POS-670 Severe Stenotrophomonas maltophilia peritonitis in a patient receiving peritoneal dialysis

Abstract

Stenotrophomonas maltophilia (S.maltophilia) is an aerobic, non-fermentative, Gram-negative bacillus. It behaves like an opportunistic pathogen affecting individuals with severe debilitation or immunosuppression. In peritoneal dialysis (PD), S.maltophilia peritonitis is associated with a pejorative prognosis and loss of peritoneal catheter in front of its common resistance to different groups of antibiotics including beta-lactams, aminoglycosides and fluoroquinolones. We report a case of S.maltophilia infection related to continuous ambulatory peritoneal dialysis (CAPD) in our PD unit. It's about a 44-year-old female patient receiving peritoneal dialysis since 6 years. She had a past history of hypertension and chronic hepatitis C. It was her first episode of peritonitis after 6 years undergoing peritoneal dialysis. She consulted our PD unit for vomiting, fever, and abdominal pain. At the exam, she was painful, temperature was at 36.5 blood pressure was at 9/5. Blood test and peritoneal fluid analyses were performed. The fluid was turbid, we found 300 cells/mm3 in the peritoneal effluent with 100 % polymorph nuclear. Laboratory data showed C reactive protein at 389, white blood cells at 8700, with a hypokalemia due to abundant diarrhea. The patient was at her third day of antibiotherapy by intra peritoneal gentamycin (0.6mg/kg) prescribed in the emergency room. Our attitude was to continue intra peritoneal gentamycin until 5days, and add intra peritoneal ceftazidim (1g/d) and prophylaxis of fungal peritonitis by fluconazole that was subsequently stopped.Peritoneal fluid culture was positive for a multiresistant S. maltophilia sensitive to ceftazidim and trimethoprim-sulfamethoxazole that was added to the previous treatment. We had an initial transient improvement: decrease of diarrhea with negative culture of peritoneal fluid. (130 nucleated cells with 92% PMN). Unfortunately, after more than 3 weeks of antibiotherapy the cell count increased again(2700 nucleated cells with 100% PMN) and a stenotophomonas maltophila was isolated again in the peritoneal fluid that is why it was decided to remove the peritoneal catheter and transfer the patient definitely to hemodialysis. S.maltophilia has been increasingly recognized as a nosocomial pathogen in patients with immunodepression. It's an uncommon cause of peritonitis in patients under peritoneal dialysis, but it is always a therapeutic challenge because of its resistance to several antibiotics. In many cases the removal of the peritoneal catheter is required . The prognosis of this peritonitis is usually poor and a prolonged attempt of antibiotic treatment would make them prone to further opportunistic infection without saving the catheter. Immune dysfunction due to uremia, anemia, malnutrition … and also, an indwelling peritoneal catheter may be predisposing factors for the S. maltophilia infection in patients undergoing peritoneal dialysis.