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Nasal hygiene in patients with end-stage renal disease

Zhao Fan

Dialysis Department of Nephrology Hospital, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710061, P.R. China

Baiya Li

Dialysis Department of Nephrology Hospital, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710061, P.R. China

Department of Otorhinolaryngology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China

E-mail : lby0929@163.com

DOI: 10.15761/IMM.1000181.

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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

References

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Editorial Information

Editor-in-Chief

Masayoshi Yamaguchi
Emory University School of Medicine

Article Type

Short Communication

Publication history

Received date: October 28, 2015
Accepted date: November 17, 2015
Published date: November 20, 2015

Copyright

©2015 Fan Z. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Fan Z, Li B (2015) Nasal hygiene in patients with end-stage renal disease. Integr Mol Med 2: DOI: 10.15761/IMM.1000181.

Corresponding author

Baiya Li

No. 277 Yanta West Road, Xi’an, Shaanxi Province, PR-China, 710061, Tel: 86-177-9182-4589.

E-mail : lby0929@163.com

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