three weeks for other nontuberculous mycobacteria (NTM). 7 Of the NTM, these three are the most common causes of community-acquired and nosocomial skin and soft tissue infections. 3 The overall incidence, however, is difficult to ascertain secondary to limited reporting and the sporadic nature of NTM infections. According to a report by the Centers for Disease Control and Prevention from the states Public Health Laboratory System (PHLIS) database, skin and soft tissue infections comprised only 2%of all NTM isolated. 7 In an epidemiologic study, it was found that within the United States, clusters of RGM infections appear to occur more frequently in southern coastal regions. 7 These organisms are present in a range of environments, includ- ing a mixture of soils in the Northern and Southern United States, tap water, municipal water supplies, and moist ar- eas in hospitals. 3,8,9 Other mycobacterial species associated with PD and having been reported as causes of peritonitis include M. gordonae , M. Kansasii , M. avium-intracellulare , and M. gastri . 3,10-12 Treatment of skin and soft tissue infections with RGM usually require a combination of antibiotics and surgical debridement, and removal of foreign bodies is essential to recovery. 7 Combination of two or more antibiotics is recommended to minimize development of resistance, and antibiotic choice should be guided by in vitro susceptibili- ties. Macrolides, fluoroquinolones, carbapenems, and ami- noglycosides are most commonly used. Treatment should last 6 to 10weeks. 7 Inmore serious infections, therapy should include parenteral amikacin or cefoxitin for approximately four weeks following removal of the indwelling catheter, and overall therapy should be continued for three to six months. 4,13,14 Published reports regarding the management of myco- bacterial infections in the peritoneal dialysis patient popula- tion are scarce. Most reports describe case series focusing on patients with peritonitis, 3,9,15-18 and only a few describe the management of catheter exit-site infections. 3,4,13 Interest- ingly, two of these series are from the state of Louisiana. 3,4 Although the majority of ESI with Mycobacterium sp . will require catheter removal, successful treatment of a M. fortuitum ESI without catheter loss has been documented. 3 In their report, White et al. treated one of their patients with oral ofloxacin 400 mg bid for six weeks, followed by an additional two weeks of oral ofloxacin 200 mg bid. The patient was maintained on PD during the treatment period, and the infection resolved without further intervention. In our series, an attempt at catheter salvage surgery was made for one patient with an ESI from M. fortuitum . However, we did not have final cultures showing NTM prior to the surgery (these returned two weeks after surgery), and the patient subsequently developed infection at the new exit-site as well, despite the initiation of appropriate antibiotics. It is possible that had the patient been on appropriate antibiotics at the time of the salvage surgery, the catheter might have been saved. Interestingly, in the case series by Tse et al., 13 that de- scribes a cluster of five cases of atypical mycobacterium ESI
within a 20-month period at an institution in Hong Kong, it was noticed that all patients had used topical gentamicin ointment for ESI treatment or prophylaxis. Furthermore, in one patient, following removal of the gentamicin ointment, the infection cleared on its own. They postulated that growth of these organisms might be enhanced further in areas where there is an overall warmer climate and increased humidity, such as theirs. More recent reports have also implicated gen- tamicin as a potential risk factor for mycobacterial ESI due to its selective pressure on other microorganisms. 19 In our series, none of the patients were treated with prophylactic gentamicin, although one was started on it upon concern of a presumed bacterial ESI. CONCLUSION Atypical mycobacterial infections of PD catheter exit- sites are rare, yet the few cases described in the literature occurred in warm and humid climates, such as Louisiana. We report here our experience with a cluster of cases at an institution inNewOrleans. Further thorough epidemiologic studies are needed to identify the incidence of ESI and geographic variation. They are often difficult to recognize and treatment may require catheter removal and long-term therapywith dual antibiotic regimens. Successful reinitiation of PD is possible after treatment, as we have demonstrated. Catheter salvage has been reported but should be attempted under the umbrella of appropriate antibiotic coverage. In 2011, the Centers for Medicare and Medicaid (CMS) introduced a new bundling system for payment of dialysis services. 20 This encourages the use of home dialysis thera- pies, especially PD. In this setting of increased PDutilization, clinicians should be alert for atypical infections such as these. REFERENCES 1. Vas SI. Peritonitis, in Nolph KD (ed). Peritoneal dialysis (ed 3). Dordrecht, The Netherlands. Kluwer Academic Publishers. 1989: 261-288. 2. Twardowski ZJ. Peritoneal catheter exit-site and tunnel infections, in Nissenson AR, Fine RN. Dialysis therapy (ed 3). Philadelphia, PA. Hanley & Belfus, Inc. 2002: 239-244. 3. White R, AbreoK, FlanaganR, et al. Nontuberculousmycobacterial infections in continuous ambulatory peritoneal dialysis patients. Am J Kidney Dis . 1993; 22(4):581-587. 4. Kleinpeter M, Krane K. Treatment of mycobacterial exit-site infections in patients on continuous ambulatory peritoneal dialysis. Adv Perit Dial . 2001; 17:172-175. 5. Cheung AH, Wheeler MS, Limm WM, Wong LL, Fan FL, Wong LM. A salvage technique for continuous ambulatory peritoneal dialysis catheters with exit-site infections. Am J Surg . 1995; 170(1):60-61. 6. Gokal R, Alexander S, Ash SR, et al. Peritoneal catheters and exit- site practices toward optimumperitoneal access: 1998 update. Perit Dial Int . 1998; 18:11–33. 7. Griffith DE, Aksamit T, Brown-Elliott BA. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med . 2007; 175(4):367- 416.
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