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Clinical Infection & Immunity

Case Report

Volume 1, Number 1, September 2016, pages 16-18

Successful Treatment of Peritoneal Dialysis Catheter-Related Chryseobacterium indologenes Peritonitis Without Catheter Removal

Chryseobacterium indologenes is a rare cause of infection in select immunosuppressed hosts. Most prior reports are from Taiwan, in patients with diabetes mellitus or malignancies. Infections caused by C. indologenes are generally associated with indwelling devices, and the organism may be resistant to many commonly utilized broad-spectrum antibiotics [1]. Here, we present a case of peritonitis caused by C. indologenes and we briefly review the literature about peritonitis episodes caused by this micro-organism.

A 48-year-old male patient developed end-stage renal disease due to diabetes mellitus and underwent continuous ambulatory peritoneal dialysis (CAPD) for 5 years. His peritoneal dialysis regime included 2,000 mL of 1.5% peritoneal dialysis solution (dianeal 1.5%, Baxter, International Inc.) with three exchanges daily (PD3) and 2,000 mL of 3.5% PDF overnight (PD2). His daily peritoneal dialysis ultrafiltration volume was 1,000 - 1,500 mL and his urine output was 400 - 800 mL/24 h. In general, his CAPD therapy went well during the past 60 months, and the peritoneal dialysis effluent was always clear. Abdominal distension accompanied with abdominal pain and fewer developed in July 2014. On admission, physical examination was remarkable with oral temperature 38.3 °C, blood pressure 130/70 mm Hg, pulse 100 beats/min, and disclosed diffuse tenderness with rebounding pain over the lower abdomen. The exit site of the drainage catheter showed no erythematous change or pus formation. Cloudy fluid was drained from the indwelling catheter. Laboratory examinations showed hemoglobin 10.6 g/dL (normal 12 - 16 g/dL), white blood cell count 10.6 × 10⁹/L (normal 4 - 12 × 10⁹/L) (80% neutrophil and 12.6% lymphocyte), and C-reactive protein 25 mg/L (normal 0 - 5 mg/L). Ascitic fluid analysis revealed elevated white blood cell count (126.0 × 10⁶/L) with lymphocyte predominant (60%), protein 26.2 g/L, glucose 7.72 mmol/L, and lactate dehydrogenase 186 U/L. Gram stain of the ascitic fluid obtained from the catheter revealed gram-negative bacilli. The patient was treated with ampicillin-sulbactam (1.0/0.5 g every 8 h) intravenously on the first day in the hospital. The blood cultures taken from the peripheral veins did not yield any bacteria. On the sixth day in the hospital, the bacilli were identified as C. indologenes. Growth on 5% sheep blood agar showed smooth, yellow-pigmented colonies. Antimicrobial susceptibility testing showed resistance to most antibiotics including ampicillin-sulbactam, imipenem, meropenem, piperacillin, and ciprofloxacin, but not to colistin, piperacillin-tazobactam, cefepime, cefoperazone-sulbactam, tigecycline, levofloxacin, and trimethoprim-sulfamethoxazole. Due to the results, previous therapy was discontinued, and trimethoprim-sulfamethoxazole was initiated intravenously. The patient’s condition improved with trimethoprim-sulfamethoxazole treatment after 4 days. We retained the catheter because the patient’s condition improved. He received antibiotic treatment for 2 weeks. Cultures of repeated ascites did not yield any bacteria during the following 2 weeks. The patient was discharged without sequelae after 25 days of hospitalization.

Peritonitis is known as a leading complication of peritoneal dialysis that may result in death, peritoneal membrane failure and switching to hemodialysis in patients carrying out CAPD. Therefore, it is recommended that empirical treatment including broad-spectrum antibiotics should be initiated in patients with peritonitis immediately, until the results of the ascitic fluid and exite-site culture can direct the choice of antibiotic [2]. One of the rare pathogens of humans that can cause peritonitis is C. indologenes [3]. However, it is widely found in soil, water and on wet surfaces in the hospital environment. Numerous infections have been reported with this pathogen, including pneumonia, pyelonephritis, peritonitis, biliary tract infection, wound infection and catheter-related bacteremia [3, 4]. Most of cases that have been reported in the literature are associated with indwelling devices or some severe underlying diseases such as malignancies and diabetes mellitus [1, 5, 6]. However, the indwelling catheters should be removed if the clinical symptoms do not improve despite appropriate antiobiotic treatment. Hsueh et al reported that removal of the carheter may not always be necessary during the indwelling device-related infections caused by C. indologenes [5]. Literature about peritonitis caused by C. indologenes in CAPD patients is very limited. Afshar et al achieved in the treatment of a patient with C. indologenes-associated CAPD peritonitis responding to antibiotic therapy without catheter removal [3]. On the contrary, others suggested that removal of the carheter should be performed in patients with peritonitis which did not respond to antibiotics [7]. The present case suggests that catheter-related peritonitis caused by C. indologenes can be treated successfully using appropriate antibiotics in CAPD patients without catheter removal.

Although C. indologenes has been shown to have low virulence, it is inherently resistant to many antimicrobial agents such as aminoglycosides, penicillins, erythromycin, clindamycin, tetracyclines, aztreonam, first-, second-, and third-generation cephalosporins, chloramphenicol, linezolid, teicoplanin and glycopeptides [8]. According to the SENTRY Antimicrobial Surveillance Program, the effective drugs of choice against isolates of C. indologenes are the quinolones (levofloxacin, gatifloxacin, and garenoxacin), trimethoprim-sulfamethoxazole, and piperacillin-tazobactam [9]. Other effective agents are ciprofloxacin, piperacillin, cefepime, ceftazidime, and rifampin [9, 10].

Antimicrobial susceptibility testing is gaining more importance in multidrug resistant organisms for making the best patient-care decisions. Antibiotic regimens should be modified based on results of culture and susceptibility testing. Although there are currenly no specific guidelines for treating C. indologenes, empirical therapy should be initiated as soon as possible with broad-spectrum antibiotic regimens covering both gram-positive and gram-negative organisms in CAPD patients with peritonitis [2].

Afshar et al reported a case of CAPD-related peritonitis with C. indologenes that was treated successfully with ceftazidime [3]. Another reported case of C. indologenes peritonitis in a patient with malignant ascites showed a successful treatment of peritonitis with trimethoprim-sulfamethoxazole [6]. In this case report, C. indologenes isolated from our patient showed various susceptibilities to trimethoprim-sulfamethoxazole, levofloxacin, ciprofloxacin, piperacillin-tazobactam, cefepime, cefoperazone-sulbactam, colistin and tigecycline in accordance with previous reports [8-10]. Due to the results, previous therapy was discontinued, and antibiotic therapy was changed to trimethoprim-sulfamethoxazole. The patient was treated successfully by trimethoprim-sulfamethoxazole without removal of Tenckhoff catheter. Lin et al showed that trimethoprim-sulfamethoxazole (75% susceptible) was the most potent agent against the overall collection of C. indologenes [11].

In conclusion, clinicians caring for patients with these infections throughout the world should keep in mind C. indologenes as a rare cause of carheter-related peritonitis in patients undergoing CAPD. We believe that catheter removal is usually not required in patients with C. indologenes peritonitis under appropriate antibiotic regimen.

Consent

Written informed consent was obtained from the patient for publication of this case report.

Author Contributions

The patient was admitted to our hospital during this episode and followed up in the out-patient clinic by AB and SUI. BKU, BD, MB and ASDA were major contributors to the writing of the manuscript. All authors read and approved the final manuscript.

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