This is a descriptive cross-sectional observational study conducted between 2022 June and July, targeting young nephrologists. These nephrologists were required to complete an anonymous online questionnaire. A total of 65 questionnaires were sent to various physicians (residents-in-training and hospital–university assistants). Forty-four physicians (67.69%) responded to the questionnaire.

The questionnaire consisted of 11 questions: four regarding the physicians’ status and the training they received concerning PD, and seven on the prevention of infections in PD. There were 10 single-choice questions and one multiple-choice question.

The questionnaire focused on the following themes:

• Prophylactic antibiotic therapy and infections

• Technical procedures and infections

• Screening for nasal carriage of Staphylococcus aureus and its eradication

• Timing of the first dressing change

• Systematic local antibiotic therapy and infections

The seven questions assessing the theoretical and practical knowledge of young nephrologists (residents and hospital–university assistants) regarding the prevention of infections in PD were scored on a scale of 0 to 7. Each question was scored as either correct (1 point) or incorrect (0 points). There was no partial credit: 0 points for an incorrect response and 1 point for a correct response. The total score ranged from 0 to 7.

The questionnaire was distributed to young nephrologists via email and through social media platforms. Responses were collected using the Google Forms interface and through email for analysis.

We computed simple frequencies and relative frequencies (percentages) for qualitative variables. For quantitative variables, we calculated means, medians, and standard deviations and identified extreme values.

Thirty-four physicians (77.27%) who responded to the questionnaire are residents. The distribution of residents according to residency year is shown in Figure 1.

Ten physicians (22.73%) are hospital–university assistants. The distribution of physicians according to assistantship year is shown in Figure 2.

In response to this question, 50% of the respondents answered that they did not receive specialized training. Moreover, 22 physicians had received training from Baxter in PD, and one physician obtained a university diploma in PD. Only one physician received two types of specialized training (university diploma in PD and Baxter training in PD).

Question 4: Have you undergone training in peritoneal dialysis during your practice?

Among the respondents, 40.9% said that they had not undergone training in PD for a period lasting at least 3 months.

Descriptive study of questions regarding theoretical and practical knowledge on the prevention of infections in peritoneal dialysis

Regarding this question, 63.6% of physicians incorrectly answered yes, stating that burying the catheter under the skin until the need to initiate renal replacement therapy reduces the incidence of exit-site infections.

Among the participants, 90.9% (n = 40) answered this question correctly.

Responses were divided: 59.1% answered affirmatively, suggesting systematic screening for nasal carriage of S. aureus should be done.

Responses were also divided: Slightly more than half of the participants (54.5%; n = 24) answered no to this question.

Seventy-one physicians (81.80%) answered this question correctly.

According to 68.2% of the surveyed physicians (n = 30), it is necessary to change the first dressing sometime after placement, typically approximately 7 days after.

To this question, 72.7% responded affirmatively that adding a local antibiotic reduces the risk of infection.

Preoperative antibiotic prophylaxis is recommended to reduce the risk of infections, particularly early peritoneal infections. A clinical trial by Gadallah et al. [6]demonstrated that antibiotic prophylaxis significantly reduces peritoneal infection rates though it does not affect exit-site infections. Recent guidelines from the Indian Society of Peritoneal Dialysis [7]and ISPD [5], supported by randomized trials [8], also recommend systemic antibiotic administration before catheter insertion. Antibiotic prophylaxis should be brief, typically lasting less than 24 h, and should be tailored to local ecology covering enterobacteria and common Gram-positive skin flora. Notably, the majority of organisms cultured from catheter exit-site swabs are Gram-positive bacteria commonly found on the skin, such as S. aureus, coagulase-negative Staphylococcus spp., and Streptococcus spp. [9][10][11].

In 1991, Moncrief and Popovich introduced a new technique for implanting PD catheters. The technique involves a coiled tip, two cuffs, and an arched bend to prevent fluid leakage [18]. Further, the external segment of the catheter is buried in a subcutaneous tunnel for 4 to 6 weeks before exteriorizing it. This method aims to promote tissue growth around cuffs, reducing bacterial colonization and peri-catheter infections [12]. Despite its benefits in extending catheter lifespan and reducing some infections, burying the catheter is not recommended by ISPD for preventing exit-site infections or peritonitis [5][7]. Furthermore, opinions are divided on the Moncrief method for catheter implantation. Some studies suggest it may increase catheter lifespan and reduce peri-catheter infections [13]. However, Osako et al. reported a 3.3% incidence of exit-site and tunnel infections within 2 weeks of using this technique, with an incidence of catheter malfunction of 1.9% due to occlusion [14]. ISPD has found insufficient evidence supporting reduced peritonitis rates due to the use of buried catheters [15].

The first dressing change after the placement of a PD catheter marks a crucial moment in a patient’s care. This change is typically done 5 to 7 days post-surgery, allowing time for initial healing to begin. It is important to perform the dressing change in a sterile environment to minimize the risk of infection, which could lead to complications such as peritonitis. The change process involves careful removal of the old dressing, inspection of the catheter site for any signs of infection or poor healing, and the application of a new sterile dressing. This step is essential in ensuring the long-term success of PD treatment.

There is ongoing debate over the ideal time to start peritoneal dialysis (PD) following catheter insertion. The Timely study found higher rates of peritoneal fluid leaks when PD began one week post-insertion compared to waiting two to three weeks [16][17]. Further, Leblanc et al. (2001) associated these leaks with exit-site infections and peritonitis [17]. Currently, we wait three weeks before using the PD catheter. If renal replacement therapy is needed sooner, we opt for intermittent hemodialysis. Delaying the first dressing change to seven days in routine practice has reduced catheter mobilization, minimizing leaks and peritonitis cases. Although guidelines are lacking, 68.2% of young nephrologists advocate for a seven-day delay, which may be considered acceptable given the absence of guidelines in this regard.

Systematic screening for nasal carriage of S. aureus after catheter placement is not recommended by medical societies [5][6][7]. Nasal carriage of S. aureus is frequent but intermittent, and a negative sample does not rule out a diagnosis.

The systematic eradication of nasal carriage of S. aureus is also not recommended for patients undergoing PD. The mupirocin group study, which included 1144 PD patients across 9 European centers, found that nasal mupirocin did not reduce tunnel infections or peritonitis incidence. ISPD recommends screening before PD catheter insertion (Grade 2D) and suggests nasal mupirocin application (Grade 1B) if carriage is detected to reduce exit-site infection risk though the insertion does not affect peritonitis risk [19].

Amato et al. demonstrated identical genotypic S. aureus at both exit sites and in peritonitis [20]. Eradicating catheter exit site carriage prevents tunnel infections and peritonitis [7]. The administration of oral rifampicin, 600 mg daily for 5 days every 3 months, reduces exit site infections but not peritonitis and has high adverse effects [21]. Moreover, meta-analysis shows mupirocin reduces S. aureus infections by 72% and peritonitis by 40% [22]. Local mupirocin has equivalent efficacy to systemic rifampicin but with fewer adverse effects [23]. Notably, resistance to mupirocin has been reported in recent years, primarily with intermittent use rather than daily application [24][25]. Piraino found high numbers of Pseudomonas with mupirocin [26]. Gentamicin cream is comparable to mupirocin: gentamicin also reduces infection incidence [27].

ISPD recommends daily topical application of mupirocin or gentamicin at the catheter exit site (Grade 1B) [15]. Application of mupirocin at the catheter exit site reduces the incidence of S. aureus peritonitis, while gentamicin application reduces infections caused by gram-negative bacilli and S. aureus, providing a viable alternative to mupirocin cream [7]. However, in Tunisia, mupirocin cream is not available. In current practice, Tunisian nephrologists disinfect the exit site using povidone-iodine but do not apply local antibiotics.

Education for patients and healthcare professionals is crucial, and at least 3 sessions per patient are recommended. Moreover, ISPD and the Indian Society of Peritoneal Dialysis recommend qualified nursing staff (grade 1C) administer PD [5][6][7]. Additionally, emphasis is placed on connection learning during education and post-infection re-education. “Flush before fill” reduces peritoneal infections (grade 1A) [15].

In Tunisia, there is a lack of dedicated videos or brochures for patient education, hindering program adherence.