Peritoneal catheter exit-site infections caused by rapidly-growing atypical mycobacteria
Covadonga Hevia,
M. Auxiliadora Bajo,,
J. Antonio Sánchez-Tomero1,
Gloria del Peso,
Antonio Fernández-Perpén1,
Isabel Millán,
Abelardo Aguilera and
Rafael Selgas1
Servicio de Nefrología, Hospitales Universitarios La Paz and
1 La Princesa, Madrid, Spain
Keywords: exit-site infection; Mycobacterium chelonae; Mycobacterium fortuitum; peritoneal dialysis; rapidly-growing Mycobacteria
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Introduction
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The incidence of mycobacteriae infections has grown rapidly over the last few years. In particular, non-tuberculous mycobacteriae infections, especially those caused by Mycobacterium fortuitum and Mycobacterium chelonae, are becoming highly prevalent [1]. Several cases of peritonitis due to these organisms among patients receiving peritoneal dialysis (PD) have been described [2,3]. Although peritoneal catheter exit-site infections are very rare [46], we report here five cases, one of which was complicated by peritonitis.
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Cases
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Case 1
A 61-year-old woman diagnosed with diabetes mellitus and hypertension started PD in August 1993 and progressed well until September 1994. At this time, she presented with a granuloma and purulent drainage from the catheter sinus. Drainage culture revealed Corynebacterium and Staphylococcus epidermidis, which were eradicated after treatment with vancomycin and mupirocin. Subsequently a purulent discharge appeared and all cultures were negative. Two acid-fast stains, the last performed in June 1995, were also negative. Two months later the infection was accompanied by a peritonitis episode. At this time the peritoneal effluent and exit-site drainage culture showed growth of M. chelonae. The peritoneal catheter was removed and the patient was treated for 2 months with varying combinations of antibiotics recommended by sensitivity testing (ciprofloxacin, clarithromycin and amikacin), she suffered from side effects including vomiting, hepatic alterations and anaemia. The patient refused to continue PD and was transferred to haemodialysis.
Case 2
A 27-year-old woman with renal failure due to systemic lupus erythaematosus was treated with PD for 16 months. During this time, she observed granulation tissue and purulent discharge at the catheter exit-site. Repeated cultures were negative until August 1995. At that time M. fortuitum was isolated and treatment with clarithromicin and ciprofloxacin commenced. It was necessary to replace these antibiotics by amikacin and doxycyclin due to gastric intolerance. The duration of treatment was 1.5 months. In September 1995, the catheter was prophylactically removed and substituted with another 5 days later, with no recurrence of the mycobacterial infection. In June 1997, the second catheter was removed after she received a successful renal allograft. No recurrence appeared.
Case 3
A 67-year-old woman with renal failure due to tubulointerstitial disease had been treated with PD for 5 months when she observed an exit-site granuloma with purulent drainage. Staphylococcus epidermidis and Corynebacterium, isolated in culture, disappeared after correct treatment, but signs of infection persisted. In August 1995, the exit-site was incised and M. fortuitum grew in the purulent material cultured. Treatment with clarithromycin and ciprofloxacin was administered for 1 month, followed by clarithromycin for an additional month. Symptoms disappeared and the follow-up over 3 months after onset revealed no clinical recurrence. In October 1996, the patient received a kidney transplant and the catheter was removed.
Case 4
A 20-year-old man diagnosed with haemolytic uraemic syndrome received a peritoneal catheter in May 1997 with good outcome until October. At this time, he showed an exit-site infection characterized by indolent purulent discharge with redundant negative cultures and a giant granuloma. Finally, M. fortuitum was isolated and treatment was initiated with ciprofloxacin and clarithromicin. The former was withdrawn due to nausea and vomiting and clarithromicin was continued for 3 months. The granuloma was treated with gentian violet and completely disappeared. The infection was cured and 
the peritoneal catheter remained. The patient currently continues on PD 11 months after this treatment without recurrence of infection.
Case 5
A 65-year-old man with focal sclerosing glomerulonephritis started PD at the beginning of 1998. In May, he presented with an exit-site infection with granuloma and suppuration and no bacterial growth for a month. The eventual identification of M. fortuitum indicated treatment with ciprofloxacin and clarithromicin for 2 weeks, followed by quinolone for a further 3 weeks (clarithromicin was discontinued due to gastric intolerance). The exit-site improved, but 2 months later a purulent discharge recurred and cultures showed the same organism. The treatment on this occasion was amikacin (2 weeks) and cefoxitin (6 weeks). The granuloma, previously treated unsuccessfully with silver nitrate, was resolved with gentian violet. The exit-side infection was cured.
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Discussion
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Non-tuberculous mycobacteriae infections were first described a century ago. In the 1950s, Timpe and Runyon proposed a method of classification (photochromogens, scotochromogens, nonchromogens and rapid growers) [7] that is still in use. The last of these classifications takes its name from the capacity to grow in special culture media in a shorter period of time than other mycobacteria (710 days). They may also grow in ordinary culture media, but the time required is longer than that for other pathogens found in routine bacteriology. The rapid growers are Gram-positive rods that resemble diphteroids on Gram stain, and with which they may be mistaken (occasionally they may be considered contaminants). These ubiquitous organisms survive nutritional deprivation and extreme temperatures, and are present in a variety of environments, including water, soil, dust and contaminate biologicals. Mycobacterium fortuitum and M. chelonae are the major pathogens in this group, and skin and soft tissue infections (suppuration, abscess and granuloma) are the most frequent manifestations [1].
In PD, they are not commonly considered as possible infection-causing pathogens although several cases of peritonitis have been described [2,810]. Peritoneal catheter exit-site infections are very rare [46]. The five cases we present here (Table 1
) were seen among 320 PD patients (prevalence 1.6%). None had undergone surgery other than peritoneal catheter placement. All infections were characterized by a granuloma and indolent purulent discharge with redundant negative cultures (over 211 months), as have been described by others [5]. One patient suffered a peritonitis episode as a complication. This was the only case caused by M. chelonae, which is described as being more aggressive than M. fortuitum [8].
The optimal type and duration of therapy has yet to be defined. These organisms are resistant to classic agents and treatment may be directed by in vitro testing [3]. Multiple drug therapy is recommended because of resistance. Long treatment periods (212 months) are also recommended [6]. In our experience, quinolones and macrolides are effective, but side effects, including gastric intolerance, make it difficult to reach appropriate combinations and periods of therapy.
In three cases, the infection was cured and removal of the peritoneal catheter was not required. In another patient, catheter substitution was performed prophylactically. The fifth case, caused by M. chelonae and complicated by peritonitis, was the only case where the patient was transferred to haemodialysis. A review of the literature revealed five exit-site infections and 15 peritonitis cases caused by M.fortuitum or M. chelonae. In all but one, catheter withdrawal was necessary (Table 2
).
In conclusion, rapidly-growing Mycobacterium infections should be considered in the case of any indolent, culture-negative, exit-site infection of the peritoneal catheter. Appropriate culture media should be used, or routine culture prolonged. Once diagnosed, a combination of two adequate antibiotics and local gentian violet treatment may resolve the condition allowing preservation of the catheter.
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Notes
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Correspondence and offprint requests to: Dr M. Auxiliadora Bajo, Servicio de Nefrología, Hospital Universitario La Paz, Paseo Castellana 261, 28046 Madrid, Spain. 
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Received for publication: 15. 6.99
Accepted in revised form: 12. 4.00