Atypical Mycobacterial Infections of Peritoneal Dialysis Catheter Exit Sites - A Louisiana Issue
Adam Hauch, MD, MBA; Bridget Ory, MD; Anil Paramesh, MD, FACS
Exit-site infections involving peritoneal dialysis catheters are a cumbersome issue that can be difficult to manage. Such infections are usually due to gram-positive organisms and are often treated successfully with oral and/or topical antibiotics. Infections associated with Mycobacterium sp . are much more rare and difficult to treat. We report our experience with four cases of exit-site infections with Mycobacterium sp . in the New Orleans area, along with a review of risk factors and current literature.
BACKGROUND Infectious complications of long-termPeritoneal Dialy- sis (PD) most often include peritonitis and exit-site infections (ESI) of the catheter. In fact, up to 31% of individuals will experience an ESI within the first year of PD. 1 ESI are most commonly due to gram-positive bacteria, occasionally to gram-negative organisms, and less commonly to fungi and mycobacteria. 2,3 Mycobacterial infections, such as Mycobacterium tuber - culosis or nontuberculous (atypical) mycobacterial (NTM) species, often present as indolent infections refractory to treatment with antibiotics. These mycobacterial infections are infrequent, and there have been few documented case reports in the literature to date. Interestingly, several of these reports come from remote cases occurring throughout the Louisiana area, some of these more than two decades ago. 3,4 Given the sporadic nature of these infections and the limited data on their management, as well as the seemingly relative frequency with which they occur in this area, it seems prudent that we report the management and out- comes of four cases of NTM PD catheter infections at our institution in New Orleans. CASE 1 The first patient, a 70-year-old Caucasian woman with a history of hypertension and diabetes, had a PD cath- eter placed in January of 2010. She presented in July 2010 with complaints of intermittent purulent drainage from the catheter exit site for several weeks. The catheter was functional, and the patient denied systemic symptoms of illness. Cultures from the peritoneal fluid and the exit site were negative. However, because of its appearance, the decision was made to remove the PD catheter. Hemodialysis was initi- ated through the patients existing arteriovenous fistula for
approximately four to six weeks, at which time a new PD catheter could be placed. At the time of catheter removal, initial cultures demonstrated no organismgrowth; however, final culture results almost three weeks later grew Myco - bacterium abscessus . After consultation with our infectious disease staff, the patient was placed on azithromycin 250 mg PO qday and moxifloxacin 400 mg PO qday. After five weeks of treatment with the combined regi- men, the exit site demonstrated marked improvement and the patient did very well clinically. Moxifloxacin was dis- continued, and the patient was maintained on azithromycin for a full four-month course for extrapulmonary localized infection due to M. abscessus . Following completion of her antibiotic treatment, the patient underwent successful laparoscopic placement of a new PD catheter, which is still functioning without issues. CASE 2 The second case was a 67-year-old Caucasianmale with ESRD secondary to hypertensionwho had a laparoscopic PD catheter placed in February 2013. In May 2013, the patient developed purulent drainage from the catheter exit site without other signs of systemic infection. Peritoneal fluid cultures were negative. Cultures of the exit-site were performed, and in an attempt to salvage the catheter, the distal portion of the catheter with the subcutaneous cuff was excised, leaving the intraperitoneal segment intact. There were no signs of infection noted in the subcutaneous tissue where the cath- eter was divided. The residual stump of the catheter was attached to an extension catheter and routed subcutaneously to an alternate exit-site, remote from the infected area in a fashion similar to the one first describe by Cheung et al. 5 This allowed continuation of PD without interruption. Two weeks later, the final exit-site culture results from two different samples grew Mycobacterium fortuitum . In ad-
J La State Med Soc VOL 166 September/October 2014 213
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