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Table of Contents
Year : 2020  |  Volume : 38  |  Issue : 1  |  Page : 30-33

Unusual organisms causing continuous ambulatory peritoneal dialysis peritonitis

1 Institute of Nephrology, Madras Medical College, Chennai, Tamil Nadu, India
2 Department of Microbiology, Madras Medical Mission, Chennai, Tamil Nadu, India

Date of Submission03-Feb-2020
Date of Decision30-May-2020
Date of Acceptance13-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. A T Maasila
Madras Medical College, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IOPD.IOPD_1_20

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Peritonitis is an important cause for morbidity and mortality in Continuous Ambulatory Peritoneal Dialysis (CAPD) patients. There is an emerging trend towards unusual organism causing CAPD peritonitis. We report our experience with unusual organisms and its impact on survival. We had 43 CAPD peritonitis episodes, out of which, six were due to unusual organisms. Although five patients responded to antibiotic therapy, one lost her CAPD access (catheter). Clinically, peritonitis caused by unusual organism is similar to that caused by other pathogens. Adherence to diligent hygienic practices while handling catheter and bag is most important in avoiding such peritonitis episodes.

Keywords: Continuous Ambulatory Peritoneal Dialysis, Peritonitis, unusual organisms

How to cite this article:
GaneshAravind S, Rohit A, Gopalakrishnan N, Dhanapriya J, Dineshkumar T, Sakthirajan R, Malathy N, Balasubramaniyan T, Maasila A T. Unusual organisms causing continuous ambulatory peritoneal dialysis peritonitis. Indian J Perit Dial 2020;38:30-3

How to cite this URL:
GaneshAravind S, Rohit A, Gopalakrishnan N, Dhanapriya J, Dineshkumar T, Sakthirajan R, Malathy N, Balasubramaniyan T, Maasila A T. Unusual organisms causing continuous ambulatory peritoneal dialysis peritonitis. Indian J Perit Dial [serial online] 2020 [cited 2023 Jun 5];38:30-3. Available from: http://www.ijpd.org.in/text.asp?2020/38/1/30/305750

  Introduction Top

Staphylococcus epidermidis and Staphylococcus aureus are common pathogens causing CAPD peritonitis,[1] followed by Gram-negative organisms and fungi. However, recently there are increasing reports of rare and unusual organisms causing CAPD peritonitis.[2] Unusual organisms are usually considered as contaminants or organisms with low pathogenic potential.[3] However, these organisms have recently been recognized as opportunistic human pathogen in immunocompromised and debilitated patients with foreign synthetic intravascular and Peritoneal Dialysis (PD) catheters.[4] Advancement and automation in microbiological diagnostic techniques have paved way for better identification of such unusual organisms and treating challenging infective episodes in an efficient manner. Peritonitis still remains the leading cause for discontinuation of CAPD as therapeutic modality for chronic kidney disease.

  Case Report Top

We had 43 acute CAPD peritonitis episodes between August 2013 and December 2017. As per International Society of Peritoneal Dialysis (ISPD) 2016 guidelines, we used following techniques for culture and sensitivity: BactAlert, Chocolate blood agar, sheep blood agar (bacteria), Sabouraud dextrose chloramphenicol agar (fungal Culture), MGIT 320 (Mycobacterium tuberculosis) and Gaspak system (anaerobic organism). Pseudomonas spp and coagulase negative Staphylococcus spp were common pathogens, followed by Escherichia coli.

Out of these, six episodes were due to unusual organisms [Table 1]. Eradication of infection could be achieved in these patients with 'unusual organism peritonitis' by using empirical antibiotic therapy (as suggested by international society of peritoneal dialysis) except for one patient (Rhodotorula) in whom CAPD catheter was removed. Catheter was reinserted after 8 months of removal, and currently she is doing well with continuous ambulatory peritoneal dialysis. Observed risk factors for occurrence of such infections in our study group were previous history of CAPD peritonitis, intraperitoneal administration of antibiotics (in three patients), unhygienic handling of catheter, diabetes mellitus, smoking and thorn prick (specifically in patient with Pantoea peritonitis).
Table 1: Case series of unusual organism causing continuous ambulatory peritoneal dialysis peritonitis

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  Discussion Top

Unusual microbes can cause clinically significant human disease. Similar to common organisms (Pseudomonas spp, coagulase negative Staphylococcus spp and Escherichia coli – common organisms in our CAPD program), unusual organisms can affect patient and technique survival. Simple contact of CAPD catheter with non-sterile surface can lead to peritonitis. Hence adherence to hygienic practices in handling CAPD catheter and bags is very important to avoid contamination with unusual pathogens.

Pantoea agglomerans (Previously named Enterobacter agglomerans and Erwinia herbicola) is a gram negative aerobic bacillus. It can be isolated from plants, fruits, vegetable and feculent material.[1] Transmission occurs through thorn injuries, intravenous catheters, periodontal diseases, contaminated parenteral nutrition, intravenous fluids and anaesthetic agents.[2] Among CAPD patients, rate of peritonitis caused by this organism has significantly increased in recent years. Incubation period and pathogenesis of the disease in CAPD patients remains unclear. Inappropriate growth media and identification methods could be the reason for frequent negative results. P.agglomerans peritonitis shows good response to antibiotics such as ciprofloxacin and aminoglycoside.[4] So far there were around 8 reports of CAPD associated pantoea infection in literature. Except for one report of death, most of these episodes were benign.[3],[4],[5]

Rhodotorula (basidiomycetous yeast) belongs to fungal family sporidiobolaceae.[6] It is a normal gastrointestinal flora. Rhodotorula mucilaginosa (74%), R. glutinis (7.7%), R. minuta are common species of this ubiquitous saprophytic yeast. Fungemia, endocarditis, peritonitis, meningitis, and endophthalmitis are clinical manifestations of Rhodotorula infection reported in literature.[7] Past history of bacterial peritonitis and antibiotic therapy were main predisposing factors for fungal peritonitis. Since Rhodotorula produces orange red colonies in Sabouraud Dextrose Chloramphenicol agar, it can be identified earlier than other fungi [Figure 1]. Rhodotorula has intrinsic resistance to triazoles and echinocandins. Treatment should include catheter removal; antifungal therapy with amphotericin, 5-flucytosine and occasionally azoles.[8] Rate of successful re-initiation of CAPD is significantly low following filamentous fungal infection due to peritoneal adhesion. In literature review, we found 12 reports of Rhodotorula associated CAPD peritonitis. CAPD catheter couldn't be salvaged in most of these patients. And mortality rate was also high among this group of population.[9],[10]

Moraxella catarrhalis, formerly known as Branhamella catarrhalis, is a fastitious gram negative, aerobic, non-motile diplococcus. Nasopharyngeal colonization is seen in 70 to 80% of children and 1–5% of adults.[11] Cardiopulmonary disease, chronic obstructive lung disease and cigarette smoking are common predisposing factors. Empirical choice of antibiotic therapy with vancomycin and ceftazidime, as recommended by the ISPD guidelines,[12] is effective in treating Moraxella related peritonitis. Since many strains of M. catarrhalis produce beta-lactamase, (mostly of the BRO-1 isotype), they have inherent resistance to penicillin, ampicillin and co-trimoxazole. One out of nine reported cases died due to Moraxella related peritonitis.[13],[14]
Figure 1: Rhodotorula produces orange red colonies in Sabouraud dextrose chloramphenicol agar

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Neisseria spp. is a gram-negative, oxidase-positive, aerobic, non-motile, rod-shaped organism. Neisseria is an oropharyngeal flora. Poor nutrition and chronic kidney disease could be the predisposing factors for developing Neisseria peritonitis. From previous case reports, it is clear that Neisseria peritonitis can be successfully treated with appropriate antibiotics, without removal of the Tenckhoff catheter.[11] Reported cases in literature were around twelve. Except for a death, most of these episodes responded to antibiotic therapy.[15]

Sphingomonas paucimobilis (previously called Pseudomonas paucimobilis) is a gram negative bacillus with single polar flagellum, shows slow motility and produces yellow pigmented colonies. S. paucimobilis is isolated from hospital equipments (such as nebulizers, ventilators and humidifiers), and environmental sources (such as soil and water).[16] Absence of lipopolysaccharide in cell wall is responsible for its low virulence. Although Hseuh et al., suggested that imipenem alone or a third generation cephalosporine plus aminoglycoside could effectively treat S. paucimobilis,[17] there is no definitive guideline for treating this organism as of date. Literature analysis reveals that fifty percent of reported CAPD peritonitis cases were treated successfully with antibiotics alone, while the rest underwent CAPD catheter removal. So far, no death was reported but recurrence rate was high among patients with S. paucimobilis peritonitis.[18]

Pluralibacter gergoviae (previously Enterobacter gergoviae) is a gram negative bacillus which belongs to the family Enterobacteriaceae. It is isolated from natural environments, such as food, cosmetic products, soil and sewages. This urinary tract opportunistic pathogen is responsible for antibiotic-resistant hospital outbreaks. It has innate resistance to rifampicin, lincosamide, glycopeptides and fusidic acid which in turn is attributed to the bacterial outer membrane.[19] Resistance to Cephalosporin and quinolone is increasing among the Enterobactericeae species.[20] So far there was only one report of P. gergoviae associated CAPD peritonitis which ended up in CAPD catheter removal.[20]

Novel pathogens are emerging from the environmental and commensal bacterial flora as a result of horizontal pathogenic gene transfer and competitive selective pressures. Most of these organisms become pathogenic in order to compete with other microbes/to prevent predation or to obtain nutrition from the host. Given the enormous amount of ecological niches with which human comes in contact, and vast size of accessible supra-genomes available to each of the species in ecological niches, 'emergence of novel pathogens' is likely to be a permanent feature of human existence.[21]

Possible reasons behind the surge of unusual pathogens in recent years are recognition of these unusual environmental organisms as pathogen, newer treatment modalities with catheter, advanced microbiological techniques to identify microorganism, extensive use of broad spectrum antibiotics, short/long term parenteral nutrients, chemotherapy, immunosuppression therapy and organ transplantation.

Factors enhancing the virulence among these unusual organisms in CKD patients are weakened immune system, altered gut microbiota produced by uremic melieu, malnutrition and loss gut epithelial integrity.

Although peritonitis episodes in our series were amenable to common empirical antibiotics, few of these unusual organisms have intrinsic resistance to certain antibiotics posing a huge threat to patient and technique survival. It is also important to have a good rapport between the Nephrologist and the Microbiologist so that results can be correlated clinically especially when unusual pathogens are isolated.

  Conclusion Top

It is important to encourage adherence to strict infection prevention and control strategies while handling the permanent catheter. It is also very important to consider unusual microorganisms as virulent pathogens rather than contaminants, particularly, in patient with clinical relevance. Antibiotic sensitivity testing should always be ordered from the laboratory and patients should be treated accordingly. If there are no signs of improvement with antibiotic therapy for prescribed period, peritoneal catheter should be removed at the earliest.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Bottone E, Schneierson SS. Erwinia species: An emerging human pathogen. Am J Clin Pathol 1972;57:400-5.  Back to cited text no. 1
Boszczowski I, de Almeida J Jr., de Miranda EJ, Freire MP, Guimarães T, Chaves CE, et al. Nosocomial outbreak of Pantoea agglomerans bacteraemia associated with contaminated anticoagulant citrate dextrose solution: New name, old bug? J Hosp Infect 2012;80:255-8.  Back to cited text no. 2
Borràs M, Roig J, Garcia M, Fernández E. Adverse effects of pantoea peritonitis on peritoneal transport. Perit Dial Int 2009;29:234-5.  Back to cited text no. 3
Kahveci A, Asicioglu E, Tigen E, Ari E, Arikan H, Odabasi Z, et al. Unusual causes of peritonitis in a peritoneal dialysis patient: Alcaligenes faecalis and Pantoea agglomerans. Ann Clin Microbiol Antimicrob 2011;10:12.  Back to cited text no. 4
Moreiras-Plaza M, Blanco-García R, Romero-Jung P, Feijóo-Piñeiro D, Fernandez-Fernandez C, Ammari I. Pantoea agglomerans: The gardener's peritonitis? Clin Nephrol 2009,72:159-161.  Back to cited text no. 5
Fell JW, Boekhout T, Fonseca A, Scorzetti G, Statzell-Tallman A. Biodiversity and systematics of basidiomycetous yeasts as determined by large-subunit rDNA D1/D2 domain sequence analysis. Int J Syst Evol Microbiol 2000;50 Pt 3:1351-71.  Back to cited text no. 6
Samonis G, Anatoliotaki M, Apostolakou H, Maraki S, Mavroudis D, Georgoulias V. Transient fungemia due to Rhodotorula rubra in a cancer patient: Case report and review of the literature. Infection 2001;29:173-6.  Back to cited text no. 7
Tuon FF, Silvia F. Costa rhodotorula infection. A systematic review of 128 cases from literature. Rev Ibero Am Micol 2008;25:135-40.  Back to cited text no. 8
Unal A, Koc AN, Sipahioglu MH, Kavuncuoglu F, Tokgoz B, Buldu HM, et al. CAPD-related peritonitis caused by Rhodotorula mucilaginosa. Perit Dial Int 2009;29:581-2.  Back to cited text no. 9
Verdugo ZFJ, Briones E, Porte L, Fica JA. Fungal peritonitis due to Rhodotorula mucilaginosa in a patient with automated peritoneal dialysis. Literature review. Rev Chilena Infectol 2016;33:222-5.  Back to cited text no. 10
Sadjadi SA, Obedoza P, Annamarju P. Moraxella catarrhalis peritonitis. Am J Case Rep 2012;13:19-21.  Back to cited text no. 11
Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 2010;30:393-423.  Back to cited text no. 12
MacArthur RD. Branhamella catarrhalis peritonitis in two continuous ambulatory peritoneal dialysis patients. Perit Dial Int 1990;10:169-71.  Back to cited text no. 13
Hernandez-Egido S, Mateo AP, Cores-Calvo O, Ruiz-Ferraras E. Peritonitis due to Moraxella osloensis: A case report and review of literature. Rev Esp Quimioter 2016;29:161-3.  Back to cited text no. 14
Awdisho A, Bermudez M. A case report of Neisseria mucosa peritonitis in a chronic ambulatory peritoneal dialysis patient. Infect Dis Rep 2016;8:6950.  Back to cited text no. 15
Kawasaki S, Moriguchi R, Sekiya K, Nakai T, Ono E, Kume K, et al. The cell envelope structure of the lipopolysaccharide-lacking gram-negative bacterium Sphingomonas paucimobilis. J Bacteriol 1994;176:284-90.  Back to cited text no. 16
Hsueh PR, Teng LJ, Yang PC, Chen YC, Pan HJ, Ho SW, et al. Nosocomial infections caused by Sphingomonas paucimobilis: Clinical features and microbiological characteristics. Clin Infect Dis 1998;26:676-81.  Back to cited text no. 17
Mohan D, Railey M. Sphingomonas paucimobilis peritonitis: A case report and review of the literature. Saudi J Kidney Dis Transpl 2015;26:567-71.  Back to cited text no. 18
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Périamé M, Pagès JM, Davin-Regli A. Enterobacter gergoviae membrane modifications are involved in the adaptive response to preservatives used in cosmetic industry. J Appl Microbiol 2015;118:49-61.  Back to cited text no. 19
Rashid AM, Lim CT. Enterobacter gergoviae peritonitis in a patient on chronic ambulatory peritoneal dialysis – First reported case. Mal J Med Health Sci 2017;13:67-9.  Back to cited text no. 20
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