복막 투석 환자에서 도관 관련 감염 및 복막염에 대한 Mupirocin 과 Catheter Revision 의 효과

정항재(Hang Jae Jung),도준영(Jun Young Do),윤경우(Kyung Woo Yoon),박준범(Jun Bum Park),조규향(Kyu Hyang Jo),김정미(Jung Mi Kim),최준혁(Jun Heuk Choe),김영진(Yeung Jin Kim) 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.3

N/A Background: Exit site/tunnel infection causes con-siderable morbidity and technique failure in CAPD patients. We presently use a unique revision method for the treatment of refractory ESl/TI in CAPD patients and mupirocin prophylaxis for high risk patients. Methods : We reviewed one hundred-thirty nine CAPD patients about the ESI/TI from Qctober 1993 to February 1999 at Yeungnam University Hospital. At the beginning of the ESI, we usually started me-dications with rifampicin and ciprofloxacin and then changed the antibiotics according to the sensitivity test. If the ESI had persisted and there were TI symptoms(purulent discharge, abscess lesion around exit site), we performed catheter revision(external cuff shaving, disinfection around tunnel and new exit site on opposit direction) with a combination of proper antibiotics. We applied local mupirocin ointment at the exit site three times per week to the 34 patients who had the risk of ESI starting from October 1998. Results : The total follow-up was 2401 patient months(pt.mon). ESI occurred on 105 occasions in 36 out of 139 patients, and peritonitis occurred on 112 occasions in 67 out of 139 patients. Cumulative incidence of ESI and peritonitis was 1 per 23.0 pt.mon and 1 per 21.6 pt.mon. The most common organism responsible for ESI was Staphylococcus aureus(26 of 54 isolated cases, 43%), followed by Methicillin resistant S. aureus(MRSA)(13 cases, 24%). Seven patients (5: MRSA, 2: Pseudomonas) had to be treated with a revision to control infection. Three patients experienced ESI relapse after revision. One of them im-proved with antibiotics, while another needed a second revision and the remaining required catheter removal due to persistent MRSA infection with re-insertion at the same time. But, there was no more ESI in these 3 patients who were received management to relapse(The mean duration : 14.0 months) The rates of ESI were more reduced after using mupi-rocin than before(l per 12.7 vs 34.0 pt.mon, p<0.01). Conclusion: In summary, revision technique can be regarded as an effective method for refractory ESI/TI before catheter removal. Also local mupirocin ointment can play a significant role in the prevention of ESI.

복막 투석중인 만성 신부전 환자의 혈압 조절에 관한 연구

정항재,배성화,박준범,조규향,김영진,도준영,윤경우 영남대학교 의과대학 1999 Yeungnam University Journal of Medicine Vol.16 No.2

Background and Methods: In order to evaluate characteristics and modulatory factors of blood pressure in peritoneal dialysis(PD), studies were conducted on the 69 patients who had underwent peritoneal equilibration test(PET). Results: The results were as follows; 1) All patients received an antihypertensive drug before PD. but, 15 of 69 patients successfully quit taking the antihypertensive drug after peritoneal dialysis. 2) During peritoneal dialysis. mean artcrial pressure(MAP) was significantly decreased for the first 3 months, and this lasted for 1 year. and antihypertensive drug requirpments were significantly decreased continuously up to 9 months(p<0.05). 3) After changing the modality from hemodialysis to peritoneal dialysis, MAP(mmHg. from 107 0±4.5 to 98.6±8.8, p<0.05), antihypertensive drug requirements(from 5.6±2.6, to 2.0±2.5, p<0.01) and erythropoietin dosages(Uint/week, from 4600±2660 to 2000±1630, p<0.05) were decreased. 4) Multiple logistic regression analysis showed that MAP(p<0.01) and daily ultrafiltration volume(p<0.05) can contribute to the determination of antihypertensive drug requirements. However the relationship between antihypertensive drug requirements and PET results or dialysis adequacy indices(weekly Kt/V, weekly creatinine clearance) was not revealed. Conclusion: In conclusion, the prescription of antihypertensive drugs should be considered according to daily ultrafiltration volume, especially during first year after initiating PD, and follow-ups for over a year may be needed.

복막 평형 검사에 영향을 주는 인자 및 시행시기에 관한 분석

정항재,조규향,박준범,배성화,김영진,도준영,윤경우 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.4

The peritoneal equilibration test(PET) is used as a tool for determining the characteristics of the peritoneal membrane. Initial PET is recommended at least 1 month after peritoneal dialysis, but PET after 1 month may be difficult to perform on an out- patients basis. Two standard PETs(D/P4Cr) were performed in 60 CAPD patients(DM:non DM=22:38). Initial PETs, within one week after starting CAPD and follow up PETs, at least 3 months after CAPD were performed. The initial PET values were compared with subsequent PET values. Clinical data (age, sex, body surface area, BMI, presence of diabetes mellitus, ascites) and laboratory indices(serum albumin, dialysate creatinine clearance, KT/V, protein catabolic rate) were compared with the results of the PETs. In initial PET result, there was negative correlation between D/P4Cr and serum albumin(r=-0.522, p$lt;0.001 N=60). There was no significant difference between initial and follow up(mean±S.D.:8.84±5.2months after CAPD) D/P4Cr(0.68±0.14 vs 0.68±0.13). But with pge of time, delta D/P4Cr and delta serum albumin were also negatively correlated (r=-0.459, p$lt;0.001). According to the linear regression analysis, the factor significantly associated with D/P4Cr was serum albumin(coefficients -0.111). In conclusion, serum albumin level is the most important predictor of the peritoneal membrane transport characteristics, and it seems that the timing of PET does not matter, rather the changes of with time are strongly correlated with the changes of the serum albumin level.

MRI상 다발성 병변을 보인 Neuro-Behcet병 1예

박형국,정항재,조상걸,이광호 순천향대학교 1990 논문집 Vol.13 No.3

We describe a case of Neuro-Behcet's disease with recurrent meningoencephalitis in which MRI showed multiple high-signal lesions in the thalamus, frontal and parietal lobes, and brainstem on T2-weighted image. Treatment with prednisolone was acompanied by marked improvement of the patient's clinical status.

말초혈액 조혈모세포 채집 시기를 결정하기 위한 예측지표의 평가

김병덕,이은영,정항재,최재혁,이상엽,류헌모,이경희,현명수 대한조혈모세포이식학회 1999 대한조혈모세포이식학회지 Vol.4 No.1

연구배경: 자가 말초혈액 조혈모세포 이식술은 다양한 혈액질환과 항암 화학요법에 반응하는 고형종양의 치료에 있어 고용량의 화학요법 후 골수기능 재건에 종전의 골수 조혈모세표의 대체원으로 광범위하게 사용되고 있다. 그러나 자가 말초혈액 조혈모세포 이식술은 말초혈액 내로 조혈모세포가 최대한 가동화된 시기를 포착하여 최소의 백혈구분반술로 최대의 조혈모세포를 채집하는 것이 필수적이다. 본 연구자는 본원에서 혈액종양과 고형종양으로 자가 말초혈액 조혈모세포 이식술을 시행하기 위해 백혈구분반술을 시행한 환자를 대상으로 채집직전에 말초혈액에서 CD34^(+) 세포 수, 단핵구 수, 백혈구 수를 측정하고 채집된 조혈모세포 부유액 내의 CD34^(+) 세포수와 CFU-GM치 등과의 상관관계를 비교 분석함으로써 조혈모세포의 가동화 시기를 가장 정확히 예측하여 백혈구분반술 시행의 최적 시기를 예측할 수 있는 지표를 찾고자 하였다. 방법: 영남대학병원 내과에 입원하여 자가 말초혈액 조혈모세포이식술을 시행할 예정인 환자 12명을 대상으로 조사하였다. 본연구에서는 말초혈액의 백혈구수가 1-2×10^(6)/kg 이상으로 갑자기 증가하는 시기를 택하여 백혈구분반술을 시행하였고, 매일 한번씩 8-12L의 전혈(평균10 L)을 처리하여 성공적인 말초 조혈모 세포 이식에 필요한 최소한의 CD34^(+) 세포수로 알려진 2-5×10^(6)/kg 이상으로 CD34^(+)세포가 채집될때까지 12명의 환자를 대상으로 총 55회의 백혈구 분반술을 시행하였다. 말초혈액의 백혈구 수, 단핵구 수, CD34^(+) 세포 수를 측정하여 채집된 조혈모세포 부유액 내의 CD34^(+) 세포수 혹은 CFU-GM 집락수와의 상관관계를 SPSS (SPSS, USA)를 사용하여 Pearson 상관계수로 처리하여 말초조혈모세포 채집시기 결정의 예측인자로서의 의미를 조사하였다. 결과: 총 12audd의 환자를 대상으로 환자당 2-6(평균 4.58회), 총 55예의 백혈구분반술을 시행하였고 백혈구분반술 1회당 평균 0.88±0.65×10^(6)/kg의 CD34^(+) 세포, 1.03±1.02×10^(8)/kg의 단핵구, 그리고 0.63±0.62×10⁴/kg의 CFU-GM을 얻을수 있었다. 말초혈액의 여러 지표 가운데 백혈구분반술 당일의 말초혈액 CD34^(+) 세포수(n=29)와 백혈구 수(n=55)가 조혈모세포 부유액내의 CD34^(+) 세포수와 통계학적으로 유의한 상관관계(r=0.433 and r=0.275, respectively)를 나타내었고, 말초혈액의 단핵구 수는 통계적으로 유의한 상관관계가 관찰되지 않았다. 결론: 말초혈액 조혈모세포 채집시기를 결정을 위한 여러 예측인자 중에서 말초혈액의 CD34^(+) 세포 수 측정이 조혈모세포의 가동화를 예측할수 있는 가장 좋은 검사 방법으로 판단되었으나 기준이 되는 CD34^(+) 세포의 절대수 결정을 위해서는 더 많은 환자를 대상으로 연구가 필요할 것으로 생각된다. Background: Peripheral blood stem cell transplantation (PBSCT) has been widely used as a substitute of bone marrow transplantation in treatment of various hematologic disorders and solid tumors. To obtain enough peripheral blood stem cells (PBSC), ensuring successful transplantation with the least number of leukapheresis procedure, the optimal time for collection must be predicted as accurately as possible. We analyzed our experiences of PBSC collections and evaluated the peripheral blood parameters that may predict the PBSC yields. Methods: The study comprised 12 patients undergoing varied mobilization regimens with chemotherapy and G-CSF/GM-CSF for both soild tumors and haematological maligncies. Fifty- five PBSC harvests were collected. Full blood counts and CD34^(+) cell enumeration were performed assayed for full blood samples taken immediately prior to leukapheresis. All PBSC collections were number of CD34^(+) cells collected a single leukapheresis harvest were evaluated. Results: The white blood cell count on the day of harvest showed only weak correlation (r=0.27, p=0.04) with the total number of CD34^(+) cells more strongly correlated with CD34^(+) cells of corresponding apheresis product (r=0.44, p=0.01) Conclusion: Monitoring the circulating CD34^(+) cells in peripheral blood samples during a patient's mobilization regimen is a very useful predictor of when to collect PBSC to provide an adequate harvest of successful engraftment. But, because the CD34^(+) cell enumeration is not a standardized test between laboratories, it is important to evaluate the absolute level of peripheral blood CD34^(+) cells that predicts when to perform the leukapheresis.

지속성 외래 복막투석 환자에서 Vancomycin 복강 내 투여 후 발생한 화학성 복막염

김영진,박준범,정항재,조규향,도준영,윤경우 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.5

Background: Intraperitoneal(IP) vancomycin has been widely used for the treatment of peritonitis or exit-site infection associated with continuous ambulatory peritoneal dialysis(CAPD). However, some previous reports in the literature have suggested that IP administration of certain vancomycin may be associated with chemical peritonitis in CAPD patients. Methods: Between 1 February 1994 and 1 February 1997, 35 consecutive CAPD patients requiring treatment with intraperitoneal vancomycin for either exit-site infection or peritonitis in the Yeungnam University Hospital were recruited retrospectively into the study. We compared retrospectively the incidence of chemical peritonitis after using two different preparations of vancomycin from different pharmaceutical companies, namely vancocin CP^ⓡ and vancomycin^ⓡ. Results: Thirty-three cases(all 26 cases given vancocin CP^ⓡ and 7 out of the 9 cases given vancomycin^ⓡ) showed improvement. None of them developed fever, abdominal pain or cloudy dialysate. Out of the 9 cases given IP vancomycin^ⓡ, two who currently did not have abdominal pain and cloudy dialysis effluent develolped these symptom and sign at 5 and 6 hours after administration of IP vancomycin. The chemical peritonitis may be secondary to prolonged contact of the peritoneal membrane with one or more of the impurities present in vancomycin preparation. Conclusion: In summary, it is necessary for the nephrologists to be aware of the possible chemical peritonitis which can be caused by the impurities of certain brand of vancomycin.

혈액 투석 환자에서 나타나는 rHuEPO 저항성 빈혈에 대한 Desferrioxamine 의 장기 효과

윤경우,배성화,정항재,도준영,임상우 영남대학교 의과대학 1997 Yeungnam University Journal of Medicine Vol.14 No.2

신 부전 환자에게 발생하는 빈혈의 원인은 여러 가지가 있다. 그러나 rHuEPO를 투여할 시 이러한 요인들을 극복하고 빈혈을 교정할 수가 있다. 하지만 약 10%의 환자들에서는 고용량의 rHuEPO에도 불구하고 rHuEPO 저항성 빈혈을 나타낸다. 이러한 경우 DFO는 이러한 저항성을 극복할 수 있다고 하며, 이에 대한 기전은 아직 논란이 많다. 따라서 저자들은 DFO를 투여시 나타나는 여러 인자들을 고려해보고 기존의 보고보다 장기적인 관찰을 통하여 이러한 환자에게서 DFO가 빈혈을 교정할 수 있을지 여부를 알아보고 DFO가 rHuEPO 저항성 빈혈을 극복하는 기전을 추측해보고자 하였다. 영남대학교 의과대학 부속병원 투석실에서 투석을 시행하는 만성 신부전 환자 중 rHuEPO의 효과에 저항성을 나타내는 7명의 환자가 실험군(DFO+EPO)으로 정해지고, 다른 7명이 대조군으로 선정되었다. 실험군은 주당 4000 U의 고용량이 rHuEPO에도 불구하고 혈색소치가 9 g/dL이하 이며 출혈이나 철결핍성 빈혈같은 뚜렷한 원인 없이 정구성 정색소성 빈혈을 나타낸 환자들이었으며 대조군은 나이, 평균 투석 기간에 있어서 대조군과 차이를 보이지 않으며 rHuEPO에 비교적 적절한 반응을 보이는 환자들이었다. DFO는 8주간 rHuEPO와 함께 투여 되어 졌고 rHuEPO의 사용 용량은 지난 6개월의 평균 용량과 같게 투여 되었다(평균 사용 용량은 123.5 U/Kg/Wk). 8주간 DFO가 투여된 후 15개월간 혈색소치와 rHuEPO 사용 용량을 추적하였다. 이 15개월간은 각 개인의 혈색소치와 경제 사정에 의해 rHuEPO의 용량이 결정지어 졌다. 대조군에서는 같은 기간 실험군에서와 같은 방법으로 rHuEPO가 투여되어 졌으나 DFO는 사용되지 않았다. DFO가 투여된 15 개월의 추적기간은 Time I (DFO투여후 7개월간)과 Time II(Time I 이후 8개월간)으로 나누었다. 성적은 다음과 같다 : DFO 투여 전, 실험군의 평균 혈색소치는 대조군과(평균 8.2 g/dL) 같은 정도의(p>0.05) 수준인 7.8 g/dL 이었다. 하지만 rHuEPO의 사용 용량은 평균 123.5 U/Kg/Wk으로서 대조군의 그것(평균 41.6 U/Kg/Wk)보다 의미있게 많은(p<0.05) 용량을 사용하여 rHuEPO에 대한 저항성을 나타내었다. 하지만 DFO사용후 실험군에서 혈색소치는 의미있게 상승되었고(p<0.05) 이것은 Time II에 이르기 까지 지속되었다(Time I : 평균 8.6 g/dL, Time II : 평균 8.6 g/dL). 즉, 혈색소치에 대한 DFO의 효과는 투여 후 15 개월간 Time I, Time II의 시기에 걸쳐 균등한 정도로 지속되었다. 또한 실험군에서 rHuEPO의 사용 용량은 DFO투여후 대조군과 유사한 수준으로 감소하였고 이것도 마찬가지로 15개월간 지속되었다(Time I ;: 평균 48.1 U/Kg/Wk, Time II : 평균 51.8 U/Kg/Wk). 한편, 같은 기간 대조군에서의 혈색소치와 rHuEPO사용 용량의 변화는 없었다. 특히, 실험군에서 혈색소치의 증가와 rHuEPO의 사용 용량의 감소는 DFO투여 후 1개월동안에 극대점을 이루었다. 즉, DFO 사용 후 감소된 rHuEPO사용 용량으로도 조혈 작용을 증강시킬 수 있었고 따라서 DFO를 사용함으로써 rHuEPO의 저항성을 극복할 수 있으리라고 생각된다. 보다 대규모의 실험과 잠재적으로 위험한 DFO의 부작용을 최소화 할 수 있는 적절한 용량과 투여 방법에 대한 연구가 더 필요하다고 사료된다. There are several factors concerning to anemia in chronic renal failure patients. But when rHuEPO is used, most of these factors can be overcome. and the levels of hemoglobin are increased. However, about 10% of the renal failure patients represent rHuEPO-resistant anemia eventhough high dosage of rHuEPO. For these cases, desferrioxamine can be applied to correct rHuEPO resistnacy, and many mechanism of DFO are arguing. So we are going to know whether DFO can be applied to correct anemia of the such patients, how long its effect can be continued. The seven patients as experimental group(DFO+EPO) who represent refractoriness to rHuEPO and the other seven patients as control group(EPO) were included. Experimental group had lower than 9 g/dL of hemoglobin levels despite high rHuEPO dosage (more than 4000U/Wk) and showed normocytic normochromic anemia. There were no definitve causes of anemia such as hemorrhage or iron deficiency. Control group patients had similar characteristics in age, mean dialysis duration but showed adequate response to rHuEPO. DFO was adminsitered to experimental group for 8 weeks along with rHuEPO(the rHuEPO individual mean dosage had been determined by mean dosage of the previous 6 months. Total mean dosage; 123.5 U/Kg/Wk). After 8 weeks of DFO administration, the hemoglobin and rHuEPO dosage levels were checked for 15 consecutive months. It should be noted that the patients determined their own rHuEPO dosage levels according to hemoglobin levels and economic status. In conrol group, rHuEPO was administered by the same method used in experimental group without DFO through the same period. Fifteen months of observation period after DFO trial were divided as Time Ⅰ(7 months after DFO trial) and Time Ⅱ(8months after Time Ⅰ). The results are as follows: Before DFO trial, mean hemoglobin level of experimental group was 7.8g/dL, which is similar level(p>0.05) to control group(mean Hb; 8.2 g/dL). But in experimental group, significantly(p<0.05) higher dosages of rHuEPO(mean; 123.5 U/Kg/Wk) than control group (mean; 41.6 U/Kg/Wk) had been used. It means resistancy to rHuEPO of experimental group. But after DFO trial, the hemoglobin levels of the experimental group were increased significantly(p<0.05), and these effect were continued to Time Ⅱ.(Time Ⅰ; mean 8.6g/dL, Time Ⅱ; mean 8.6g/dL) The effects of DFO to hemoglobin were continued for 15 months after DFO trial with similar degree through Time Ⅰ, Time Ⅱ. Also rHuEPO dosages used in the experimental group were decreased to similar levels of the control group after DFO trial and these effect were also continued for 15 months(Time Ⅰ; mean 48.1 U/Kg/Wk. Time Ⅱ; mean 51.8 U./Kg/Wk). In the same period, hemoglobin levels and rHuEPO dosages used in the control group were not changed significantly. Notibly, hemoglobin increment and rHuEPO usage decrement in experimental group were showed maxilly in the 1st month after DFO trial. That is,after the use of DFO, erythopoiesis was enhanced with a reduced rHuEPO dosage. So we think rHuEPO reisistancy can be overcome by DFO therapy. In conclusion, the DFO can improve the anemia caused by chronic renal failure at least over 1 year, and hence, can reduce the dosage of rHuEPO for anemia correction. Additional studies in order to determine the mechanism of DFO on erythropoiesis and careful attention to potential side effects of DFO will be needed.

신이식 환자에서의 파종성 Nocardiosis1예

도준영,윤경우,정항재,김병덕,이은영,조규향,박준범,배성화,김영진 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.4

Nocardiosis is a rare infection seen most commonly in immunocompromized patients. Most patients have pulmonary involvement, but some develop disseminated infection. A 52-year-old man, treated with immunosuppressive drugs for 3 months after kidney transplantation, developed pulmonary nocardiosis and disseminated infection involving brain, skin, and both uvea. The diagnosis was made by open lung biopsy specimens showing characteristic weak acid fastness with modified Ziel-Neelsen stainig and histologic examination. Immunosuppressive therapy was continued and combination of surgical drainage of brain abscess and chemotherapy with Minocycline were successful. With the increasing number of allograft recipients and concomitant immunosuppression, the possibility of an increase in Nocardia opportunistic infections exists.

급성 호산구성 심근염으로 나타난 과호산구 증후군 1예

박용호,홍그루,김민경,정항재,신동구,김영조,심봉섭 대한내과학회 2004 대한내과학회지 Vol.66 No.3

과호산구 증후군은 특별한 원인없이 호산구가 1,500/㎣ 이상의 호산구 증가증이 6개월 이상 지속되고 다양한 기관의 침범으로 인한 증상과 증후를 보이는 질환이다. 본 저자들은 흉부 불쾌감을 주소로 내원한 환자에서 과호산구 증후군의 합병증의 일종으로 다발성 뇌경색과 급성 호산구성 심근염으로 나타난 1예를 체험하여 문헌고찰과 함께 보고한다. The hypereosinophilic syndrome (HES) is a leukoproliferative disorder, marked by sustained blood eosinophilia of greater than 1,500/㎣, for longer than 6 months and predilection to damage specific oragans. Any organ system may be affected in HES, but the most severe clinicopathophysio-logical involvements are of the heart and nervous system. We report a case of a 48-year-old man with acute eosinophilic myocarditis combined with hypereosinophilic syndrome who was successfully treated with steroids.

복막 투석 환자에서 도관 관련 감염 및 복막염에 대한 Mupirocin과 도관 전환술(Catheter revision)의 효과

박준범,김정미,최준혁,조규향,정항재,김영진,도준영,윤경우 영남대학교 의과대학 1999 Yeungnam University Journal of Medicine Vol.16 No.2

Background: Exit site/tunnel infection causes considerable morbidity and technique failure in CAPD patients. We presently use a unique revision method for the treatment of refractory ESI/TI in CAPD patients and mupirocin prophylaxis for high risk patients. Materials and Methods: We reviewed 139 CAPD patients about the ESI/TI from October 1993 to February 1999 at Yeungnam University Hospital. At the beginning of the ESI, we usually started medications with rifampicin and ciprofloxacin and then changed the antibiotics according to the sensitivity test. If the ESI had persisted and there were TI symptoms (purulent discharge, abscess lesion around exit site). we performed catheter revision(external cuff shaving, disinfection around tunnel and new exit site on opposit direction) with a combination of proper antibiotics. We applied local mupirocin ointment at the exit site three times per week to the 34 patients who had the risk of ESI starting from October 1998. Results: The total follow-up was 2401 patient months(pt. mon). ESI occurred on 105 occasions in 36 out of 139 patients, and peritonitis occurred on 112 occasions in 67 out of 139 patients. The total number of incidences of ESI and peritonitis was 1 per 23.0 pt.mon and 1 per 21.6 pt.mon. The most common organism responsible for ESI was Staphylococcus aureus (26 of 54 isolated cases, 48%), followed by the Methicillin resistant S, aureus(MRSA) (13 cases, 24%). Seven patients(5: MRSA, 2: Pseudomonas) had to be treated with a revision to control infection. Three patients experienced ESI relapse after revision. One of them improved with antibiotics, while another needed a second revision and the remaining ??quired catheter removal due to persistent MRSA infection with re-insertion at the same ??me. But, there was no more ESI in these 3 patients who were received management to ??lapse (The mean duration: 14.0 months) The rates of ESI were significantly reduced after ??sing mupirocin than before(1 per 12.7 vs 34.0 pt.mon, P<0.01). Conclusions: In summary, revision technique can be regarded as an effective method for ??efractory ESI/TI before catheter removal. Also local mupirocin ointment can play a ??gnificant role in the prevention of ESI.