PDI

NOVEMBER  2014 - VOL. 34, NO. 7 CORRESPONDENCE

*email: [email protected] REFERENCES

doi: 10.3747/pdi.2012.00347

Peritonitis in a Peritoneal Dialysis Patient Due to Rhizobium Radiobacter and Moraxella Osleonsis: Case Report and Literature Review Editor: Peritonitis is a common complication in peritoneal dialysis (PD) patients. It has been associated with significant morbidity, catheter loss, transfer to hemodialysis, and occasionally death. In 50­– 61% of PD patients, peritonitis is caused by gram-positive bacteria, in 15 – 20% by gram-negatives, and in about 4% by a mixture of micro-organisms (1,2). We report a case of a PD patient with peritonitis caused by both Rhizobium radiobacter (RR) and Moraxella osloensis (MO). These microorganisms are uncommon causes of peritonitis and appropriate therapy is uncertain because of limited literature.

A 47-year-old Caucasian man with end-stage renal failure secondary to membranous nephropathy started on continuous ambulatory PD (CAPD). After 17 months, he developed bacterial peritonitis due to a Streptococcus gordonii with good response to therapy. Our patient lives alone with his dog. The patient claimed to have taken all the necessary hygienic precautions in his daily CAPD exchanges. After 36 months he was admitted with abdominal pain, fever, cloudy peritoneal fluid, and increased leukocyte count (2.1 × 109/L) in the peritoneal fluid, diagnosed as bacterial peritonitis. There were no signs of exit-site infection. After cultures were taken, treatment was started with cefazolin intraperitoneally (250 mg, 4 times daily). The next day, preliminary culture results indicated gram-negative bacteria so treatment was switched to ceftazidime i.p. (500 mg, once daily). The fever subsided; however, the peritoneal fluid remained cloudy. Two days after admission, cultures showed RR, resistant to cefazolin, ceftazidime, and ceftriaxone, and sensitive to meropenem, ciprofloxacin, and amoxicillin/clavulanic acid. Subsequently, antibiotic therapy (AB-therapy) was switched to ciprofloxacin intraperitoneally (400 mg, once daily). The fourth day, another intraperitoneal culture was taken because the peritoneal fluid remained cloudy even though the patient had no fever. The seventh day, the microbiological diagnosis of the second culture was completed and showed a MO (confirmed using MALDI-TOF technique) with in vitro sensitivity to all antibiotics. However, AB-therapy was switched to meropenem because of uncertainty of in vivo sensitivity of MO. Despite the change in antibiotics, the patient continued to have abdominal pain and the peritoneal fluid remained cloudy with high leukocyte counts. After 12 days, it was decided to remove the Tenckhoff-catheter and initiate intermittent hemodialysis. DISCUSSION

Rhizobium radiobacter (formerly known as Agrobacterium tumefaciens) is an aerobic gram-negative pathogen found in soil and plants globally. There are some reports of the RR as an opportunistic pathogen in humans (3). Peritonitis in patients with peritoneal dialysis due to RR was first described in 1990 (4). Since then, there have been only a few case reports on peritonitis caused by RR (5–9). The antibiotic resistance patterns of RR in the case reports differ. Levitski-Heikkila et al. (9) discussed 12 case reports (including Lui et al. [5]). From those 11 patients, 7 required catheter removal after an

This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]

813

Downloaded from http://www.pdiconnect.com/ at ARIZONA HEALTH SCIENCES LIBRARY on November 21, 2015

1. Alobaidi HM, Coles GA, Davies M, LIoyd D. Host defence in continuous ambulatory peritoneal dialysis: the effect of the dialysate on phagocyte function. Nephrol Dial Transplant 1986; 1:16–21. 2. Keane WF, Comty CM, Verburgh HA, Peterson PK. O ­ psonic deficiency of peritoneal dialysis effluent in continuous ambulatory peritoneal dialysis. Kidney Int 1984; 25:539–43. 3. Govindarajulu S, Hawley CM, Macdonald SP, Brown FG, Rosman JB, Wiggins KJ, et al. Staphylococcus aureus peritonitis in Australian peritoneal dialysis patients: predictors, treatment, and outcomes in 503 cases. Perit Dial Int 2010: 30(3); 311–9. 4. Ghali JR, Bannister KM, Brown FG, Rosman JB, Wiggins KJ, Johnson DW, et al. Microbiology and outcomes of peritonitis in Australian peritoneal dialysis patients. Perit Dial Int 2011;31;651–62. 5. Parikova A, Zweers MM, Strujik DG, Krediet RT. Peritoneal effluent markers of inflammation in patients treated with icodextrin-based and glucose-based dialysis solutions. Adv Perit Dial 2003; 19:186–90. 6. Opatrna S, Lysak D, Trefil L, Parker C, Topley N. Intraperitoneal IL-6 signaling in incident patients treated with icodextrin and glucose bicarbonate/lactatebased peritoneal dialysis solutions. Perit Dial Int 2012; 32:37–44.

CASE REPORT

NOVEMBER  2014 - VOL. 34, NO. 7 PDI

CORRESPONDENCE

814

The International Society for Peritoneal Dialysis (ISPD) guidelines/recommendations (14) state a similar strategy for peritonitis treated with appropriate antibiotics without resolution after 5 days (refractory peritonitis). In the case of MO peritonitis, we advise attempting antibiotic treatment without catheter removal based on extrapolation of other (non-PD) MO catheter infections. DISCLOSURES

The authors have no financial conflicts of interest to declare. The contents of this paper have not been published previously in whole or part. S. Badrising1 L. Bakker2 S. Lobatto1 A. van Es1 Department of Nephrology1 Department of Medical Microbiology2 Tergooi Hospitals, Hilversum, the Netherlands *email: [email protected] REFERENCES 1. Mujais, S. Microbiology and outcomes of peritonitis in North America. Kidney Int 2006; 70:S55. 2. Port FK, Held PJ, Nolph KD, Turenne MN, Wolfe RA. Risk of peritonitis and technique failure by CAPD connection technique: a national study. Kidney Int 1992; 42:967. 3. Edmond MB, Riddler SA, Baxter CM, Wicklund BM, Pasculle AW. Agrobacterium radiobacter: a recently recognized ­opportunistic pathogen. Clin Infect Dis 1993; 16:388–91. 4. Harrison G, Morris R, Holmes B, Stead DG. Human infections with strains of Agrobacterium. J Hosp Infect 1990; 16:383–90. 5. Lui SL, Lo WK. Agrobacterium radiobacter peritonitis in a Chinese patient on CAPD. Perit Dial Int 2005; 25(1):95. 6. Rothe H, Rothenpieler U. Peritonitis due to multiresistent Rhizobium radiobacter. Perit Dial Int 2007; 27:214. 7. Minguela JI, de-Pablos M, Castellanos T, Ruiz-de-Gauna R. Peritonitis by Rhizobium radiobacter. Perit Dial Int 2006; 26:112. 8. Melgosa-Hijosa M, Ramos-Lopez MC. Agrobacterium radiobacter peritonitis in a Down’s syndrome child maintained on peritoneal dialysis. Perit Dial Int 1997; 17:515. 9. Levitski-Heikkila TV, Ullian ME. Peritonitis with multiple rare environmental bacteria in a patient receiving long-term peritoneal dialysis. Am J Kidney Dis 2005; 46(6):e119–24. 10. Schreckenberger PC, von Graevenitz A. Acinetobacter, Achromobacter, Alcaligenes, Moraxella, Methylobacterium,

This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]

Downloaded from http://www.pdiconnect.com/ at ARIZONA HEALTH SCIENCES LIBRARY on November 21, 2015

RR infection, either because of resistance to therapy or recurrence. Three patients responded to antibiotic therapy and were cured. One patient died while being treated for another cause. One patient had 2 episodes of peritonitis in a short period of time. In both episodes, a total of 3 different bacteria of environmental origin (including RR) were found. The PD catheter was removed during the second episode of peritonitis. Cultures did not show RR during the second episode. We found 3 additional case reports (6–8): in 2, the PD catheter was removed after unsuccessful antibiotic treatment; in the third, the patient responded well to 3 weeks of intraperitoneal antibiotic treatment and received a kidney transplant 6 months later. Of the 15 patients described in the case reports, 4 were cured with antibiotic treatment alone, 10 ended up having their catheter removed after being infected with RR and 1 died. If we exclude the patient who died, these numbers suggest that there is only a 28.5% chance that antibiotic treatment without catheter removal will be successful. In 71.4% of the cases, the catheter has to be removed eventually. Moraxella osloensis is an aerobic gram-negative bacteria that is saprophytic on skin and mucosa of humans and other warm-blooded animals. Moraxella osloensis has been identified as being one of the natural symbionts of bacteria-feeding nematodes (roundworms). Moraxella osloensis has been found in hospital environments (10) and is also responsible for locker-room smell or showercurtain odor (11). Moraxella osloensis rarely causes infections in humans. There have been some case reports of serious systemic diseases caused by MO, but we found no reports of peritonitis in PD patients. Han et al. (12) described 10 cases of MO blood or catheter infections that occurred during anticancer chemotherapy or without preexisting neutropenia. Nine of these patients had central venous catheters, 6 had catheter colonization and infection. All patients responded well to antibiotic therapy and none of the catheters had to be removed. Hadano et al. (13) report a central venous catheter-related infection caused by MO in a Japanese patient with advanced pancreatic cancer 7 days after administering chemotherapy. The infection was successfully controlled with antibiotic therapy without the need for removal of the central venous catheter. These reports suggest that PD patients with peritonitis due to MO will also respond well to antibiotic therapy. However, no data exist to validate extrapolation to PD-related peritonitis. Considering the high probability of insufficient response to antibiotic treatment, early removal of the PD catheter in RR-related peritonitis without prompt reaction to antibiotic therapy should be considered.

PDI

NOVEMBER  2014 - VOL. 34, NO. 7 CORRESPONDENCE

doi: 10.3747/pdi.2013.00238

Actinomyces neuii PD Peritonitis— Resolution of Infection Without Catheter Removal Editor: We report a case of a patient with peritoneal dialysis (PD) peritonitis caused by Actinomyces neuii subspecies neuii treated successfully without need for catheter removal. The patient is an 87-year-old woman with type II diabetes mellitus, coronary artery disease, and peripheral vascular disease from a long-term health care facility on continuous cycling PD (CCPD). She developed abdominal pain and cloudy fluid. The PD fluid leukocyte count on the day of onset of symptoms was 449/mm3 with 89% neutrophils. While awaiting the PD fluid cultures, she was started on empiric intermittent intra-peritoneal (IP) cefazolin and ceftazidime as per International Society for Peritoneal Dialysis (ISPD) guidelines (1) along with oral nystatin as anti-fungal prophylaxis. The clinical and laboratory response was immediate with normalization of the fluid leukocyte count in 1 day. She was continued on the same IP antibiotics. Fourteen days after diagnosis, the initial PD fluid grew Actinomyces neuii subspecies neuii. The Actinomyces was identified on routine culture. It did not grow on direct plating to agar but grew in the BacT/Alert FN anaerobic bottle, which, when subcultured, grew on both the sheep blood agar and chocolate agar subcultures. The PD fluid count was normal at this point and thereafter and cultures also remained sterile. On the recommendation of the infectious disease service, the IP antibiotic

was changed to Penicillin G 50,000 U per liter of PD fluid loading dose, and 25,000 U per liter for a subsequent 4 weeks. She did not require catheter removal as there was no recurrence of PD peritonitis at any time in the course of her treatment. The etiology of culture-negative PD peritonitis is presumed to be gram-positive microbes such as coagulase-negative staphylococci (1) and if the peritonitis improves, ISPD guidelines recommend continuation of initial empiric therapy for 2 weeks. However, it may be prudent to consider unusual organisms as being causative as in this case. This becomes relevant especially in the event of relapse or recurrence of PD peritonitis. Peritoneal dialysis peritonitis due to Actinomyces is extremely rare and has been reported 3 times previously (2–4), requiring catheter removal in the first 2 cases (2,3). Actinomyces peritonitis has also been reported in 2 patients on hemodialysis, having been on PD at an earlier time (5,6). One of these patients presented with large bowel perforation due to actinomycosis of the sigmoid colon (6). Actinomyces has been reported to cause PD exit-site infections (7). Actinomyces neuii (formerly “CDC coryneform group 1” bacteria) (8) is unique among all species of Actinomyces in that it rarely shows classic sulfur granules and grampositive filaments on microscopy, appearing instead as coccoid or diphtheroidal without branching (9). Infection may present in a myriad of ways such as abscesses, infected atheromas, infected cutaneous ulcers, endophthalmitis, endocarditis, and even bacteremia. Rarer presentations include chorioamnionitis, pericarditis, osteomyelitis, prosthetic joint infection, ventriculo-peritoneal shunt infection, urinary tract infection, and prostatitis. Actinomyces neuii PD peritonitis has only been reported once previously and, owing to rapid resolution of infection, did not require catheter removal (4). There is no known age or gender predilection or increased presentation among the immunocompromised. Antibiotic susceptibility of A. neuii is similar to other Actinomyces i.e. beta-lactam antibiotics, carbapenem, vancomycin, macrolides, clindamycin, and rifampin. The appropriate duration of therapy has not been determined and possibly needs to be tailored based on the site of infection. Peritoneal dialysis peritonitis probably necessitates between 2 and 6 weeks and needs negative cultures to ensure eradication. Catheter removal may be needed in polymicrobial infection and where there is inadequate clinical response (4). Prompt and early initiation of IP cefazolin as part of empiric treatment probably led to easy resolution of neuii PD peritonitis in our patient and successful treatment without the need of catheter removal.

This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]

815

Downloaded from http://www.pdiconnect.com/ at ARIZONA HEALTH SCIENCES LIBRARY on November 21, 2015

and other nonfermentative gram-negative rods. In: Murray PR, Baron EJ, Pfaller MA, et al., eds. Manual of Clinical Microbiology. 7th ed. Washington, DC: ASM Press; 1999:539–60. 11. Kubota H, Mitani A, Niwano Y, Takeuchi K, Tanaka A, Y­ amaguch N, et al. Moraxella species are p­ rimarily r­ espon­si­ble for generating malodor in laundry. Appl ­Environ Microbiol 2012; 78(9):3317–24. 12. Han XY, Tarrand JJ. Moraxella osloensis blood and catheter infections during anticancer chemotherapy: clinical and microbiologic studies of 10 cases. Am J Clin Pathol 2004;121(4):581-7. 13. Hadano Y, Ito K, Suzuki J, Kawamura I, Kurai H, Ohkusu K. Central venous catheter infection due to Moraxella osloensis. Int J Gen Med 2012; 5:875–7. 14. Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, et al. ISPD Guidelines/Recommendations “Peritoneal Dialysis-Related Infections Recommendations: 2010 update.” Perit Dial Int 2010; 30:393–423.

Peritonitis in a peritoneal dialysis patient due to Rhizobium radiobacter and Moraxella osleonsis: case report and literature review.

Peritonitis in a peritoneal dialysis patient due to Rhizobium radiobacter and Moraxella osleonsis: case report and literature review. - PDF Download Free
1000KB Sizes 0 Downloads 6 Views