Saudi Journal of Kidney Diseases and Transplantation

LETTER TO THE EDITOR
Year
: 2014  |  Volume : 25  |  Issue : 4  |  Page : 888--889

Extended-spectrum beta-lactamase-producing klebsiella pneumoniae causing peritonitis in a patient on continuous ambulatory peritoneal dialysis


Sanjay Vikrant1, Ramesh Chander Guleria2,  
1 Department of Nephrology, Indira Gandhi Medical College, Shimla (Himachal Pradesh), India
2 Department of Microbiology, Indira Gandhi Medical College, Shimla (Himachal Pradesh), India

Correspondence Address:
Sanjay Vikrant
Department of Nephrology, Indira Gandhi Medical College, Shimla (Himachal Pradesh)
India




How to cite this article:
Vikrant S, Guleria RC. Extended-spectrum beta-lactamase-producing klebsiella pneumoniae causing peritonitis in a patient on continuous ambulatory peritoneal dialysis.Saudi J Kidney Dis Transpl 2014;25:888-889


How to cite this URL:
Vikrant S, Guleria RC. Extended-spectrum beta-lactamase-producing klebsiella pneumoniae causing peritonitis in a patient on continuous ambulatory peritoneal dialysis. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2022 Jan 16 ];25:888-889
Available from: https://www.sjkdt.org/text.asp?2014/25/4/888/135202


Full Text

To the Editor,

There are very few reported cases of perito­nitis caused by extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumonia, and as such there is no standard protocol for its treatment in patients on continuous ambulatory peritoneal dialysis (CAPD). The International Society for Peritoneal Dialysis (ISPD) recom­mends the use of intra-peritoneal (IP) cepha­losporin or aminoglycosides to cover gram negative bacteria. [1]

A 65-year-old man was on CAPD for two years because of end-stage renal diseases re­sulting from diabetes mellitus and presented with pain abdomen, vomiting, fever and cloudy effluent fluid. The effluent fluid cell count was 1800/µL (90% neutrophils, 10% lymphocytes). Gram stain showed capsulated gram negative cocco-bacili. A patient was empirically started on vancomycin and ceftazidime IP; however, after two days of antibiotics, there was no relief from peritonitis. The effluent peritoneal fluid culture was positive for ESBL-producing K. pneumonia, which was sensitive to carba-penem (imipenem); the antibiotic was changed to imipenem/cilastatin 2 g IP daily. The repeat effluent cell count was 100/µL, gram stain was negative and the culture of peritoneal fluid was sterile. The patient fully recovered after three weeks of imipenem/cilastatin.

Because the production of ESBL enzyme by the bacterial pathogens is the most commonly encountered mechanism of resistance to β-lactam antibiotics, the hydrolysis of broad-spectrum oxyimino-cephalosporins renders these antibiotics ineffective. [2] The propensity of ESBL-producing organisms to be concomi­tantly resistant to other classes of antibiotics greatly limits the choice of antibiotics that can be used for treatment. [3] Infections caused by ESBL-producing organisms such as K. pneu-monae and Eshcherichia coli are associated with adverse clinical outcomes and signifi­cantly higher mortility. [4] The ESBL-producing pathogens should be suspected in patients who have recently received broad-spectrum anti­biotics, with age older than 60 years, those with other comorbid conditions and those who underwent recent hospital and intensive care unit admissions and were treated with invasive devices. [5]

Carbapenems are the most reliable antimicro­bial agents against ESBL isolates. With increa­sing prevalence of ESBL infections, higher incidences of ESBL peritonitis are likely to be encountered in CAPD patients. Although the current ISPD recommendations have not yet discussed the issue, the clinician should be aware of these emerging and difficult-to-treat bacteria in CAPD patients with peritonitis. Further studies are needed to identify effective IP antibiotics for peritonitis caused by ESBL.

References

1Li PK, Szeto CC, Piraino B, et al; International Society for Peritoneal Dialysis. Peritoneal Dialysis-related infections recommendations: 2010 update. Perit Dial Int 2010;30:393-423.
2Kanj SS, Kanafani ZA. Current concept in antimicrobial therapy against resistant Gram negative organisms: Extended -spectrum beta-lactamase-producing Enterobacteriaceae, carbapenam-resistant Enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa. Mayo Clin Proc 2011;86:250-9.
3Pitout JD, Laupland KB. Extanded-spectrum beta-lactamase-producing Enterobacterceae; an emerging public- health concern. Lancet Infect Dis 2008;8:159-66.
4Yip T, Tse KC, Lam MF, et al. Risk factors and outcomes of extended-spectrum beta-lactamase-producing E. coli peritonitis in CAPD patients. Perit Dial Int 2006;26:191-7.
5Paterson DL, Bonomo RA. Extended-spectrum beta-lactamases: A clinical update. Clin Microbiol Rev 2005;18:657-86.