Nontuberculous mycobacteria infections of peritoneal dialysis patients: A multicenter study

Unusual and complicated peritonitis: Your questions answered

Effective treatment of infections is a growing challenge owing to antimicrobial resistance. Peritoneal dialysis (PD) patients experience more frequent hospitalisations than the general population and have greater exposure to antibiotics, making them particularly vulnerable to this threat. Over the last decade, we have noted a surge in cases of complicated peritoneal dialysis-associated peritonitis (PD peritonitis) caused by antimicrobial-resistant organisms, including extended-spectrum beta-lactamase (ESBL), AmpC beta-lactamase-producing Enterobacterales, Pseudomonas aeruginosa and fungi. Practitioners must be alert to these organisms, seek early recognition of these resistance patterns and make timely adjustments in order to avoid delay in treatment that may increase risk of PD catheter removal and technique failure. We present a case of successful treatment of ESBL peritonitis, highlight its challenges, while providing guidance on management of other unusual and complicated PD peritonitis.

Fatal peritoneal dialysis-associated peritonitis caused by Mycobacterium mageritense: a case report with review

Background

Peritonitis is a serious and potentially fatal complication of peritoneal dialysis. We report a case of fatal peritonitis caused by Mycobacterium mageritense that was detected for the first time in peritonitis.

Case presentation

A male patient in his 60 s undergoing peritoneal dialysis was admitted for catheter diversion with exit-site renewal. The patient had a refractory exit-site infection. Mycobacterial culture was not performed at the exit site prior to admission. After the surgery, the patient developed a fever, and a cloudy effluent was observed. Various antibiotics, including anti-tuberculosis drugs, were administered; however, his symptoms did not improve. The catheter was removed on the thirty-seventh day of admission. Bacteria positive for Ziehl–Neelsen staining were found in the peritoneal sample collected during the surgery. Since nontuberculous mycobacteria were considered the cause of peritonitis, the patient was administered imipenem/cilastatin, amikacin, and clarithromycin. However, he died of septic shock on the fifty-first day after admission. Mycobacterium mageritense was detected in the ascites culture after death.

Conclusion

This is, to our knowledge, the first report of peritonitis caused by Mycobacterium mageritense. In patients undergoing peritoneal dialysis, when a refractory exit-site infection is observed, mycobacterial culture is necessary to prevent the development of peritonitis.

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment

Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.

Mycobacteria avium-related peritonitis in a patient undergoing peritoneal dialysis: case report and review of the literature

BACKGROUND

Mycobacteria avium (M. avium) is a species of ubiquitous slowly growing nontuberculous mycobacteria. It causes opportunistic infections. However, M. avium-related peritonitis in peritoneal dialysis (PD) patients is rare.

CASE PRESENTATION

A 51-year-old female end-stage kidney disease patient undergoing PD was admitted for a noninfectious complication. She presented catheter exit site drainage and slightly increased PD effluent white cell count (WCC) with polymorphonuclear predominance on admission. Exit site infection and PD-related peritonitis were diagnosed. Repeated cultures of effluent and drainage were negative. Initial empirical antibiotics and further adjustment were not rewarding. PD was terminated 2 weeks later, however, shortly the patient developed stupor, high fever, peritoneal irritation, and spontaneous chylous ascites, and showed elevated ascitic adenosine deaminase (ADA). The manifestations persisted and the patient's general condition deteriorated despite intensified antibiotic therapy. Massive parallel sequencing identified M. avium in ascites on hospital day 25, and 4-drug treatment with azithromycin, amikacin, rifampin, and ethambutol was initiated. Nevertheless, the patient died from sepsis on hospital day 30.

CONCLUSIONS

We report a case of PD-related M. avium peritonitis. Prolonged culture-negative peritonitis, chylous ascites, and elevated ascitic ADA may hint the possibility of mycobacterial infections. Diagnostic method allowing prompt identification of the pathogen is warranted. The prognosis can be extremely poor, and the prophylaxis and treatment should be better defined.

Clinical course of peritoneal dialysis-related peritonitis due to non-tuberculosis mycobacterium - A single centre experience spanning 20 years

BACKGROUND

Peritoneal dialysis (PD)-related peritonitis caused by non-tuberculous mycobacteria (NTM) are difficult to diagnose, is associated with significant morbidity and mortality, and clinical course remains unclear. We determined the prevalence and clinical course of peritonitis caused by these organisms through our kidney registry over 20-year period.

METHOD

We reviewed all patients with NTM peritonitis identified in our tertiary centre between July 2000 and July 2020. The demographic characteristics, microbiological and clinical outcomes were examined.

RESULT

Among 27 patients identified, 20 patients presented with abdominal pain and all had cloudy peritoneal fluid. Twenty-one cases had concomitant exit site infection and 14 cases had prior antibiotic use. The majority of the cases are caused by Mycobacterium chelonae (37%) and Mycobacterium fortuitum (29.7%), with most being resistant to fluoroquinolones (59.3%) and cefoxitin (73.1%). They are all sensitive to amikacin otherwise. None of the cases achieve primary response at day 10 and 20 cases resulted in Tenckhoff catheter removal. Only two of them were able to resume PD. Eight patients died in our cohort. The presence of exit site infection, the use of prior antibiotics and topical disinfectants did not associate with a poorer outcome.

CONCLUSION

NTM peritonitis remains difficult to treat and often with a delay in diagnosis. Refractory peritonitis with negative culture and a poor response to standard antibiotics should raise a possibility of NTM infection and prompt catheter removal and an expert with experience treating NTM infections should be consulted.