Journal of the Louisiana State Medical Society
CASE 4 The final case was a 60-year-old female who had origi- nally undergone laparoscopic peritoneal dialysis catheter placement at our center in October 2013 and had been dialyzing through this catheter without issues until Febru- ary 2014. It was at this time that the dialysis center noticed seropurulent drainage at the exit site and obtained cultures. The patient denied any other symptoms of illness and was prophylactically started on ciprofloxacin and Augmentin by her dialysis center. The patient was referred to our center for further man- agement after culture results returned positive for AFB and subsequently, Mycobacterium fortuitum . Initial management consisted of cefoxitin 2 gm IV, as well as amikacin 7.5mg/ kg IV following dialysis, with the plan to treat the patient for three to four weeks and then attempt a catheter salvage procedure (as described in Case 2, above). Unfortunately, after two weeks of antibiotic treatment, the patient’s cath- eter began to malfunction, likely due to omental adhesions. Instead of trying to revise the catheter, she elected to have her peritoneal dialysis catheter removed. She will be con- tinued on her antibiotic regimen for a full six-week course. DISCUSSION The diagnosis and treatment of peritoneal dialysis ESI can be challenging. Diagnosis requires distinguishing nor- mal tissue reaction around the catheter from infection. The presence of a small amount of exudate or crust formation may occur in non-infected tissue; however, if infection does develop, the amount of exudate often increases. 2 Positive cultures from skin flora colonization also com- plicate the diagnosis. Most ESI are due to common bacterial pathogens, including gram-positive bacteria and occasion- ally, gram-negative organisms; and the majority of these
dition, we noticed evidence of infection developing at the new exit site. The patient was started on a six-week course of ceftazidime 2 gm IV q48hr after dialysis, amikacin 7.5 mg/ kg IV following dialysis, and ciprofloxacin 250 mg PO bid. We decided to remove the catheter at this point. The patient returned to the operating room for PD catheter removal and creation of an arteriovenous fistula. The patient has since completed his course of antibiotics but has elected to stay on hemodialysis. CASE 3 We performed a laparoscopic PD catheter placement in April 2013 on a 62-year-old Caucasian male with end-stage renal disease secondary to diabetes and hypertension. He had been on hemodialysis for two years before expressing a desire to switch to PD. In August 2013, the patient began experiencing seropurulent drainage at the catheter exit site without other signs of infection. The dialysis center per- formed cultures of this fluid, and the patient was empirically treated with topical gentamicin. Three weeks later, cultures turned positive for Mycobacterium abscessus chelonae (group name that encompasses both M. abscessus and M. chelonae ), and the patient was referred to our hospital for treatment. Following consultation with the infectious disease team and the review of culture sensitivities, the patient was started on clarithromycin 250 mg PO bid and amikacin 7.5 mg/kg IV following hemodialysis, and the catheter was removed. During removal, indication of subcutaneous in- fection was evidenced as a gelatinous purulent collection along the catheter (Figure 1). The patient completed a six-week course of antibiot- ics, and his wound healed completely. He has undergone repeat placement of PD catheter and is undergoing dialysis successfully.
bacterial ESI can be treated success- fullywith topical and oral antibiotics without removal of the catheter or interruption of peritoneal dialysis. 2,6 Conditions that make therapy more difficult include cuff and/or tunnel infections or infections due to resis- tant or virulent organisms, such as Pseudomonas sp ., Candida , or Myco - bacterium sp . In these cases, catheter removal is imperative, as there is a high failure rate with antibiotics alone; and untreated infections can progress from exit-site infections to tunnel infections and subsequently, to possible peritonitis. M. fortuitum , M. abscessus, and M. chelonei are subcategorized as rap- idly growing mycobacteria (RGM). They may grow on culture media within seven days versus two to
Figure 1
214 J La State Med Soc VOL 166 September/October 2014
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