialysis possible? Results of a prospective medium long term study. Am J Kidney Dis 1994;23(1):64-73.  Back to cited text no. 3    
4.Davis SJ, Bryan J, Phillips L, et al. Longi­tudinal changes in peritoneal kinetics: the effects of peritoneal dialysis and peritonitis. Nephrol Dial Transplant 1996;11(3):498-506.  Back to cited text no. 4    
5.Monteon F, Correa-rotter R, Paniagua R, et al. Prevention of peritonitis with disconnect systems in CAPD: a randomized controlled trial. Kidney Int 1998;54(6):2123-8.  Back to cited text no. 5    
6.Li PK, Szeto CC, Law MC, et al. Comparison of double-bag and Y set disconnect systems in continuous ambulatory peritoneal dialysis: a randomized prospective multicenter study. Am J Kidney Dis 1999;33(3):535-40.  Back to cited text no. 6    
7.Zimakoff J, Bangsgaard-Pederson F, Bergen L, et al. Staphylococcus aureus carriage and infections among patients in four haemo-and­peritoneal dialysis centers in Denmark. The Danish Study Group pf Peritonitis in Dialysis (DASPID). J Hosp Infect 1996;33:289-300.  Back to cited text no. 7    
8.Davis SG, Ogg CS, Cameron JS, et al. Staphylococcus aureus nasal carriage, exit site infection, and catheter loss in patients treated with continuous ambulatory peritoneal dialysis (CAPD). Perit Dial Int 1989;9:61-4.  Back to cited text no. 8    
9.Wanten GJ, van Oost P, Schneeberger PM, et al. Nasal carriage and peritonitis by Staphy­lococcus aureus in patients on continuous ambulatory peritoneal dialysis: a prospective study. Perit Dial Int 1996;16(4):352-6.  Back to cited text no. 9    
10.Pignatari A, Pfaller M, Hollis R, Sesso R, Leme I, Herwaldt L. Staphylococcus aureus colonization and infection in patients on continuous ambulatory peritoneal dialysis. J Clin Microbiol 1990;28(9):1898-902.  Back to cited text no. 10    
11.Sesso R, Draibe S, Castelo A, et al. Staphy­lococcus aureus skin carriage and development of peritonitis in patients on continuous ambulatory peritoneal dialysis. Clin Nephrol 1989;31(5):264-8.  Back to cited text no. 11    
12.Mupirocin Study Group. Nasal mupirocin pre­vents Staphylococcus aureus exit-site infection during peritoneal dialysis. J Am Soc Nephrol 1996;7:2403-8.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Gold HS, Moellering RC Jr. Antimicrobial­drug resistance. N Engl J Med 1996;335(19):1445-53.  Back to cited text no. 13    
14.Fridkin SK. Increasing prevalence of anti­microbial resistance in intensive care units. Crit Care Med 2001;29(S4):N64-8.  Back to cited text no. 14    
15.Berns JS, and Tokars JI. Preventing bacterial infections and antimicrobial resistance in dialysis patients. Am J Kidney Dis 2002;40 (5):886-98.  Back to cited text no. 15    
16.Centers for Disease Control and Prevention: recommendations for preventing transmission of infections among hemodialysis patients. MMWR Morbid Mortal Wkly Rep 2001;50:2­32.  Back to cited text no. 16    
17.Tokars JI, Frank M, Alter MJ, Arduino MJ. National surveillance of dialysis-associated diseases in the United States 2000. Semin Dial 2002;15(3):162-71.  Back to cited text no. 17    
18.Al-Maa'edah, (Chapter 5, Verse 6).The Holy Quraan.  Back to cited text no. 18    
19.Churchill DN, Thorpe KE, Vonesh EF, et al. Lower probability of patient survival with continuous ambulatory peritoneal dialysis in the United States compared with Canada. Canada-USA (CANUSA) Peritoneal Dialysis Study Group. Am J Soc Nephrol 1997;8:965­71.  Back to cited text no. 19    
20.Digenis GE, Abraham G, Savin E, et al.Peritonitis-related deaths in continuous ambu­latory peritoneal dialysis (CAPD) patients. Perit Dial Int 1990;10(1):45-7.  Back to cited text no. 20    
21.Piraino B. Staphylococcus aureus infection in dialysis patients: focus on prevention. ASAIO J 2000;46(6):S13-7.  Back to cited text no. 21    
22.Annigeri R, Conly J, Vas S, et al. Emergence of mupirocin-resistant Staphylococcus aureus in chronic peritoneal dialysis patients using mupirocin prophylaxis to prevent exit-site infection. Perit Dial Int 2001;21(6):554-9.  Back to cited text no. 22    
23.Zelentisky S, Barns L, Findlay I, et al. Analysis of microbiological trends in peri­toneal dialysis-related peritonitis from 1991 to 1998. Am J Kidney Dis 2000;36(5):1009-13.  Back to cited text no. 23    
24.Oxton LL, Zimmerman SW, Roecker EB, et al. Risk factors for peritoneal dialysis-related infections. Perit Dial Int 1994;14(2):137-44.  Back to cited text no. 24    
25.Salusky IB, Holloway M. Selection of peri­toneal dialysis for pediatric patients. Perit Dial Int 1994;17:S35-7.  Back to cited text no. 25    
26.Vas S, Oreopoulos DG. Infections in patients undergoing peritoneal dialysis. Infect Dis Clin North Am 2001;15:743-74.  Back to cited text no. 26  [PUBMED]  
27.Schaefer F. Management of peritonitis in chil­dren receiving chronic peritoneal dialysis. Pediatr Drugs 2003;5:315-25.  Back to cited text no. 27    
28.Golper TA, Brier ME, Bunke M, et al. Risk factors for peritonitis in long-term peritoneal dialysis: The Network 9 peritonitis and catheter survival studies. Academic Subcommittee of the Steering Committee of the Network 9 peritonitis and catheter survival studies. Am J Kidney Dis 1996;28:428-36.  Back to cited text no. 28    
29.Holley JL, Bernardini J, Piraino B. A compa­rison of peritoneal dialysis-related infections in black and white patients. Perit Dial Int 1993;13 (1):45-9.  Back to cited text no. 29    
30.Fine A, Cox D, Bouw M. Higher incidence of peritonitis in native Canadians on continuous ambulatory peritoneal dialysis. Perit Dial Int 1994;14(3):227-30.  Back to cited text no. 30    
31.Peraino B. ADEMEX: How should it change our practice? Adequacy of peritoneal dialysis in Mexico. Perit Dial Int 2002;22:552-4.  Back to cited text no. 31    
32.Williams RE. Healthy carriage of Staphylo­coccus aureus: Its prevalence and importance. Bacteriol Rev 1963;27:56-71.  Back to cited text no. 32  [PUBMED]  [FULLTEXT]
33.Armstrong-Esther CA, Smith JE. Carriage patterns of Staphylococcus aureus in healthy non-hospital population of adults and children. Ann Hum Biol 1976;3(3):221-7.  Back to cited text no. 33    
34.Wertheim HF, Verveer J, Boelens HA, van Belkum A, Verbrugh HA, Vos MC. Effect of mupirocin treatment on nasal, pharyngeal, and perineal carriage of Staphylococcus aureus in healthy adults. Antimicrob Agents Chemother 2005;49(4):1465-7.  Back to cited text no. 34    
35.Ridely M. Perineal carriage of Staph. aureus. Br Med J 1959;34:270-3.  Back to cited text no. 35    
36.Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus aureus: Epidemio­logy, underlying mechanisms, and associated risks. Clin Microbiol Rev 1997;10(3):505-20.  Back to cited text no. 36    
37.Eriksen NH, Espersen F, Rosdahl VT, et al. Carriage of Staphylococcus aureus among 104 healthy persons during a 19-month period. Epidemiol Infect 1995;115(1):51-60.  Back to cited text no. 37    
38.VandenBergh MF, Yzerman EP, van Belkum A, et al. Follow-up of Staphylococcus aureus nasal carriage after 8 years: redefining the persistent carrier state. J Clin Microbiol 1999; 37(10):3133-40.  Back to cited text no. 38    
39.Maxwell JG, Ford CR, Peterson DE, Mitchell CR. Long-term study of nasal staphylococci among hospital personnel. Am J Surg 1969; 118(6):849-54.  Back to cited text no. 39    
40.White A. Increased infection rates in heavy nasal carriers of coagulase-positive Staphylo­cocci. Antimicrobial Agents Chemother 1962; 161:667-70.  Back to cited text no. 40    
41.Nouwen JL, Fieren MW, Snijders S, et al. Persistent (non-intermittent) nasal carriage of Staphylococcus aureus is the determinant of CPD-related infections. Kidney Int 2005;67: 1084-92.  Back to cited text no. 41  [PUBMED]  [FULLTEXT]
42.Nouwen JL, Ott A, Kluytmans-Vanderbergh MF, et al. Predicting the Staphylococcus aureus nasal carrier state: derivation and validation of a "culture rule". Clin Infect Dis 2004;39 (6):806-11.  Back to cited text no. 42    
43.Hu L, Umeda A, Kondo S, et al. Typing of Staphylococcus aureus colonizing human nasal carriers by pulsed-field gel electrophoresis. J Med Microbiol 1995;42(2):127-32.  Back to cited text no. 43    
44.Nouwen JL, Boelens H, van Belkum A, et al. Human factor in Staphylococcus aureus nasal carriage. Infect Immun 2004;72(11):6685-8.  Back to cited text no. 44    
45.Cole AM, Tahk S, Oren A, et al Determinants of Staphylococcus aureus nasal carriage. Clin Diag Lab Immunol 2001;8:1064-9.  Back to cited text no. 45    
46.Herwaldt LA, Cullen JJ, French P, et al. Preoperative risk factors for nasal carriage of Staphylococcus aureus. Infect Control Hosp Epidemiol 2004;25(6):481-4.  Back to cited text no. 46    
47.Peacock SJ, Justice A, Griffiths D, et al. Deter­minants of acquisition and carriage of Staphy­lococcus aureus in infancy. J Vlin Microbiol 2003;41:5718-25.  Back to cited text no. 47    
48.Parnaby RM, O'Dwyer G, Monsey HA, et al. Carriage of Staphylococcus aureus in the elderly. J Hosp Infect 1996;33(3):201-6.  Back to cited text no. 48    
49.Lipsky BA, Pecoraro RE, Chen MS, et al. Factors affecting staphylococcal colonization among NIDDM outpatients. Diabetes Care 1987;10(4):483-6.  Back to cited text no. 49    
50.Chapoutot C, Pageaux GP, Perrigault PF, et al. Staphylococcus aureus nasal carriage in 104 cirrhotic and control patients. A prospective study. J Hepatol 1999;30:249-53.  Back to cited text no. 50    
51.Nguyen MH, Kauffman CA, Goodman RP, et al. Nasal carriage of and infection with Staphy­lococcus aureus in HIV-infected patients. Ann Intern Med 1999;130(3):221-5.  Back to cited text no. 51    
52.Yu VI, Goetz A, Wagner M, et al. Staphy­lococcus aureus nasal carriage and infection in patients on hemodialysis. Efficacy of antibiotic prophylaxis. N Engl J Med 1986;315:91-6.  Back to cited text no. 52    
53.Kirmani N, Tuazon CU, Murray HW, Parrish AE, Sheagren JN. Staphylococcus aureus carriage rate of patients receiving long-term hemodialysis. Arch Intern Med 1978;138: 1657-59.  Back to cited text no. 53  [PUBMED]  
54.Luzar MA, Coles GA, Faller B, et al. Staphy­lococcus aureus nasal carriage and infection in patients on continuous ambulatory peritoneal dialysis. N Engl J Med 1990;322(11):505-9.  Back to cited text no. 54    
55.Kaliner MA. Human nasal respiratory secre­tions and host defense. Am Rev Respir Dis 1991;144(3.2):S52-6.  Back to cited text no. 55    
56.Nagaoka I, Hirota S, Yomogida S, Ohwada A, Hirata M. Synergistic actions of antibacterial neutrophils defensins and cathelicidins. Inflamm Res 2000;49(2):73-9.  Back to cited text no. 56    
57.Ong PY, Ohtake T, Brandt C, et al. Endo­genous antimicrobial peptides and skin infec­tions in atopic dermatitis. N Engl J Med 2002; 347(15):1151-60.  Back to cited text no. 57    
58.Peschel A. How do bacteria resist human anti­microbial peptides? Trends Microbiol 2002;10 (4):179-86.  Back to cited text no. 58    
59.Jin T, Bokarewa M, Foster T, Mitchell J, Higgins J, Tarkowski A. Staphylococcus aureus resists human defensins by production of staphylokinase; a novel bacterial evasion mechanism. J Immunol 004;172(2):1169-76.  Back to cited text no. 59    
60.Peschel A, Jack RW, Otto M, et al. Staphylococcus aureus resistance to human defensins and evasion of neutrophils killing via the novel virulence factor MprF is based on modification of membrane lipids with I-lysine. J Exp Med 2001;193(9):1067-76.  Back to cited text no. 60    
61.Bera A, Herbert S, Jakob A, et al. Why are pathogenic staphylococci so lysozyme resis­tant? The petidoglycan O-acetyltransferase OatA is the major determinant for lysozyme resistance of Staphylococcus aureus. Mol Microbiol 2005;55:778-87.  Back to cited text no. 61    
62.Kaplowitz LG, Comstock JA, Landwehr DM, Dalton HP, Mayhall CG. Prospective study of microbial colonization of the nose and skin and infection of the vascular access site in hemo­dialysis patients. J Clin Microbiol 1988;26(7): 1257-62.  Back to cited text no. 62    
63.Rebel MH, Van Furth R, Stevens P, et al. The flora of renal hemodialysis shunt sites. J Clin Pathol 1975;28(1):29-32.  Back to cited text no. 63    
64.Nielsen J, Landefoged SD, Kolmos HJ. Dia­lysis catheter-related septicemia-focus on Staphylococcus aureus septicemia. Nephrol Dial Transplant 1998;13(11):2847-52.  Back to cited text no. 64    
65.Goldblum SE, Ulrich JA, Goldman RS, Reed WP. Nasal and cutaneous flora among hemo­dialysis patients and personnel: Quantitative and qualitative characterization and patterns of Staphylococcus carriage. Am J Kidney Dis 1982;2(2):281-6.  Back to cited text no. 65    
66.Boelaert JR, De Baere YA, Geernaert MA, Godard CA, Van Landuyt HW. The use of nasal mupirocin ointment to prevent Staphy­lococcus aureus bacteraemias in hemodialysis patients: an analysis of cost-effectiveness. J Hosp Infect 1991;19(suppl B):41-6.  Back to cited text no. 66  [PUBMED]  
67.Boelaert JR, Van Landuyt HW, Godard CA, et al. Nasal mupirocin ointment decreases the incidence of Staphylococcus aureus bacte­raemias in hemodialysis patients. Nephrol Dial Transplant 1993;8(3):235-9.  Back to cited text no. 67    
68.Bloom BS, Fendrck AM, Chernew ME, Patel P. Clinical and economic effects of mupirocin calcium on preventing Staphylococcus aureus infection in hemodialysis patients: a decision analysis. Am J Kidney Dis 1996;27(5):687-94.  Back to cited text no. 68    
69.Kluytmans JA, Manders MJ, van Bommel E, Verbrugh H. Elimination of nasal carriage of Staphylococcus aureus in hemodialysis patients. Infect Control Hosp Epidemiol 1996;17(12): 793-7.  Back to cited text no. 69    
70.Davies SJ, Ogg CS, Cameron JS, Poston S, Noble WC. Staphylococcus aureus nasal carriage, exit-site infection and catheter loss in patients treated with continuous ambulatory peritoneal dialysis (CAPD). Perit Dial Int 1989;9(1):61-4.  Back to cited text no. 70    
71.Sesso R, Draibe S, Castelo A, et al. Staphy­lococcus aureus skin carriage and development of peritonitis in patients on continuous ambulatory peritoneal dialysis. Clin Nephrol 1989;31:164-8.  Back to cited text no. 71    
72.Lye WC, Leong SO, van der Straaten J, et al. Staphylococcus aureus CAPD-related infections are associated with nasal carriage. Adv Perit Dial 1994;10:163-5.  Back to cited text no. 72  [PUBMED]  
73.Wanten GJ, van Oost P, Schneeberger PM, et al. Nasal carriage and peritonitis by Staphy­lococcus aureus in patients on continuous ambulatory peritoneal dialysis: a prospective study. Perit Dial Int 1996;16(4):352-6.  Back to cited text no. 73    
74.Zimakoff J, Bangsgaard Pederson F, Bergen L, et al. Staphylococcus aureus carriage and infections among patients in four hemo-and peritoneal dialysis centers in Denmark. J Hosp Infect 1996;33(4):289-300.  Back to cited text no. 74    
75.Perez-Fonta M, Rosales M, Rodriguez­Carmona A, et al. Treatment of Staphylo­coccus aureus nasal carriage in CAPD with mupirocin. Adv Perit Dial 1992;8:242-5.  Back to cited text no. 75    
76.Thodis E, Bhaskaran S, Pasadakis P, et al. Decrease in Staphylococcus aureus exit-site infections and peritonitis in CAPD patients by local application of mupirocin ointment at the catheter exit site. Perit Dial Int 1998;18(3): 261-70.  Back to cited text no. 76    
77.Mylotte JM, Kahler L, Jackson E. "Pulse" nasal mupirocin maintenance regimen in patients undergoing continuous ambulatory peritoneal dialysis. Infect Control Hosp Epidemiol 1999;20(11):741-5.  Back to cited text no. 77    
78.Thodis E, Passadakis P, Panagoutsos S, Bacharaki D, Euthimiadou A, Vargemezis V. The effectiveness of mupirocin preventing Staphylococcus aureus in catheter-related infections in peritoneal dialysis. Adv Perit Dial 2000;16:257-61.  Back to cited text no. 78  [PUBMED]  
79.Al-Khayat MH. The Right Path to Health. Health Education through Religion: an Islamic Perspective. WHO East Mediter Health J 1997;7:1-32.  Back to cited text no. 79    
80.Hashim AO, Al-Khayat MH. The Right Path to Health. Islamic Ruling. WHO East Mediter Health J 2004;9:325-31.  Back to cited text no. 80    

Correspondence Address:
Abdulla K Al-Hwiesh
King Fahd University Hospital, P.O. Box 40246, Al-Khobar, 31952
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None

PMID: 18711288

Rights and PermissionsRights and Permissions


  [Figure 1]

  [Table 1], [Table 2]


    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
  Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

    Patients and Methods
    Statistical analysis
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded1180    
    Comments [Add]    

Recommend this journal