Non-Tuberculous Mycobacterial Infections Related to Peritoneal Dialysis

Continuous Ambulatory Peritoneal Dialysis Peritonitis Guidelines - Consensus Statement of Peritoneal Dialysis Society of India - 2020

Continuous ambulatory peritoneal dialysis (CAPD) related peritonitis is a major cause of technique failure, morbidity, and mortality in patients on CAPD. Its prevention and management is key to success of CAPD program. Due to variability in practice, microbiological trends and sensitivity towards antibiotics, there is a need for customized guidelines for management of CAPD related peritonitis (CAPDRP) in India. With this need, Peritoneal Dialysis Society of India (PDSI) organized a structured meeting to discuss various aspects of management of CAPDRP and formulated a consensus agreement which will help in management of patients with CAPDRP.

Approach to the diagnosis and treatment of non-tuberculous mycobacterial disease

Non-tuberculous mycobacteria (NTM) is a collective name given to a group of more than 190 species of Mycobacterium. The clinical presentation for most NTM infections is non-specific, often resulting in delayed diagnosis. Further complicating matters is that NTM organisms can be difficult to isolate. Medications used to treat NTM infection can be difficult for patients to tolerate, and prolonged courses of anti-mycobacterial therapy are often required for adequate suppression or eradication. Herein, we review different NTM syndromes, appropriate diagnostic tests, and treatment regimens.

Opportunistic peritonitis in peritoneal dialysis: The example of Paracoccus yeei

Paracoccus yeei, a Gram-negative coccobacillus, is an emergent opportunistic pathogen. It originates from soil and water. VITEK and MALDI-TOF are used for identification. There are few reports of peritoneal dialysis peritonitis. Its presentation is usually indolent. It can be successfully treated with several antibiotics: β-lactams, aminoglycosides, without removing the catheter.

Simultaneous catheter removal and reinsertion, is it acceptable in M. abscessus exit site infection?

In recent times, increasing reports of exit site infections (ESI) in peritoneal dialysis (PD) patients related to environmentally acquired atypical organisms, such as nontuberculous mycobacterium (NTM), have been reported in the literature. Among these NTM, Mycobacterium abscessus (M. abscessus) is unique and is associated with high morbidity and treatment failure rates. The international society of PD guidelines suggests individualizing therapeutic options for NTM-related ESI. Moreover, the guidelines encourage simultaneous catheter removal and reinsertion (SCRR) in isolated ESI, not responding to antimicrobial therapy to avoid PD interruptions. Physicians should be aware of the limitations of such approaches as delay in appropriate PD catheter intervention can be fraught with complications in patients with M. abscessus ESI. We report an M. abscessus ESI in a PD patient who underwent SCRR in conjunction with targeted antimicrobial therapy, and developed M. abscessus peritonitis requiring PD catheter removal and conversion to hemodialysis. The patient also developed ESI at the new exit site long after the PD catheter was removed, requiring prolonged antimicrobial therapy. Our case, taken together with available published case reports, highlights the futility of the SCRR approach towards the M. abscessus ESI and makes the cases for early PD catheter removal in these patients.

Simultaneous catheter removal and reinsertion, is it acceptable in M. abscessus exit site infection?

In recent times, increasing reports of exit site infections (ESI) in peritoneal dialysis (PD) patients related to environmentally acquired atypical organisms, such as nontuberculous mycobacterium (NTM), have been reported in the literature. Among these NTM, Mycobacterium abscessus (M. abscessus) is unique and is associated with high morbidity and treatment failure rates. The international society of PD guidelines suggests individualizing therapeutic options for NTM-related ESI. Moreover, the guidelines encourage simultaneous catheter removal and reinsertion (SCRR) in isolated ESI, not responding to antimicrobial therapy to avoid PD interruptions. Physicians should be aware of the limitations of such approaches as delay in appropriate PD catheter intervention can be fraught with complications in patients with M. abscessus ESI. We report an M. abscessus ESI in a PD patient who underwent SCRR in conjunction with targeted antimicrobial therapy, and developed M. abscessus peritonitis requiring PD catheter removal and conversion to hemodialysis. The patient also developed ESI at the new exit site long after the PD catheter was removed, requiring prolonged antimicrobial therapy. Our case, taken together with available published case reports, highlights the futility of the SCRR approach towards the M. abscessus ESI and makes the cases for early PD catheter removal in these patients.

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.

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.

Cause Analysis of an Infection in Facelift Surgery Due to Mycobacterium chelonae

We report a post-facelift infection due to Mycobacterium chelonae. An environmental strain recovered from the water supply network of the surgical clinic and the clinical strains were considered non-differentiable using whole genome sequencing. After the unhealed wound's exposure to M. chelonae while showering early at the clinic after surgery, a lasting exposure of the colonized wound to the warm and moist working conditions of a bakery may have been favorable to the infection's development.