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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2018  |  Volume : 29  |  Issue : 6  |  Page : 1494-1497
Relapsing Serratia peritonitis resulting in peritoneal catheter loss


1 Department of Nephrology, Kìrklareli State Hospital, Kìrklareli, Turkey
2 Department of Infectious Diseases, Medical Faculty, Trakya University, Edirne, Turkey
3 Department of Nephrology, Medical Faculty, Trakya University, Edirne, Turkey

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Date of Submission26-Oct-2017
Date of Decision24-Jan-2018
Date of Acceptance02-Feb-2018
Date of Web Publication27-Dec-2018
 

   Abstract 

Serratia marcescens (SM) is an opportunistic Gram-negative bacterium. It can cause technique failure or severe sepsis despite being a rare agent causing peritonitis. We present a case of a 40-year-old woman with end-stage renal disease secondary to chronic glomerulo-nephritis on continuous ambulatory peritoneal dialysis (PD). She presented with severe abdominal pain and a cloudy peritoneal fluid. The fluid was cultured according to our unit protocol. The organism isolated was identified as SM; this was after the patient was treated for SM peritonitis one week earlier. The response to treatment with ceftazidime was poor despite being sensitive in vitro. The peritoneal catheter was removed due to rapid clinical deterioration. Piperacillin-tazobactam (PIP/TAZ) monotherapy was successfully administered subsequently. Eventually, she was transferred to hemodialysis (HD). SM is an uncommon cause of PD-related peritonitis. It may cause catheter loss and even death. In our case, the infection could be controlled only after catheter removal, and she was transferred to HD. Cephalosporins should rapidly be changed to PIP/TAZ when SM is isolated from the peritoneal fluid.

How to cite this article:
Kilic I, Gungor K, Kurultak I, Ustundag S. Relapsing Serratia peritonitis resulting in peritoneal catheter loss. Saudi J Kidney Dis Transpl 2018;29:1494-7

How to cite this URL:
Kilic I, Gungor K, Kurultak I, Ustundag S. Relapsing Serratia peritonitis resulting in peritoneal catheter loss. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 Mar 21];29:1494-7. Available from: http://www.sjkdt.org/text.asp?2018/29/6/1494/248298

   Introduction Top


Continuous ambulatory peritoneal dialysis (CAPD) is an important treatment option for end-stage renal disease (ESRD). Peritoneal dialysis (PD) has significant advantages such as better patient quality of life and lower mortality in the first years over hemodialysis (HD), particularly for patients with residual renal function. Peritonitis is a leading cause of hospitalization and technique failure for PD patients. Catheter loss and transfer to HD can occur. Peritonitis can even result in death if it is arising from antibiotic-resistant microorganisms. Prompt detection of the offender organism is obligatory. This will allow administering proper antibiotic regimen. In general, Grampositive species are detected as causative organisms. Gram-negative organisms are rare. Serratia marcescens (SM) is a highly virulent Gram-negative bacteria. It is a rare agent causing peritonitis. Herein, we present a PD patient with SM peritonitis.

Dialysis effluent cultures were obtained carefully by our experienced CAPD nurse following strict aseptic precautions. Samples were sent to the microbiological laboratory rapidly. Leukocyte count was performed with Nageotte Bright-Line Hemacytometer. Giemsa and Gram staining was performed to dialysate samples. Dialysate was inoculated into a BACTEC BacT/ALERT (bioMerieux, Inc., Durham) blood culture bottle and 5% sheep blood and eosin methylene blue (EMB) agar. Cultures were read after 24 h of inoculation. Identifications and antibiotic susceptibility patterns were determined using the Vitek2 system (bioMerieux SA, France)


   Case Report Top


A 40-year-old female had a history of ESRD secondary to chronic glomerulonephritis. She was on CAPD for five years. She had not experienced any peritonitis during this period. She presented with severe abdominal pain and dirty peritoneal fluid of 12-h duration. She had abdominal tenderness on physical examination. Her body temperature was 38°C. Dialysate leukocyte count was 6400/mm3, 90% being polymorphs (PNL). Serum C-reactive protein (CRP) was 470 mg/L. Leukocyte count was 15,000/mm3, and 89% were PNL on hemogram. Intravenous cefazoline and ceftazidime were started empirically. The peritoneal fluid leukocyte count rose up to 11,400/mm3 on the 2nd day. SM was isolated from peritoneal fluid culture on the 2nd day in the EMB agar and blood agar. Subsequently, it was isolated on the 3rd day in the blood culture bottle. Dialysis effluent cultures were obtained carefully by our experienced CAPD nurse following strict aseptic precautions. Samples were sent to the microbiological laboratory rapidly. Leukocyte count was performed with Nageotte Bright-Line Hemacytometer. Giemsa and Gram staining was performed to dialysate samples. Dialysate was inoculated into a BACTEC BacT/ALERT (bioMerieux, Inc., Durham) blood culture bottle and 5% sheep blood and EMB agar. Cultures were read after 24 h of inoculation. Identifications and antibiotic susceptibility patterns were determined using the Vitek2 system (bioMerieux SA, France).

The organism was sensitive to piperacillin-tazobactam (PIP/TAZ). Clinical status continued to deteriorate. Cefazoline and ceftazi-dime therapy was switched to intravenous PIP/TAZ based on the antibiogram result on the 2nd day. On the next day, the fluid leukocyte count decreased to 80/mm3 and CRP decreased to 180 mg/L. Dialysate was no longer cloudy, and subsequent cultures were negative. Seven days after treatment modification, the peritoneal fluid leukocyte count decreased to 6/mm3 and CRP decreased to 4 mg/L. Since it is very rare, we were not sure whether the causative organism was SM. Hence, the PIP/TAZ therapy was stopped on the 14th day, and the patient was discharged. Seven days later, she was admitted again with severe nausea, dirty dialysate, and abdominal pain. On microbiological examination, peritoneal fluid showed a leukocyte count of 14,000/ mm3, 91% being PNL. Serum CRP was 9 mg/L. The total leukocyte count was 23,000/mm3, 87% being PNL on hemogram. Intravenous cefazoline and ceftazidime were started empirically. Yet, CRP level rose rapidly up to 260 mg/L and 440 mg/L on the 2nd and 3rd days, respectively. A signal was received from BACTEC BacT/ALERT system out of the blood culture bottle into which dialysate was inoculated. A Gram-negative bacterium was detected. Thus, cefazoline and ceftazidime therapy was quickly changed to previously effecttive PIP/TAZ with the suspicion of relapsing SM peritonitis. However, the clinical status worsened, and thus, the peritoneal catheter was removed. The patient got better clinically after the removal. SM was isolated on the 2nd day in the EMB and blood agar and was isolated on the 3rd day in the blood culture bottle from the dialysate culture. It was a PIP/TAZ-sensitive strain again. The bacterium had the same resistance pattern as the previous one, except for the amoxicillin-clavulanic acid minimum inhibitory concentration value.

HD was started three times weekly through a jugular catheter. CRP decreased to 30 mg/L by the 13th day. Leukocyte count decreased to 5600/mm3 by the 5th day. Antibiotics were continued up to the 21st day.


   Discussion Top


SM is an opportunistic Gram-negative bacteria classified in the Enterobacteriaceae family. Immunosuppression, diabetes mellitus, renal insufficiency, steroid use, malignancy, and prior administration of antibiotics are documented risk factors for SM sepsis in another trial.[1] It is a problematic bacterium for clinicians due to high mortality. The seven-day and six-month mortality rates of SM bacteremia were as high as 5% and 37% in a population-based study.[2] It can result in catheter-related nosocomial infections. For instance, contamination of HD catheters was detected as the cause of SM bacteremia in 21 episodes by Merino et al.[3] In addition, SM infections were generally resistant to multiple antibiotics in the case series of Haddy et al.[4]

Despite infrequently reported as the cause of peritonitis, when isolated, SM generally follows a worse course than most other organisms.[5] In a retrospective analysis of resistant peritonitis cases in CAPD patients, Nakamoto et al found that 13% of cases were infected with Serratia species.[6] In a study of Krishnan et al, outcomes of peritonitis caused by Gram-negative organisms were worse than those caused by Gram-positive organisms. The peritonitis caused by SM had the worst outcomes in that study.[7] Kang et al reported a 45-year-old PD patient with SM peritonitis that was resistant to cefazoline, ceftazidime, gentamicin, and ciprofloxacin; this patient was reported to improve only after catheter removal.[8] Although rare and reported in only 4% of all cases, Serratia peritonitis was associated with increased technique failure in PD in a retrospective trial. Catheter loss was more frequent in these patients. Unfortunately, one patient had died as a result of sepsis.[9] The clinical status of our patient also deteriorated rapidly. Since her peritonitis was a recurrent episode, biofilm formation was also suspected. The catheter was removed on the 3rd day. After removal, her status improved quickly.

Some derepressed mutants of Serratia are known to overexpress AmpC beta-lactamase. Third-generation cephalosporins such as ceftazidime or cefotaxime can cause selection of those derepressed mutants misleading initial susceptibility testing and causing treatment failure. Furthermore, some SM strains produce plasmid-mediated AmpC beta-lactamases in high levels. Both derepressed mutants and plasmid-mediated AmpC producers are reported to be resistant to all beta-lactams except carbapenems.[10] This can explain the failure of ceftazidime in our patient although it was sensitive on antibiogram. There was no large study in literature describing treatment failure with PPI/TAZ therapy for Serratia infections, if susceptible on antibiogram. This may show PPI/TAZ to be less selective for AmpC-derepressed mutants than cephalosporins.[11] The empirically started antibiotics for CAPD-related peritonitis in routine clinical practice must be modified according to this resistance pattern even if the SM seems to be susceptible to cephalosporins. The organism that was isolated from our patient was resistant to cefuroxime, ampicillin, and amoxicillin and sensitive to cefepime, ceftriaxone, ceftazidime, and PIP/TAZ in vitro. We continued with ceftazidime until the culture result was available. However, it was unsuccessful clinically, although sensitive on antibiogram. We switched ceftazidime to PIP/TAZ as compatible with the sensitivity pattern. PIP/TAZ was effective. From this standpoint, the course of our patient confirms preferential PIP/TAZ treatment for SM infections.


   Conclusion Top


PD-related SM peritonitis is a serious complication of PD. Relapse and repeat peritonitis may occur. Catheter loss is also highly probable. Beyond technique failure, delay in diagnosis may also be life-threatening. Prompt isolation of the organism and proper treatment compatible with antibiogram is crucial. However, clinicians must regard potential resistance to third-generation cephalosporins that may not be evident during initial susceptibility testing.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflict of interest: None declared.

 
   References Top

1.
Bouza E, García de la Torre M, Erice A, Cercenado E, Loza E, Rodríguez-Créixems M. Serratia bacteremia. Diagn Microbiol Infect Dis 1987;7:237-47.  Back to cited text no. 1
    
2.
Engel HJ, Collignon PJ, Whiting PT, Kennedy KJ. Serratia sp. bacteremia in Canberra, Australia: A population-based study over 10 years. Eur J Clin Microbiol Infect Dis 2009; 28:821-4.  Back to cited text no. 2
    
3.
Merino JL, Bouarich H, Pita MJ, et al. Serratia marcescens bacteraemia outbreak in haemo-dialysis patients with tunnelled catheters due to colonisation of antiseptic solution. Experience at 4 hospitals. Nefrologia 2016;36:667-73.  Back to cited text no. 3
    
4.
Haddy RI, Mann BL, Nadkarni DD, et al. Nosocomial infection in the community hospital: Severe infection due to Serratia species. J Fam Pract 1996;42:273-7.  Back to cited text no. 4
    
5.
Hejazi A, Falkiner FR. Serratia marcescens. J Med Microbiol 1997;46:903-12.  Back to cited text no. 5
    
6.
Nakamoto H, Hashikita Y, Itabashi A, Kobayashi T, Suzuki H. Changes in the organisms of resistant peritonitis in patients on continuous ambulatory peritoneal dialysis. Adv Perit Dial 2004;20:52-7.  Back to cited text no. 6
    
7.
Krishnan M, Thodis E, Ikonomopoulos D, et al. Predictors of outcome following bacterial peritonitis in peritoneal dialysis. Perit Dial Int 2002;22:573-81.  Back to cited text no. 7
    
8.
Kang JH, Kim MJ, Kang YU, et al. Serratia marcescens peritonitis in a diabetic patient receiving continuous ambulatory peritoneal dialysis. Infect Chemother 2013;45:105-7.  Back to cited text no. 8
    
9.
Hiremath S, Biyani M. Technique survival with Serratia peritonitis. Adv Perit Dial 2006; 22:73-6.  Back to cited text no. 9
    
10.
Hanson ND, Sanders CC. Regulation of inducible AmpC beta-lactamase expression among Enterobacteriaceae. Curr Pharm Des 1999;5:881-94.  Back to cited text no. 10
    
11.
Harris PN, Ferguson JK. Antibiotic therapy for inducible ampC β-lactamase-producing gramnegative bacilli: What are the alternatives to carbapenems, quinolones and aminoglycosides? Int J Antimicrob Agents 2012;40:297-305.  Back to cited text no. 11
    

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Correspondence Address:
Dr. Ilhan Kilic
Department of Nephrology, Kirklareli State Hospital, Kirklareli
Turkey
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DOI: 10.4103/1319-2442.248298

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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
 

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