A rare cause of peritonitis caused by Flavimonas oryzihabitans in ...

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Flavimonas (formerly Pseudomonas) oryzihabitans, a yellow pigmented, gram-negative, oxidase-nega- tive, nonfermenting bacillus, has rarely been implicated ...
 Springer 2005

International Urology and Nephrology (2005) 37:433–436 DOI 10.1007/s11255-004-4650-3

A rare cause of peritonitis caused by Flavimonas oryzihabitans in continuous ambulatory peritoneal dialysis (CAPD) Stamatina Papakonstantinou, Evangelia Dounousi, Kyriakos Ioannou, Ioannis Tsouchnikas, Apostolos Kelesidis, Nikolaos Kotzadamis & Dimitrios Tsakiris Department of Nephrology, General Hospital of Veria, Greece Flavimonas (formerly Pseudomonas) oryzihabitans, a yellow pigmented, gram-negative, oxidase-negative, nonfermenting bacillus, has rarely been implicated as a human pathogen. Most cases have been reported in immunocompromized hosts, mainly related to central venous catheters rather than to other foreign materials. Although most cases are nosocomialy acquired, there has been an increasing frequency of community acquired infections. Flavimonas oryzihabitans has been reported as a causative organism of peritonitis in CAPD only in a few cases worldwide [1–4]. We report the first case of peritonitis caused by Flavimonas oryzihabitans recorded in CAPD patient in Greece.

Case report A 22-year-old male patient had urgently started hemodialysis due to uraemic syndrome in December 2001 followed by CAPD one month later with four exchanges per day. His past medical history was unremarkable, apart from an operation for a femoral fracture. Since then, he has been adequately dialyzed with a weekly Kt/V ¼ 1.7. In August 2002, the patient was diagnosed to have his first episode of peritonitis due to micrococcus, for which he received 1 g vancomycin i.p. every 5 days for a total of 15 days. The last vancomycin dose was administered 3 days before the present admission. During the current episode, the patient was readmitted to our department because of abdominal pain, fever 38.7 C, chills, and cloudy peritoneal effluent. The onset of these symptoms was progressive, 12 hours before admission. The patient was hypotensive and had tachycardia, pulse rate 120 minutes)1 and tachypnoea at a rate of 24 minutes)1. The level of consciousness was not significantly altered, though signs of

restlessness were becoming evident. There was diffuse abdominal tenderness with rebound localized mostly to the left upper quadrant, accompanied by reduced bowel sounds, all suggestive of peritonitis. There were no signs of infection at the exit site or the subcutaneous tunnel of the implanted Tenckoff catheter. The laboratory tests showed WBC 12,900 per mm3 with 82% neutrophils, ESR 105 (1st hour) and CRP 12,1 mg/dl, Hb 11.3 g/dl, total proteins 5.8 g/dl and albumin 3.1 g/dl. The peritoneal fluid showed 880 cells per mm3, with 83% neutrophils. Cultures from Tenckoff’’s exit-site, peripheral blood and peritoneal fluid were taken. The chest and abdomen X-rays were with normal findings. The peritonitis was considered as a recurrent episode of the recent micrococcal infection; therefore, vancomycin was intraperitoneally administered in a reloading dose of 1 g in the overnight dwell, in combination with amikacin 250 mg i.m. The following two days the clinical picture deteriorated markedly, the patient continued to be febrile (39.4 C) and complained of pain in the left hemithorax. Crackles were auditable at the left lung base and the chest X-ray showed opacity at the left inferior lobe with concomitant, minimal in quantity, pleural effusion. The possibility that the microbical agent caused peritonitis, had also caused pneumonia at the same time unfortunately could not be excluded, although the fact that in case of heavy abdominal infection, reactive pneumonitis with pleural effusion is not rare. At the same time the peritoneal effluent continued to be cloudy with increasing WBC (26,000 mm)3) and further deterioration in the laboratory tests (Tables 1, 2 and 3). Because of the persistence of the clinical picture an abdominal CT was done, which was not diagnostic for any pathology of the abdomen.

434 Table 1. Hematology laboratory data Variable

On 1st admission

2nd hospital day

On 2nd admission

Hematocrit (%) White cells (per mm3)

34.8 12,900

28.6 17,300

38.8 9,100

52 10.3 6.3 1.2 321,000

85.3 7.1 6.6 0.7 312,000

78 14.6 5.4 1.1 258,000

14

16.6

normal

28 9 105

44.3 6 125

normal normal 54

Differential count (%) Neutrophils Lymphocytes Monocytes Eosinophils Platelets (per mm3) Prothrombin time (sec) PTT (sec) Fibrinogen (sec) ESR (1st hour)

Table 2. Blood chemical values Variable

On 1st admission

SGOT (IU/l) 16 SGPT (IU/l) 15 cGT (IU/l) 11 ALP (IU/l) 95 Total Protein (g/dl) 5.8 Albumin (g/dl) 3.1 Amylase (IU/l) 240 CRP (mg/dl) 12.1

2nd hospital On 2nd day admission 12 12 10 71 5.6 2.8 170 26.6

16 14 10 75 7.1 3.7 90 4.2

On the third day, Flavimonas Oryzihabitans was eventually isolated from the peritoneal fluid, while cultures taken from the peripheral blood and the exit site were sterile. All the microbiological cultures were done on blood and MacConkey agar plates at 37 C, and were incubated for 24 hours. Identification of the isolates was performed by

standard microbiological methods, using the API 20 NE system (BioMerieux); sensitivity test to antibiotics was performed by disk diffusion test, according to the guidelines of the National Committee for Clinical Laboratory Standards. The peritoneal effluent culture revealed a gramnegative, yellow-pigmented, catalase-positive, oxidase-negative, nonfermentative, motile bacillus, identified as Flavimonas Oryzihabitans. This unusual microbial agent was resistant to vancomycin, oxacyllin and cefamandol, but sensitive to third generation cephalosporins (cefotaxime, ceftazidime, cefepime and ceftriaxone), imipenem, aminoglycosides (amikacin, gentamycin), ciprofloxacin and titarcillin. Vancomycin was replaced by ceftriaxone, 500 mg · 4 i.p., after a loading dose of 1 g, while amikacin was continued, resulting in the complete clearing of the peritoneal effluent by the third day of the administration of the new therapeutic regimen. After 6 days, the patient was discharged asymptomatic with clear peritoneal effluent and complete resolution of the chest X-ray findings. It was recommended to continue therapy at home with ceftriaxone in a dose of 1 g day divided in four doses i.p. and amikacin 250 mg per 72 hours i.m. for 3 weeks. Two weeks after completion of the recommended therapy, the patient was readmitted with high fever, abdominal pain and cloudy peritoneal fluids. The clinical picture was suggestive of peritonitis which was milder compared to the previous episode (WBC 9100 per mm3, ESR 54 mm, CRP 4.2 mg/dl and WBC of the PD effluent 260 per mm3). The culture of the peritoneal fluid revealed Flavimonas oryzihabitans confirming the recurrence of peritonitis. The same antibiotic regimen with ceftriaxone and amikacin were given again for a period of 4 weeks followed by per os Ciprofloxacin 250 mg twice a day for a month. The patient recovered soon after the current episode and the course thereafter was uneventful of other episodes of peritonitis. Eight months later, a

Table 3. Hospitalization

Peritoneal fluid’s WBC count (per mm3)

1st day

880

2nd day

1800

3rd day

26,000

4th day

11,200

5th day

750

6th day

40

2nd admission 1st day

2nd day

260

50

435 gradual loss of ultrafiltration was noticed, which unfortunately resulted in transferring the patient to hemodialysis in June 2003.

Discussion Flavimonas Oryzihabitans, the causative agent of this peritonitis, is an opportunistic human pathogen isolated from moist environments, mainly rice paddies, sink drains and indwelling devices [5, 6]. It was rarely implicated in septic conditions, such as bacteraemias [7–9], pneumonias [10], meningitides [11], soft tissue infections [12] and peritonitis [1–4], especially among immunocompromised hosts with implanted foreign materials, such as Hickman-catheters, Tenckhoff-catheters and joint prosthesis [13–15]. Both nosocomial and community-acquired type of infections have been reported, the latter showing an increasing tedency in recent years [10, 12, 14–16]. In our case report the most likely route of infection was the exogenous-transluminal one, as both the exit site and the subcutaneous tunnel were lacking any signs of inflammation, and there was no evidence of any abdominal pathology to suggest leak of pathogens from the bladder or the intestine. In our try to reeducate the patient because of the consecutive three peritonitis episodes in the last 3 months, we realized that the patient was storing the PD fluids in a damp basement of a country house where rats were rather regular. Furthermore, he was using the same bath sponge for the last 6 months. In a recent report of infection of a Hickmancatheter by Flavimonas oryzihabitans from Spain, in order to define the possible source of colonization of the catheter, cultures were carried out from the materials used for the catheter’s and patient’s personal hygiene, such as heparanized flasks, gauze, antiseptic solution and bath sponge and it was achieved the isolation of Flavimonas oryzihabitans from the patient’s bath sponge [17]. We basically conducted a similar screening by carrying out microbiological cultures from materials used in peritoneal catheter care, from surfaces of intact bags, from unused peritoneal fluids, from Tenchoff-catheter’s exit site, patient’s axillary cavities, the inguino-femoral folds, the nasopharynx and his personal bath spong, which unfortunately could not confirm the possible source of contamination.

Flavimonas oryzihabitans is sensitive to common antimicrobial agents used in hospital practice, such as third generation cephalosporins, aminoglycosides, ureidopenicillins, monobactams, carbapenems and quinolones [18, 19]. Our isolate was sensitive to all of the above mentioned antibiotics. A 2 weeks course is thought to be sufficient by some authors [1, 2, 7, 9]. However, in our case, a 3 weeks course which was used empirically proved to be not adequate enough to prevent the recurrence of peritonitis. The recurrent episode of peritonitis required an additional 4 weeks therapeutical course followed by an equal period of preventive administration of ciprofloxacin per os. With regards to the removal or not of the peritoneal catheter, there is not sufficient evidence to justify either handling. In all the three well documented reports in the English literature, neither replacement nor removal of the peritoneal catheter was needed. Fortunately in our case peritonitis was also controlled without replacing the catheter. The patient was undergoing CAPD till June 2003, when it became obligatory, to transfer him to hemodialysis, due to gradual loss of the ultrafiltration capacity. During the course of our undisciplined young patient, fluid overload was a very common phenomenon which compelled in increasing the dialysis adequacy by using solution of greater hypertonicity, fact that could explain the exhausted peritoneal ultrafiltration capacity. Although it is likely, it still remains unclear whether the Flavimonas peritonitis was also implicated in the loss of ultrafiltration, which resulted in transferring the patient to haemodialysis. References 1. Silver MR, Felegie TP, Sorkin MI. Unusual bacterium, group Ve-2, causing peritonitis in a patient on continuous ambulatory peritoneal dialysis. J Clin Microbiol 1985; 21: 838–839. 2. Amber IJ, Reimer LG. Pseudomonas sp. group Ve-2 bacterial peritonitis in a patient on continuous ambulatory peritoneal dialysis. J Clin Microbiol 1987; 25: 744–745. 3. Bending JW, Mayers PJ, Eyers DE et al. Flavimonas oryzihabitans (Pseudomonas oryzihabitans, CDC group Ve-2): an emerging pathogen in peritonitis related to continuous ambulatory peritoneal dialysis? J Clin Microbiol 1989; 27(1): 217–218. 4. Cusimano A, Husserl FE. Flavimonas oryzihabitans peritonitis in CAPD. Perit Dial Int 1997; 17(4): 406–407. 5. Kodama K, Kimura N, Komagata K. Two new species of pseudomonas: P. oryzihabitans isolated from rice paddy

436

6.

7. 8.

9.

10.

11.

12.

13.

and clinical specimens and P. luteola isolated from clinical specimens. Int J System Bacteriol 1985; 35: 467–474. Holmes B, Pinning CA, Dawson CA. A probability matrix for the identification of Gram negative, aerobic, nonfermentative bacteria that grow on nutrient agar. J Clin Microbiol 1986; 132: 1827–1842. Pied FD. Groud Ve2 (Chromobacterium typhiflavum) bacteremia. J Clin Microbiol 1977; 6: 435–436. Hawkins RE, Moriarty RA, Lewis DE, Oldfield EC. Serious infections involving the CDC group Ve bacteria Chryseomonas luteola and Flavimonas oryzihabitans. Rev Infect Dis 1991; 13: 257–260. Lucas KG, Kiehn TE, Sobeck KA et al. Sepsis caused by Flavimonas oryzihabitans. Medicine (Baltimore) 1994; 73: 209–214. Giacommetti A, Cirioni O, Quartana M et al. Unusual clinical presentation of infection due to Flavimonas oryzihabitans. Eur J Clin Microbiol Infect Dis 1998 Sep; 17(9): 645–648. Kostman JR, Solomon F, Fekete T. Infections with Chryseomonas luteola (CDC group Ve-1) and Flavimonas oryzihabitans (CDC group Ve-2) in neurosurgical patients. Rev Infect Dis 1991; 13(2): 233–236. Lam S, Isenberg HD, Edwards B, Hilton E. Communityacquired soft tissue infections caused by Flavimonas oryzihabitans. Clin Infect Dis 1994 May; 18(5): 808–809. Decker CF, Simon GL, Keiser JF. Flavimonas oryzihabitans (Pseudomonas oryzihabitans; CDC group Ve–2) bacteremia in immunocompromised hosts. Arch Intern Med 1991 Mar; 151(3): 603–604.

14. Lin RD, Hsueh PR, Chang JC et al. Flavimonas oryzihabitans bacteraemia: clinical features and microbiological characteristics of the isolates. Clin Infect Dis 1997 May; 24(50): 867–873. 15. Qian K, Wang S. Infections caused by Flavimonas oryzihabitans. Clin Med J (Engl) 2001 Apr; 114(4): 394– 398. 16. Kansouzidou A, Charitidou C, Poubrou E et al. Haemorrhagic papular rash associated to Flavimonas oryzihabitans bacteraemia in a child. Eur J Epidemiol 2000 Mar; 16(3): 277–279. 17. Marin M, Garcia de Viedma D, Martin-Rabadan P et al. Infections of hickman catheter by Pseudomonas (formerly Flavimonas) oryzihabitans traced to a synthetic bath sponge. J Clin Microbiol 2000 Dec; 38(12): 4577– 4579. 18. Rolston KV, Ho DH, LeBlanc B, Bodey GP. In vitro activities of antimicrobial agents against clinical isolates of Flavimonas oryzihabitans obtained from patients with cancer. Antimicrob Agents Chemother 1993 Nov; 37(11): 2504–2505. 19. Higgins CS, Murtough SM, Williamson E et al. Resistance to antibiotics and biocides among non-fermentative Gram-negative bacteria. Clin Microbiol Infect 2001 Jun; 7(6): 308–315.

Address for correspondence: D. Tsakiris, Department of Nephrology, General Hospital of Veria, Greece E-mail: [email protected]