An unusual cause of continuous ambulatory peritoneal dialysis–associated outpatient peritonitis: Stenotrophomonas maltophilia

Abstract

To the Editor:Stenotrophomonas maltophilia (SM) is a nonfermentative aerobic, gram-negative bacillus formerly known as Pseudomonas maltophilia or Xanthomonas maltophilia.1Nesme X. Vaneechoutte M. Orso S. Hoste B. Swings J. Diversity and genetic relatedness within genera Xanthomonas and Stenotrophomonas using restriction endonuclease site differences of PCR-amplified 16S rRNA gene.Syst Appl Microbiol. 1995; 18: 127-135Crossref Scopus (46) Google Scholar Because of its low virulence, SM rarely infects healthy people. Infections caused by SM are mostly hospital-acquired; SM peritonitis is a rare complication of chronic peritoneal dialysis that sometimes results in mortality or loss of the dialysis catheter.2Villarino M.E. Stevens L.E. Schable B. Mayers G. Miller J.M. Burke J.P. et al.Risk factors for epidemic Xanthomonas maltophilia infection/colonization in intensive care unit patients.Infect Control Hosp Epidemiol. 1992; 13: 201-206Crossref PubMed Scopus (87) Google Scholar, 3Szeto C.C. Li P.K. Leung C.B. Yu A.W. Lui S.F. Lai K.N. Xanthomonas maltophilia peritonitis in uremic patients receiving continuous ambulatory peritoneal dialysis.Am J Kidney Dis. 1997; 29: 91-95Abstract Full Text PDF PubMed Google ScholarA 57-year-old female who had been receiving continuous ambulatory peritoneal dialysis (CAPD) therapy for almost 3 years presented at our outpatient clinic with fever, mild abdominal pain, diffuse abdominal tenderness, and cloudy peritoneal effluent. Diabetic nephropathy was identified as the cause of end-stage renal disease. The patient’s previous medical history did not include peritonitis, exit site tunnel infection, or use of broad-spectrum antibiotics. Her peritoneal fluid examination revealed CAPD-associated peritonitis with a leukocyte count of 2,100/mm3 (90% neutrophils). Empirical antibiotic treatment was initiated with intraperitoneal ceftazidime and vancomycin. On the third day of treatment, Stenotrophomonas maltophilia was isolated in peritoneal fluid culture with antibiogram susceptibility to levofloxacine and trimethoprim-sulfamethoxazole. The treatment was switched to ceftazidime and levofloxacine. Even in the face of possible resistance to ceftazidime due to clinical improvement, ceftazidime therapy was continued. The patient was discharged 15 days after admission and recovered completely without the need for catheter removal.SM is more frequently isolated in nosocomial settings.4Laing F.P. Ramotar K. Read R.R. Alfieri N. Kureishi A. Henderson E.A. et al.Molecular epidemiology of Xanthomonas maltophilia colonization and infection in the hospital environment.J Clin Microbiol. 1995; 33: 513-518PubMed Google Scholar Predisposing factors for SM infection include previous antibiotic therapy with broad-spectrum β-lactam agents, prolonged hospitalization,5Elting L.S. Khardori N. Bodey G.P. Fainstein V. Nosocomial infection caused by Xanthomonas maltophilia: a case-control study of predisposing factors.Infect Control Hosp Epidemiol. 1990; 11: 134-138Crossref PubMed Scopus (134) Google Scholar malignant lesions,6Muder R.R. Harris A.P. Muller S. Edmond M. Chow J.W. Papadakis K. et al.Bacteremia due to Stenotrophomonas (Xanthomonas) maltophilia: a prospective multi-center study of 91 episodes.Clin Infect Dis. 1996; 22: 508-512Crossref PubMed Scopus (189) Google Scholar central venous catheterization,5Elting L.S. Khardori N. Bodey G.P. Fainstein V. Nosocomial infection caused by Xanthomonas maltophilia: a case-control study of predisposing factors.Infect Control Hosp Epidemiol. 1990; 11: 134-138Crossref PubMed Scopus (134) Google Scholar, 7Elting L.S. Bodey G.P. Septicaemia due to Xanthomonas species and non-aeruginosa Pseudomonas species: increasing incidence of catheter-related infections.Medicine. 1990; 69: 296-306Crossref PubMed Scopus (175) Google Scholar and immunosuppressive therapy.8Szeto C.C. Li P.K. Leung C.B. Yu A.W. Lui S.F. Lai K.N. Xanthomonas maltophilia peritonitis in uremic patients receiving continuous ambulatory peritoneal dialysis.Am J Kidney Dis. 1997; 29: 91-95Abstract Full Text PDF PubMed Scopus (36) Google Scholar Diabetes mellitus has been identified as a significant predisposing factor for SM infections.9Baek J.E. Jung E.Y. Kim H.J. Lee G.W. Hahm J.R. Kang K.R. et al.Stenotrophomonas maltophilia infection in patients receiving continuous ambulatory peritoneal dialysis.Korean J Intern Med. 2004; 19: 104-108PubMed Google ScholarDespite its association with higher mortality and catheter loss, appropriate antimicrobial therapy promotes successful recovery from SM peritonitis. Among the known risk factors, including previous antibiotic therapy with broad-spectrum β-lactams, malignancies, central venous catheterization, immunosuppressive treatment, and prolonged hospitalization, diabetes mellitus might have been the predisposing factor in our patient. Almost one-third of the patients receiving CAPD have diabetes. SM infections are rare even in outpatients with diabetes receiving CAPD, but should be considered in these patients. To the Editor: Stenotrophomonas maltophilia (SM) is a nonfermentative aerobic, gram-negative bacillus formerly known as Pseudomonas maltophilia or Xanthomonas maltophilia.1Nesme X. Vaneechoutte M. Orso S. Hoste B. Swings J. Diversity and genetic relatedness within genera Xanthomonas and Stenotrophomonas using restriction endonuclease site differences of PCR-amplified 16S rRNA gene.Syst Appl Microbiol. 1995; 18: 127-135Crossref Scopus (46) Google Scholar Because of its low virulence, SM rarely infects healthy people. Infections caused by SM are mostly hospital-acquired; SM peritonitis is a rare complication of chronic peritoneal dialysis that sometimes results in mortality or loss of the dialysis catheter.2Villarino M.E. Stevens L.E. Schable B. Mayers G. Miller J.M. Burke J.P. et al.Risk factors for epidemic Xanthomonas maltophilia infection/colonization in intensive care unit patients.Infect Control Hosp Epidemiol. 1992; 13: 201-206Crossref PubMed Scopus (87) Google Scholar, 3Szeto C.C. Li P.K. Leung C.B. Yu A.W. Lui S.F. Lai K.N. Xanthomonas maltophilia peritonitis in uremic patients receiving continuous ambulatory peritoneal dialysis.Am J Kidney Dis. 1997; 29: 91-95Abstract Full Text PDF PubMed Google Scholar A 57-year-old female who had been receiving continuous ambulatory peritoneal dialysis (CAPD) therapy for almost 3 years presented at our outpatient clinic with fever, mild abdominal pain, diffuse abdominal tenderness, and cloudy peritoneal effluent. Diabetic nephropathy was identified as the cause of end-stage renal disease. The patient’s previous medical history did not include peritonitis, exit site tunnel infection, or use of broad-spectrum antibiotics. Her peritoneal fluid examination revealed CAPD-associated peritonitis with a leukocyte count of 2,100/mm3 (90% neutrophils). Empirical antibiotic treatment was initiated with intraperitoneal ceftazidime and vancomycin. On the third day of treatment, Stenotrophomonas maltophilia was isolated in peritoneal fluid culture with antibiogram susceptibility to levofloxacine and trimethoprim-sulfamethoxazole. The treatment was switched to ceftazidime and levofloxacine. Even in the face of possible resistance to ceftazidime due to clinical improvement, ceftazidime therapy was continued. The patient was discharged 15 days after admission and recovered completely without the need for catheter removal. SM is more frequently isolated in nosocomial settings.4Laing F.P. Ramotar K. Read R.R. Alfieri N. Kureishi A. Henderson E.A. et al.Molecular epidemiology of Xanthomonas maltophilia colonization and infection in the hospital environment.J Clin Microbiol. 1995; 33: 513-518PubMed Google Scholar Predisposing factors for SM infection include previous antibiotic therapy with broad-spectrum β-lactam agents, prolonged hospitalization,5Elting L.S. Khardori N. Bodey G.P. Fainstein V. Nosocomial infection caused by Xanthomonas maltophilia: a case-control study of predisposing factors.Infect Control Hosp Epidemiol. 1990; 11: 134-138Crossref PubMed Scopus (134) Google Scholar malignant lesions,6Muder R.R. Harris A.P. Muller S. Edmond M. Chow J.W. Papadakis K. et al.Bacteremia due to Stenotrophomonas (Xanthomonas) maltophilia: a prospective multi-center study of 91 episodes.Clin Infect Dis. 1996; 22: 508-512Crossref PubMed Scopus (189) Google Scholar central venous catheterization,5Elting L.S. Khardori N. Bodey G.P. Fainstein V. Nosocomial infection caused by Xanthomonas maltophilia: a case-control study of predisposing factors.Infect Control Hosp Epidemiol. 1990; 11: 134-138Crossref PubMed Scopus (134) Google Scholar, 7Elting L.S. Bodey G.P. Septicaemia due to Xanthomonas species and non-aeruginosa Pseudomonas species: increasing incidence of catheter-related infections.Medicine. 1990; 69: 296-306Crossref PubMed Scopus (175) Google Scholar and immunosuppressive therapy.8Szeto C.C. Li P.K. Leung C.B. Yu A.W. Lui S.F. Lai K.N. Xanthomonas maltophilia peritonitis in uremic patients receiving continuous ambulatory peritoneal dialysis.Am J Kidney Dis. 1997; 29: 91-95Abstract Full Text PDF PubMed Scopus (36) Google Scholar Diabetes mellitus has been identified as a significant predisposing factor for SM infections.9Baek J.E. Jung E.Y. Kim H.J. Lee G.W. Hahm J.R. Kang K.R. et al.Stenotrophomonas maltophilia infection in patients receiving continuous ambulatory peritoneal dialysis.Korean J Intern Med. 2004; 19: 104-108PubMed Google Scholar Despite its association with higher mortality and catheter loss, appropriate antimicrobial therapy promotes successful recovery from SM peritonitis. Among the known risk factors, including previous antibiotic therapy with broad-spectrum β-lactams, malignancies, central venous catheterization, immunosuppressive treatment, and prolonged hospitalization, diabetes mellitus might have been the predisposing factor in our patient. Almost one-third of the patients receiving CAPD have diabetes. SM infections are rare even in outpatients with diabetes receiving CAPD, but should be considered in these patients.