Year : 2020 | Volume
: 38 | Issue : 1 | Page : 36--38
A rare case of early Burkholderia cepacia peritonitis in a chronic ambulatory peritoneal dialysis patient
Sambit Sahoo1, Arvind Achra1, B Muthukumar2, Shiwangi Sharma1,
1 Department of Microbiology, ABVIMS and Dr. RML Hospital, New Delhi, India
2 Department of Nephroology, ABVIMS and Dr. RML Hospital, New Delhi, India
Dr. Arvind Achra
Department of Microbiology, ABVIMS and Dr. RML Hospital, New Delhi - 110 001
Continuous ambulatory peritoneal dialysis (CAPD) is one of the preferred forms of renal replacement therapy. However, peritonitis is the leading cause of morbidity and mortality associated with CAPD. Here, we report a case of Burkholderia cepacia peritonitis which required combination of antibiotics and catheter removal for its treatment.
|How to cite this article:|
Sahoo S, Achra A, Muthukumar B, Sharma S. A rare case of early Burkholderia cepacia peritonitis in a chronic ambulatory peritoneal dialysis patient.Indian J Perit Dial 2020;38:36-38
|How to cite this URL:|
Sahoo S, Achra A, Muthukumar B, Sharma S. A rare case of early Burkholderia cepacia peritonitis in a chronic ambulatory peritoneal dialysis patient. Indian J Perit Dial [serial online] 2020 [cited 2021 May 14 ];38:36-38
Available from: https://www.ijpd.org.in/text.asp?2020/38/1/36/305757
End-stage renal disease (ESRD) patients require some form of renal replacement therapy (RRT) for their survival. Dialysis either hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD) remain the commonly used forms of RRT. CAPD is advantageous over HD as it allows patient's greater freedom to perform daily activities and preserve residual renal function in the initial years. However, the long-term effectiveness of CAPD is limited by infectious as well as noninfectious complications.
Among the infectious complication, peritonitis is the leading cause of morbidity and mortality. It is also a major determinant affecting technical survival, shifting to HD and mortality varying from 1% to 6%.,, Commonly associated Gram-positive organisms are coagulase-negative Staphylococci and Staphylococcus aureus., The incidence of Gram-negative peritonitis is rising and multidrug-resistant Enterobacteriacea and Pseudomonadales are the most commonly implicated organisms. Gram-negative peritonitis is usually associated with increased morbidity and mortality.
Burkholderia cepacia is a Gram-negative, aerobic, glucose nonfermentative bacillus, in the family Burkholderiaceae. This bacterium is ubiquitous and could survive in nature with minimum nutritional needs. It has been isolated from soil, water, plants, contaminated disinfectants, and medical devices. It is an opportunistic pathogen, particularly in patients of cystic fibrosis and chronic granulomatous diseases. It is also an important nosocomial pathogen and causative agent of various hospital acquired infections., Peritonitis caused by B. cepacia had rarely been documented in patients with CAPD. Here, we report a case of peritonitis caused by B. cepacia in a patient on CAPD.
A 62-year-old chronic smoker, hypertensive for the past 18 years with poor compliance to medications developed edema of legs around 2 years back and was diagnosed to have chronic kidney disease secondary to hypertensive nephropathy. Due to worsening renal function and uremic symptoms, he was labeled as ESRD and advised for initiation of RRT. He preferred CAPD which was initiated 1 month back. He was given preprocedural antibiotics, trained in the hospital for 7 days and was discharged with instructions to perform peritoneal dialysis (PD) at his residence. He was advised for three PD exchanges in a day and 2% mupirocin ointment and 10% povidone iodine for exit site care. The patient presented to the department of nephrology with nausea, vomiting, diffuse abdominal pain and turbid peritoneal effluent for 4 days. He was afebrile (37.2°C) at the time of admission and denied any breach in technique or any diarrheal episodes. The exit site was healthy without any pain, discharge, or redness. Based on clinical symptoms, the patient was presumed to have developed peritonitis and empirically injection vancomycin (1 g) + ceftazidime (1 g) were given intraperitoneally after collection of samples for laboratory investigation.
Samples collected at the time of admission revealed high white blood cells (WBCs) count of 16.3 × 109/L with 70% polymorphonuclear cells. PD effluent was turbid with 1500 leukocytes/μL (normal values <100 leukocytes/μL) with 80% polymorphs and serum C-reactive protein was 19 mg/L.
Peritoneal effluent collected for culture at the time of admission grew B. cepacia on 3rd day and was found susceptible to levofloxacin, cotrimoxazole, ceftazidime, imipenem, meropenem, and doxycycline by Vitek 2. The isolate was resistant to ampicillin, amoxicillin-clavulanate, and piperacillin-tazobactam. Blood culture and exit site swab collected at the time of admission remained sterile.
After obtaining the antibiogram result on the 4th day, intraperitoneal ceftazidime was continued and intravenous injection imipenem-cilastatin 500 mg once daily in alternate exchanges was also started in view of turbid effluent with total WBC count of 1200 cells/μl and a repeat culture was performed after 2 days. This time also B. cepacia was isolated with similar antibiogram pattern and effluent WBC was also not improving (950 cells/μl with 80% polymorphs). He was advised for catheter removal but he denied for the same and wished to continue therapy for 3 more days.
In view of persistent turbid effluent, peritoneal catheter was removed and he was shifted to HD on 8th day. The patient improved symptomatically and was discharged on 10th day with modified dose of oral cotrimoxazole and doxycycline for further 7 days. He was advised to continue maintenance HD.
B. cepacia is an opportunistic pathogen causing disease in immunocompromised and hospitalized patients. In our case, B. cepacia was isolated from CAPD effluent. The possible predisposing conditions were long-term hypertension and ESRD. CAPD requires stringent hygienic activities and topical antibiotics for exit site care. Antiseptic solutions such as aqueous chlorhexidine have been implicated as source of infection with B. cepacia. We could not get any sample of the antiseptic solution for investigation this patient was using at his home. This patient belonged to rural area and developed peritonitis during rainy season. A case of repeated peritonitis has been reported with similar ecological conditions.
Exit site infection has been previously reported with this organism but it was not seen in this case and infection was limited to peritoneum. Early infection in a month after initiation of CAPD probably due to breach in the sterile technique and contamination of the catheter could be the reason for peritonitis.
Infections with B. cepacia are difficult to treat and require prolonged treatment with a combination of antibiotics. Oral cotrimoxazole therapy has been the antibiotic of choice for Burkholderia infections. Combination therapy with piperacillin-tazobactam, ceftazidime, and imipenem is also used in hospitalized patients. This patient was treated with intraperitoneal injection ceftazidime which was started empirically and continued after culture reports along with injection imipenem-cilastatin 500 mg in alternate exchanges. Even with combination of antibiotics the peritonitis did not respond. Biofilm formation on catheter could be the cause for nonresponse to combination of antibiotics as prompt clinical improvement was noted on removal of catheter. The International Society of Peritoneal Dialysis (ISPD) suggests the removal of a peritoneal catheter if no clinical improvement is observed after 5 days of appropriate antibiotic treatment to limit infection by removing the source and to preserve peritoneal membrane. Delay in presentation to hospital and hence delayed initiation of the treatment could be another added factor. The level of education, socioeconomic strata and confidence of doing PD are important determinants in success of CAPD.
Although peritonitis caused by Burkholderia spp. are not very common, physicians should keep in mind the possibility of this organism in the patients coming from rural setting particularly in the early period of CAPD. Proper training, reinforcement of sterile practices, and early presentation to hospital should be encouraged to avoid such infectious complications which may lead to failure of PD, catheter removal and switching to HD. Further B. cepacia is a difficult to treat infection, may necessitate early catheter removal as suggested by ISPD guidelines to preserve peritoneal membrane and to prevent recurrent peritonitis.
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Conflicts of interest
There are no conflicts of interest.
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