Peritoneal Dialysis-Associated Peritonitis Caused by Mycobacterium abscessus

Peritoneal Dialysis Catheter-Associated Peritonitis Caused by Mycobacterium abscessus: A True Infection?

A nine-year-old male with trisomy 21, end-stage renal disease (ESRD) due to reflux nephropathy presented with suspected peritoneal dialysis (PD) catheter-associated peritonitis. One week after receiving an intraperitoneal antibiotic, he presented again with persistent peritonitis symptoms and bloody PD fluid. He underwent exploratory laparotomy, abdominal washout, and PD catheter removal. Mycobacterium abscessus (M. abscessus) was found in the intraoperative peritoneal fluid culture. After the catheter removal, the child's symptoms significantly improved without antimicrobial medications. He was maintained on hemodialysis three times a week and underwent a successful kidney transplant eight months after this episode. Non-tuberculous mycobacterial peritonitis should be considered in patients with culture-negative peritonitis when there is no intraperitoneal antibiotic response. M. abscessus is a rapidly growing atypical Mycobacterium found in the environment and can contaminate medical devices. Our case involved an infection from a contaminated PD catheter since the patient's symptoms improved after PD catheter removal.

Improvement of multiple intraperitoneal nodules resembling peritoneal cancer that developed after peritoneal dialysis-related peritonitis caused by Mycobacterium abscessus with literature review: granuloma or carcinoma

Introduction

Peritonitis is a crucial complication that leads to hospitalization or even death in patients who are undergoing peritoneal dialysis (PD). The incidence of PD-related peritonitis associated with nontuberculous mycobacteria has increased in recent years. However, a well-established treatment for peritonitis is lacking, particularly in peritonitis caused by Mycobacterium abscessus which is a difficult to treat disease due to its inherent resistance to majority of available antibiotics. To the best of our knowledge, this case is the first to report on intraperitoneal multiple nodules that developed due to PD-related peritonitis caused by M. abscessus.

Case presentation

This case reported a case of a 40-year-old female patient who was undergoing PD and who showed multiple intraperitoneal nodules that resembled peritoneal cancer on computed tomography (CT) and that developed after PD-related peritonitis and catheter removal. After multiantibiotic therapy, multiple nodules were found to have disappeared on CT. The nodules continued to disappear and the patient did not show signs of recurrent peritonitis, although there was a possibility of recurrence.

Conclusion

To the best of our knowledge, this case is the first to report on nodules that resembled peritoneal cancer and that developed in the abdominal cavity due to PD-related peritonitis caused by M. abscessus. Positron emission tomography–CT was not useful in distinguishing peritoneal cancer from nodules caused by M. abscessus.

Mycobacterium abscessus - an uncommon, but important cause of peritoneal dialysis-associated peritonitis - case report and literature review

BACKGROUND

Peritoneal dialysis (PD) is a form of therapy for end-stage kidney disease (ESKD), and peritonitis is a known complication. Mycobacterium (M) species associated peritonitis in PD patients is uncommon. Our experience of managing PD associated peritonitis caused by M abscessus in a middle-aged man with ESKD due to focal segmental glomerulosclerosis is shared in this article with a review of the literature on this condition.

CASE PRESENTATION

A 49-year old man presented to our unit with symptoms of peritonitis and cloudy PD effluent. Initial analysis of PD fluid showed Gram stain was negative, with no organism grown. Empirical PD peritonitis treatment with intra-peritoneal antibiotics did not improve his symptoms and he required intravenous antibiotics, PD catheter removal and a switch to haemodialysis. Cultures of the PD fluid later grew M abscessus, and the antibiotic regimen was changed appropriately, leading to clinical improvement.

CONCLUSION

M abscessus associated peritonitis in PD patients is rare. It needs to be borne in mind when clinical improvement is not seen with standard broad-spectrum antibiotics, especially in situations where the PD fluid is initially deemed to be culture negative. PD fluid samples should be sent for acid-fast bacillus and if detected, should be further analysed with genome-wide sequencing to confirm the species of the Mycobacterium. Prompt removal of the catheter with peritoneal washout is critical for clinical improvement.

Therapeutic drug monitoring in peritoneal dialysis: A case of nontuberculous mycobacterium catheter-related infection treated with amikacin

The pharmacokinetics of amikacin makes it difficult to predict the appropriate dosing to avoid harmful side effects in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). The implementation of therapeutic drug monitoring may be useful in controlling amikacin serum concentrations in patients receiving CAPD.

Nontuberculous mycobacteria infections of peritoneal dialysis patients: A multicenter study

OBJECTIVES

Nontuberculous mycobacteria (NTM) infections pose a diagnostic challenge in peritoneal dialysis (PD) patients. In this study, we sought to identify findings that are suggestive of NTM infection in PD adult patients.

METHODS

All patients with NTM exit-site infection (ESI) with/without tunnel infection and peritonitis identified during the last decade in eight medical centers in Israel were included. Clinical, microbiological, and outcome data were collected and analyzed.

RESULTS

Thirty patients were identified; 16 had ESI (53%) and 14 had peritonitis (47%). Median age was 65 years (interquartile range 52-76). Abdominal pain and cloudy PD fluid were reported in all patients with peritonitis, whereas exit-site discharge and granulation tissue were common in patients with ESI. Fourteen patients (47%) had negative cultures prior NTM diagnosis, and isolation of diphtheroids or Corynebacterium spp. was reported in 9 of 30 patients (30%). Antimicrobial treatment prior to diagnosis was documented in 13 of 30 patients (43%). Delayed diagnosis was frequent. Treatment regimens and duration of therapy varied widely. In 26 of 30 (87%) patients, catheter was removed and 19 of 30 patients (63%) required permanent transition to hemodialysis. Two patients with peritonitis (2 of 14, 14%) and seven with ESI (7 of 16, 44%) were eligible for continuation of PD.

CONCLUSIONS

Culture negative peritonitis, isolation of diphtheroids or Corynebacterium spp., previous exposure to antibiotics, and/or a refractory infection should all prompt consideration of PD-related NTM infection and timely workup. Catheter removal is recommended aside prolonged antimicrobial therapy. In select patients with ESI, continuation of PD may be feasible.

Clofazimine in Mycobacterium abscessus peritonitis: A pediatric case report

Peritonitis- and catheter-related infections due to nontuberculous mycobacteria (NTM) including Mycobacterium abscessus have been reported among adults on peritoneal dialysis (PD). There is no recommended antimicrobial regimen for the treatment of M. abscessus peritonitis. Clofazimine has emerged as an important adjuvant antimicrobial treatment of M. abscessus lung infection. We report, to our knowledge, the first case of M. abscessus PD peritonitis in a child treated successfully using clofazimine as a novel adjuvant therapy to amikacin and clarithromycin. Her clinical features were similar to those of bacterial peritonitis, but she had persistence of symptoms and high inflammatory markers despite empirical therapy for peritonitis. Bacterial culture of PD effluent became positive for M. abscessus after 5 days. There was complete symptom resolution after 6 days of multidrug therapy. Due to ototoxicity, amikacin was discontinued after 6 weeks, while clarithromycin and clofazimine were continued for 9 months to ensure complete pathogen eradication before a planned renal transplant. A high index of suspicion in refractory or culture-negative cases is important for the diagnosis of NTM peritonitis. Multidrug therapy is recommended for M. abscessus infections. Clofazimine was chosen as a novel adjunct antimicrobial because of its pharmacokinetics, ease of administration, cost-effectiveness, and lack of serious adverse events.

Peritoneal dialysis-associated infection caused by Mycobacterium abscessus: a case report

Background

Peritoneal dialysis (PD)-associated infection caused by Mycobacterium spp. is rare. Mycobacterium abscessus is one of the most resistant acid-fast bacteria, and treatment is also the most difficult and refractory. Thus, we report a case of PD-associated peritonitis caused by Mycobacterium abscessus that was difficult to treat and led to PD failure.

Case presentation

We recently encountered a 56-year-old man who developed PD-associated infection. We initially suspected exit-site infection (ESI) and tunnel infection (TI) caused by methicillin-resistant coagulase-negative Staphylococcus. However, antibiotic therapy did not provide any significant improvement. Thus, we performed simultaneous removal and reinsertion of a PD catheter at a new exit site. The patient subsequently developed peritonitis and Mycobacterium abscessus was detected in the peritoneal effluent. Thus, the reinserted catheter was removed, hemodialysis was started, and the patient was eventually discharged.

Conclusions

In cases of refractory ESI or TI, it is important to consider non-tuberculous mycobacteria as the potentially causative organism. Even if acid-fast bacterial staining is negative or not performed, detection of Gram-negative bacillus may lead to suspicion and early identification of Mycobacterium spp. In PD-associated infection by Mycobacterium abscessus, catheter removal is necessary in many cases. Simultaneous removal and reinsertion of the catheter is not recommended, even in cases of ESI or TI. Reinsertion should only be attempted after complete resolution of peritoneal symptoms. After removal of the catheter, careful follow-up is necessary, paying attention to complications such as wound infection, peritonitis, and ileus. In addition, the selection and treatment period of antibiotics in PD-associated infection by Mycobacterium abscessus remains unclear, and it is an important topic for future discussion.

Peritoneal dialysis-associated catheter infection caused by Mycobacterium abscessus in an elderly patient who was successfully treated with catheter removal

An 89-year-old Japanese man on peritoneal dialysis (PD) was suspected of having a PD-associated catheter infection. He visited the hospital because of the discharge of pus from the exit site of his catheter. Gram staining of the pus showed Gram-positive bacilli, but these were acid-fast bacilli. The rapidly growing nontuberculous mycobacteria, Mycobacterium abscessus, was isolated. PD catheter removal and debridement were immediately performed. The patient received combination antibiotic therapy. His clinical course was good, but he required hemodialysis due to the discontinuation of PD. However, the patient and his family chose not to continue hemodialysis even when the symptoms of uremia appeared. Best supportive care was arranged by his primary care physician. M. abscessus is a rare causative organism for PD-associated catheter infections and is difficult to treat. In our case, a rapid and precise diagnosis was made using acid-fast staining and Mycobacterium culture. The risk of nontuberculous mycobacterial infections should be considered in patients on PD.

Disseminated Mycobacterium abscessus infection in a peritoneal dialysis patient

A disseminated peritoneal dialysis-related Mycobacterium abscessus infection is very rare. M. abscessus belongs to the rapidly growing mycobacteria and can be misidentified as a diphtheroid bacterium, which in our case delayed diagnosis and optimal treatment. Due to intrinsic resistance to most antimicrobials, therapeutic options in M. abscessus infections are limited. Infection often leads to catheter loss. A fatal outcome, like in our case, is not exceptional.