bs_bs_banner
302
Letters to the Editor
7. Yang YQ, Li JH. Clinical diagnosis and treatment of spontaneous perirenal hemorrhage. Chi Clin Res 2010;23:1100–1. 8. Rountas C, Sioka E, Karagounis A et al. Spontaneous perirenal hemorrhage in end-stage renal disease treated with selective embolization. Ren Fail 2012;34:1037–9. 9. Albi G, del Campo L, Tagarro D. Wünderlich’s syndrome: causes, diagnosis and radiological management. Clin Radiol 2002;57:840–5. 10. Dong WR, Liao K, Ma J et al. Diagnosis and treatment of spontaneous renal hemorrhage: report of 13 cases. Hainan Med J 2009;20:78–80.
Vancomycin-Resistant Staphylococcus hemolyticus Bacteremia Treated Successfully by Intravenous Daptomycin and Catheter Removal in a Hemodialysis Patient Dear Editor, Cuffed, tunneled dialysis catheter (PermCath) related bacteremia is an important infection in hemodialysis (HD) patients. Coagulase-negative staphylococci (CoNS) has been considered a lowgrade pathogen and conservative management with systemic antibiotics to salvage the infected catheter has been recommended to manage perm-cath related CoNS bacteremia without metastatic infection (1,2). Staphylococcus hemolyticus (S. hemolyticus) is the second-most isolated CoNS and considered part of normal human skin flora. There have been rare reports of vancomycin-resistant S. hemolyticus (VRSH) bacteremia in dialysis patients (3). We describe another VRSH in a HD patient treated successfully by intravenous daptomycin and catheter removal. A 68-year-old woman (160 cm, 75 kg) was admitted to hospital with complaints of general malaise for 5 days. She had end-stage renal disease from chronic glomerulonephritis and had been on HD for 6 months. Four months before this admission, she was hospitalized for an episode of right breast wound infection with CoNS and received vancomycin on HD. She had a tunneled catheter located at her left neck because it was very difficult for the vascular surgeons to create any permanent access. Her physical examination revealed fever with temp of 39.5°C with swelling and redness over the exit site of the catheter. Her laboratory data were unremarkable. Results from chest and abdominal radiography
Ther Apher Dial, Vol. 19, No. 3, 2015
including ultrasound were negative. Empirical antibiotic therapy with cefazolin was started in the emergency room but was later switched to IV vancomycin given after HD. Blood drawn from both the dialysis catheter and peripheral vein were sent for bacterial culture as the patient was febrile with chills during her treatment. Even 72 h after admission, the patient continued to spike fevers (39.5°C) while receiving her dialysis treatments only, but was afebrile between sessions. Four blood culture sets grew CoNS (S. hemolyticus) with MIC (minimum inhibitory concentration) for vancomycin and daptomycin being 16 and 2 mg/L, respectively. Antibiotic therapy was changed to daptomycin 500 mg Q48 h post-HD therapy and the PermCath was removed on hospital day 5. An echocardiography revealed no vegetations. After removal of the tunneled catheter, placement of a temporary non-tunneled catheter via femoral approach was placed for short-term dialysis access. She improved clinically, and surveillance blood cultures done on hospital day 7 after the removal of catheter were negative. After 2 weeks of antibiotic treatment, the patient improved. Follow-up cultures and echocardiography 1 week after cessation of antibiotic therapy showed normal findings and she remained stable on maintenance HD. In this patient, S. hemolyticus was responsible for the episodes of bacteremia. Both catheter removal and daptomycin use contributed to the complete eradication of this VRSH infection. To prevent dissemination of emerging strains of VRSH in the dialysis population, attempts to improve hand washing habits and improve antimicrobial prescribing practices by educational and administrative means may be helpful (1,4). Yao-Min Hung, Jao-Hsien Wang, and Shue-Ren Wann Department of Emergency Medicine, Kaohsiung Veterans General Hospital Kaohsiung, Taiwan Email: [email protected] REFERENCES 1. Fitzgibbons LN, Puls DL, Mackay K, Forrest GN. Management of Gram-positive coccal bacteremia and hemodialysis. Am J Kidney Dis 2011;57:624–40. 2. Mermel LA, Allon M, Bouza E et al. Clinical practice guidelines for the diagnosis and management of intravascular catheterrelated infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:1–45. 3. Schwalbe RS, Stapleton JT, Gilligan PH. Emergence of vancomycin resistance in coagulase-negative staphylococci. N Engl J Med 1987;316:927–32. 4. Allon M. Dialysis catheter-related bacteremia: treatment and prophylaxis. Am J Kidney Dis 2004;44:779–91. © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
302
Letters to the Editor
7. Yang YQ, Li JH. Clinical diagnosis and treatment of spontaneous perirenal hemorrhage. Chi Clin Res 2010;23:1100–1. 8. Rountas C, Sioka E, Karagounis A et al. Spontaneous perirenal hemorrhage in end-stage renal disease treated with selective embolization. Ren Fail 2012;34:1037–9. 9. Albi G, del Campo L, Tagarro D. Wünderlich’s syndrome: causes, diagnosis and radiological management. Clin Radiol 2002;57:840–5. 10. Dong WR, Liao K, Ma J et al. Diagnosis and treatment of spontaneous renal hemorrhage: report of 13 cases. Hainan Med J 2009;20:78–80.
Vancomycin-Resistant Staphylococcus hemolyticus Bacteremia Treated Successfully by Intravenous Daptomycin and Catheter Removal in a Hemodialysis Patient Dear Editor, Cuffed, tunneled dialysis catheter (PermCath) related bacteremia is an important infection in hemodialysis (HD) patients. Coagulase-negative staphylococci (CoNS) has been considered a lowgrade pathogen and conservative management with systemic antibiotics to salvage the infected catheter has been recommended to manage perm-cath related CoNS bacteremia without metastatic infection (1,2). Staphylococcus hemolyticus (S. hemolyticus) is the second-most isolated CoNS and considered part of normal human skin flora. There have been rare reports of vancomycin-resistant S. hemolyticus (VRSH) bacteremia in dialysis patients (3). We describe another VRSH in a HD patient treated successfully by intravenous daptomycin and catheter removal. A 68-year-old woman (160 cm, 75 kg) was admitted to hospital with complaints of general malaise for 5 days. She had end-stage renal disease from chronic glomerulonephritis and had been on HD for 6 months. Four months before this admission, she was hospitalized for an episode of right breast wound infection with CoNS and received vancomycin on HD. She had a tunneled catheter located at her left neck because it was very difficult for the vascular surgeons to create any permanent access. Her physical examination revealed fever with temp of 39.5°C with swelling and redness over the exit site of the catheter. Her laboratory data were unremarkable. Results from chest and abdominal radiography
Ther Apher Dial, Vol. 19, No. 3, 2015
including ultrasound were negative. Empirical antibiotic therapy with cefazolin was started in the emergency room but was later switched to IV vancomycin given after HD. Blood drawn from both the dialysis catheter and peripheral vein were sent for bacterial culture as the patient was febrile with chills during her treatment. Even 72 h after admission, the patient continued to spike fevers (39.5°C) while receiving her dialysis treatments only, but was afebrile between sessions. Four blood culture sets grew CoNS (S. hemolyticus) with MIC (minimum inhibitory concentration) for vancomycin and daptomycin being 16 and 2 mg/L, respectively. Antibiotic therapy was changed to daptomycin 500 mg Q48 h post-HD therapy and the PermCath was removed on hospital day 5. An echocardiography revealed no vegetations. After removal of the tunneled catheter, placement of a temporary non-tunneled catheter via femoral approach was placed for short-term dialysis access. She improved clinically, and surveillance blood cultures done on hospital day 7 after the removal of catheter were negative. After 2 weeks of antibiotic treatment, the patient improved. Follow-up cultures and echocardiography 1 week after cessation of antibiotic therapy showed normal findings and she remained stable on maintenance HD. In this patient, S. hemolyticus was responsible for the episodes of bacteremia. Both catheter removal and daptomycin use contributed to the complete eradication of this VRSH infection. To prevent dissemination of emerging strains of VRSH in the dialysis population, attempts to improve hand washing habits and improve antimicrobial prescribing practices by educational and administrative means may be helpful (1,4). Yao-Min Hung, Jao-Hsien Wang, and Shue-Ren Wann Department of Emergency Medicine, Kaohsiung Veterans General Hospital Kaohsiung, Taiwan Email: [email protected] REFERENCES 1. Fitzgibbons LN, Puls DL, Mackay K, Forrest GN. Management of Gram-positive coccal bacteremia and hemodialysis. Am J Kidney Dis 2011;57:624–40. 2. Mermel LA, Allon M, Bouza E et al. Clinical practice guidelines for the diagnosis and management of intravascular catheterrelated infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:1–45. 3. Schwalbe RS, Stapleton JT, Gilligan PH. Emergence of vancomycin resistance in coagulase-negative staphylococci. N Engl J Med 1987;316:927–32. 4. Allon M. Dialysis catheter-related bacteremia: treatment and prophylaxis. Am J Kidney Dis 2004;44:779–91. © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
