Silver-Impregnated Dressings for Catheter Exit-Site and Tunnel Infections in Peritoneal Dialysis Patients

Catheter exit-site infection (ESI) and tunnel infection (TI) are significant complications in patients undergoing peritoneal dialysis (PD) and remain important contributors to peritonitis, catheter loss, technique failure, and unplanned transition to haemodialysis. These complications negatively impact patient outcomes and confidence in PD as a long-term renal replacement therapy.

Current guideline-recommended management of catheter exit-site and tunnel infection includes daily exit-site cleansing with antiseptic agents, application of topical antibiotics (such as gentamicin or mupirocin), sterile dressing coverage, and systemic antibiotic therapy guided by microbiological results. Despite adherence to these measures, catheter-related infections continue to occur, and a substantial proportion of patients experience persistent or recurrent infection, catheter trauma from frequent manipulation, local skin irritation, or delayed wound healing.

Silver-impregnated dressings have been widely used in acute and chronic wound management because of their sustained broad-spectrum antimicrobial activity. Silver ions act through multiple mechanisms, including disruption of bacterial cell membranes, interference with enzymatic activity and DNA replication, and inhibition of biofilm formation. These mechanisms reduce microbial burden and may lower the risk of antimicrobial resistance associated with prolonged topical antibiotic exposure. Silver dressings provide continuous antimicrobial coverage over several days and may reduce the need for frequent dressing changes and repeated catheter manipulation. These properties support their potential role as an alternative approach to local exit-site management during active catheter-related infection.

This study is designed as a prospective, single-centre, pilot, randomised controlled trial to evaluate the feasibility and acceptability of using silver-impregnated dressings in place of standard daily topical antibiotic exit-site dressings for the management of catheter exit-site infection or tunnel infection in adult PD patients. The study also explores infection resolution, safety, and catheter-related clinical outcomes associated with this alternative exit-site care strategy.

A total of 60 adult participants with clinically diagnosed exit-site infection or tunnel infection will be recruited from the Singapore General Hospital Peritoneal Dialysis Programme, including both inpatient and outpatient settings. Eligible participants will be randomly assigned in a 1:1 ratio to one of two study arms: (1) silver-impregnated dressing for exit-site care, or (2) standard exit-site care with daily topical antibiotic dressing. Randomisation will be computer-generated and performed without stratification. The study is open-label, as blinding of participants and investigators is not feasible due to the nature of the interventions.

All participants will continue to receive systemic antibiotic therapy for exit-site or tunnel infection according to current institutional practice and clinical guidelines. The assigned dressing intervention applies only to local exit-site management.

Participants assigned to the silver-impregnated dressing arm will receive exit-site care using a silver-based dressing applied in accordance with manufacturer instructions and the study protocol. Exit-site cleansing will be performed using non-iodine-based antiseptic agents to avoid interference with the antimicrobial properties of silver. Dressing-change frequency will be guided by clinical assessment of exudate and infection status and is expected to be less frequent than daily dressing changes during active infection.

Participants assigned to the standard care arm will receive routine institutional exit-site care, consisting of antiseptic exit-site cleansing, application of topical antibiotic ointment, and coverage with a standard dressing. Dressing changes in this group will be performed daily or as required according to usual clinical practice.

Participants will be followed for up to twelve weeks, corresponding to the period of active infection management and early recovery. Scheduled follow-up visits will include routine exit-site assessment, documentation of infection status, and monitoring for adverse events. These visits are aligned with standard clinical follow-up to minimise additional participant burden. Infection resolution, recurrence, and catheter-related outcomes will be assessed through clinical evaluation and review of medical records.

Feasibility outcomes include the ability to recruit and retain participants, adherence to the assigned dressing protocol, and completion of scheduled visits. Acceptability will be assessed using participant-reported experience measures addressing comfort, usability, and satisfaction with the assigned exit-site dressing. Safety assessments include monitoring for dressing-related adverse events such as local skin irritation, hypersensitivity reactions, or other complications.

As a pilot study, this trial is not powered to detect definitive differences in clinical efficacy. Rather, it is intended to generate preliminary data on feasibility, safety, adherence, and patient acceptability of silver-impregnated dressings as an alternative to standard daily topical antibiotic exit-site care. The findings will inform the design and planning of future larger, adequately powered studies to evaluate clinical effectiveness, long-term outcomes, and cost-effectiveness.

• Participant reported acceptability of assigned dressing intervention [Time frame: At 6 weeks following enrolment.]
• Time to clinical resolution of catheter exit site or tunnel infection [Time frame: Up to 6 weeks following randomisation]
• Number of participants with dressing related adverse events [Time frame: Up to 12 weeks following randomisation.]
• Occurrence of infection related clinical outcomes [Time frame: Up to 12 weeks following randomisation.]