Avoiding “the August Infections” in PD
It’s summer, and many of us are enjoying the season by soaking up sunshine, spending more time outdoors, and vacationing. Warmer weather means more sweating. More sweating means more bacteria. For PD patients, this combination can mean more chances for exit site infection, or even peritonitis.
Old-School Cool
I used to work with a PD nurse who would joke that she had been around “since PD was invented.” It wasn’t an exaggeration.
She told me stories about how PD solutions used to come in glass bottles with rubber stoppers and she was always terrified of dropping one—but never did—and how the switch from glass to plastic changed how we use IP insulin. That’s a memorable tale, because it used to be common practice to add insulin to the dialysate of CAPD patients, but we don’t anymore, mostly because insulin sticks to the inside of the plastic bag which causes loss of potency and unpredictable underdosing. Crazy, right?
Anyway, she retired a few years ago, after more than four decades of being a very active PD nurse. She had a “little black book” with the initials of several hundred people she had taught. I am fairly certain she saw pretty much everything there was to see clinically, and am really grateful to have learned so much “by osmosis” and working alongside her.
As we round out the end of July and move into August, I keep reflecting on a term she would use every summer: “the August Infections;” her way of describing clusters of exit site irritations, inflammations, and infections she would see annually at the peak of summer when the heat, sweat, grit, and activities started to catch up with active patients. She taught and reviewed practical summertime safety with patients at clinic visits, and I think it’s wise to continue.
Swimming in…What?!
Every PD nurse I know has a spiel about bathing and swimming for patients, and we all say essentially the same things:
Do not bathe, swim, or otherwise expose the catheter or exit site to untreated freshwater. This includes lakes, ponds, rivers, streams, creeks, puddles, and everything in between. The water can (and probably does) contain a host of germs that increase the risk for infection.
A quick story I like to tell: I live near a popular vacation town that is situated around a beautiful lake. Every year, tourists flock into town and spend time sunning on the sandy public beaches and frolicking in the water. Also, every year, the DEC eventually closes the beach because sewage runs into the lake after it rains. There have also been incidents where private boats have dumped their waste in, too. There is frequently a high concentration of e-coli at the lake, and there are clear signs located on the beach informing the public of this. People swim in it anyway. That is gross, but it happens all the time. Don’t be those people!
It helps to understand why rules exist. This is why. It’s poop. Freshwater is full of 💩.
Avoid hot tubs, public swimming pools, water parks, splash pads and baths. All of this water has the potential to be just as contaminated (if not more) as the lake because a tiny bit of residual poop on a person’s skin, infects all of the water. I think a fair way of estimating if water might be safe or not is by asking questions like:
Is it possible for someone to have used the bathroom in this water?
Has a child in a swim diaper ever been in this water?
Could a person have had diarrhea, left particles behind, and gone into this water?
Did every single person who used this water take a shower first?
How much do I trust the hygiene of all who swim here?
How much do I trust that whoever maintains cleanliness does so according to all recommendations?
When was the last time the water was tested?
If the answer to any of those questions gives you pause, it’s best to assume it’s unsafe to go in.
Fun gross fact: Chlorine doesn’t kill all bacteria. It’s a misconception to think that a pool is sanitary just because it smells like chlorine—actually, that can be a sign that a pool or hot tub is extra contaminated. Cryptosporidium is a bacteria found in poop that can live in a well-maintained chlorinated pool for an entire week! Even healthy people get UTIs, ear infections, rashes, and gastroenteritis from enjoying water that was supposed to be clean. The CDC has basic public safety information about preventing swimming-related illness that everyone should read.
I guess what I’m trying to say is…communal water is usually also full of 💩
Meticulously maintained private chlorinated pools are safe. It takes a lot of work to properly maintain a pool, but it’s worth it to know the water is clean! To err on the side of caution, it’s often recommended that patients who swim cover their exit site with an occlusive, waterproof dressing while submerged. Some use an ostomy bag or dedicated catheter cover device.
The ocean is generally considered safe, and is…sometimes. Salt water is safe in theory, but because of pollution that is not always a guarantee. Be aware that coastal beach areas can be contaminated by freshwater, sewage, and pathogens like Cyanobacteria that cause algae blooms—especially after storms or flooding. The EPA has basic public safety information about beach health to review, and NOAA advises to stay aware of local beach advisories and closures.
Full exit site care should be performed immediately after any water-based activity—even showering.
Sweaty Skin Flora
“The August infections” aren’t limited to people who are exposed to unclean water. Everyone’s skin is teaming with microbes. It’s normal for us to have bacteria like Staphylococcus on us, tons of them. Everywhere. The heat of summer makes us sweat, and if our skin flora had feelings, they would absolutely love this weather. Warm and moist environments make bacteria so very happy.
Here are some facts:
Even a clean exit site under a sterile dressing can’t escape humidity. Exit sites and catheters with direct access to a sterile peritoneum don’t belong next to a soggy, boggy, dressing. The skin does not need a mini sauna treatment. Moisture that builds under the dressing can harbor germs that lead to an infection.
Normal skin flora can migrate from the exit site, down the tunnel, and into the peritoneum, infecting everything along the way. This is easier to do when the environment is wet. Sweat is wet.
Location of an exit site matters. Patients who are overweight, and/or have a PD catheter placed in a skin fold are at an even higher risk of getting an infection from trapped moisture. These patients should be advised to let the exit site “breathe” when possible to dry it out.
It’s not just bacteria we need to be concerned with. Exit site infections can be caused by yeasts too. These infections are often complicated and may lead to the loss of the catheter.
Full exit site care should be performed immediately after any “wet” activity, exercise, or even being outside in warm weather. Removing a sweaty dressing after an outing is like changing out of a wet swimsuit and into clean, dry clothes. It makes sense, and it’s more comfortable. Dampness increases the risk of infection and everything is more likely to be damp in the summer.
The Grit: Dirt and Sand
Spending time outdoors is good for us! But, some basic precautions can go a long way in preventing an unnecessary infection.
It’s a good idea for patients who do activities like camping, gardening, yardwork, or sunbathing to increase their usual hand-washing habits to avoid accidentally transferring germs from the environment to the exit site during routine care. You might suggest that they:
Consider using disposable gloves when working outside to reduce how dirty hands get in the first place. It’s not a substitution for proper hand-washing, but it can save some time.
Fingernails are a good way to gauge overall hygiene. Remind patients to clean and scrub under their finger nails, between their fingers, and around their thumbs.
Wear a dressing if there is a chance of getting dirty from being outside. The dressing acts as a protective barrier to the catheter site.
Wash hands thoroughly when finished working or playing outside. Shower, and remove the soiled dressing.
Perform full exit site care immediately after any outdoor activity. Think of it as changing out of a dusty t-shirt. Do not let a PD catheter come into direct contact with nature. Cover it!
10 Pieces of Good PD Catheter Advice for Your Patients
Know what your well-healed exit site looks like. Have photos in case you have to compare.
Keep your exit site clean and dry. Moisture makes infections more likely.
Protect the exit site from the outside world. Sand, soil, water, and sweat can all play a role in starting an infection and don’t belong near your catheter.
Unclean water can contain dangerous germs, do not swim, splash, soak, or bathe in it.
Be ready to increase exit site care during the summer. Have fresh, clean, supplies with you if you’re going out for the day.
Always use anchor tape to avoid injury (pulling and tugging) to the exit site. If the anchor tape comes loose, apply new tape to dry skin as soon as possible.
It takes more time to clear an infection than it does to prevent one. Time spent on good exit site care is worth it.
Check your exit site at least every day and contact your nurse immediately if your exit site or tunnel is red, irritated, or swollen.
Hand-hygiene is one of the best ways to prevent the spread of germs and infections.
When a PD catheter is open, close windows and vents. Turn off fans and air conditioners. Wear a mask. Contamination can come from the air.
We want patients to be out living their lives to the fullest. That includes enjoying (almost) everything the season has to offer. But there are some risks that can ruin plans and complicate an otherwise stable PD situation. Avoiding infectious complications during the summer sometimes requires extra work, but as the proverb goes, “an ounce of prevention is worth a pound of cure.”
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