Letter to the Editor
Serratia marcescens, Morganella morganii, Klebsiella oxytoca related peritonitis attacks in a patient on automated peritoneal dialysis: A case report
Serratia marcescens, Morganella morganii, Klebsiella oxytoca relacionados con ataques de peritonitis en un paciente en diálisis peritoneal automatizada: Un caso
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=> array:4 [ "nombre" => "Erol" "apellidos" => "Demir" "email" => array:1 [ 0 => "eroldemir83@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Seniha" "apellidos" => "Basaran" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Yasar" "apellidos" => "Caliskan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Semra" "apellidos" => "Bozfakioglu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Infectious Diseases and Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "<span class="elsevierStyleItalic">Serratia marcescens</span>, <span class="elsevierStyleItalic">Morganella morganii</span>, <span class="elsevierStyleItalic">Klebsiella oxytoca</span> relacionados con ataques de peritonitis en un paciente en diálisis peritoneal automatizada: Un caso" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Bacterial peritonitis is a common complication of peritoneal dialysis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> We report here a case presented with peritonitis attacks caused by rarely reported unusual pathogens, probably related with poor home environment and hygienic conditions.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 57-year-old female patient had a history of end-stage renal disease secondary to hypertensive nephrosclerosis and undergone dialysis for 4 years. She was sharing a small house in poor hygienic conditions with eleven other family members with low socioeconomic status. Five months after the initiation of automated peritoneal dialysis (APD), the patient presented with abdominal pain and nausea to our PD clinic. She was febrile (38<span class="elsevierStyleHsp" style=""></span>°C), had involuntary abdominal guarding and rebound tenderness on physical examination. Dialysate white blood cell count was 1100/mm<span class="elsevierStyleSup">3</span> (79% neutrophils). Empiric antibiotherapy was initiated with intraperitoneal cefazolin (1<span class="elsevierStyleHsp" style=""></span>g/day) and oral ciprofloxacin (250<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h).</p><p id="par0015" class="elsevierStylePara elsevierViewall">A pure growth of <span class="elsevierStyleItalic">Serratia marcescens</span> was obtained in both different culture media. The organism was resistant to cefazolin, ceftriaxone, piperacillin/tazobactam, but sensitive to cefepime. Cefazolin was stopped; cefepime could not be used due to a drug shortage; instead, intraperitoneal gentamicin (0.6<span class="elsevierStyleHsp" style=""></span>mg/kg/day). Oral ciprofloxacin was also continued based upon the susceptibility results. Following the treatment modification, high-sensitivity CRP level decreased from 240<span class="elsevierStyleHsp" style=""></span>mg/L to 9<span class="elsevierStyleHsp" style=""></span>mg/L. Peritoneal effluent became clear and drainage fluid leukocyte count was 100/mm<span class="elsevierStyleSup">3</span> (10% neutrophils) on the third week of admission.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was readmitted to the hospital with similar complaints 7 months after the first peritonitis attack. Peritoneal fluid leukocyte count was found to be 17<span class="elsevierStyleHsp" style=""></span>000/mm<span class="elsevierStyleSup">3</span> and empiric antibiotherapy was initiated with intraperitoneal cefazolin (1<span class="elsevierStyleHsp" style=""></span>g/day) and gentamicin (0.6<span class="elsevierStyleHsp" style=""></span>mg/kg/day). Dialysate cultures showed the growth of <span class="elsevierStyleItalic">Morganella morganii</span>, resistant to cefazolin, cefuroxime but sensitive to cefepime, gentamicin. Cefazolin was stopped and gentamicin was continued for 21 days. The clinical findings and laboratory results were improved during the follow-up.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient also had two more peritonitis attacks after this episode, both caused by <span class="elsevierStyleItalic">Klebsiella oxytoca</span> 4 and 8 months later, respectively. These attacks were treated successfully with cefazolin and gentamicin, as isolated pathogen was susceptible to both.</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Enterobacteriaceae</span> accounts for over 10% of cases of peritoneal dialysis associated peritonitis. Among all the gram-negative infections, <span class="elsevierStyleItalic">S. marcescens</span> peritonitis has the worst outcome. <span class="elsevierStyleItalic">Serratia</span> is an opportunistic pathogen causing nosocomial infections and is one of gram-negative organisms which have inducible beta-lactamase genes known as AmpC and summarized by the acronym SPICE (<span class="elsevierStyleItalic">Serratia</span>, <span class="elsevierStyleItalic">Providencia/Pseudomonas</span>, <span class="elsevierStyleItalic">indole-positive Proteus species</span>, <span class="elsevierStyleItalic">Citrobacter</span>, <span class="elsevierStyleItalic">Enterobacter</span>). Peritonitis by <span class="elsevierStyleItalic">S. marcescens</span> is not common and there are only few case reports in the literature, usually in diabetic patients.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Isolated organism during the first peritonitis attack of our patient had multiple drug resistance. In this case, adequate clinical response was only achieved with combination of gentamicin and ciprofloxacin, as reported in a previous report.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">M. morganii</span> is a Gram-negative bacteria, also a rare cause of peritonitis. It has been reported as an opportunistic pathogen and associated mainly with urinary tract infections, bacteremia and sepsis. <span class="elsevierStyleItalic">M. morganii</span> is naturally sensitive to aminoglycosides as in our case. However, the widespread use led to increasing resistance to third-generation cephalosporins.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleItalic">K. oxytoca</span> peritonitis has been reported in a patient with cardiac ascites and another patient on continuous ambulatory PD (CAPD).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Both <span class="elsevierStyleItalic">M. morganii</span> and <span class="elsevierStyleItalic">K. oxytoca</span> tend to cause peritonitis in a polymicrobial fashion.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> However in our case, they were both isolated as a single pathogen.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary, we present a rare case of peritonitis attacks caused by <span class="elsevierStyleItalic">S. marcescens</span>, <span class="elsevierStyleItalic">M. morganii</span> and <span class="elsevierStyleItalic">K. oxytoca</span>. Antibiotic options should be chosen carefully for peritonitis with these pathogens due to their ability to produce beta lactamase, which often complicates the therapy. We think that low socioeconomic status, poor home environment and hygienic conditions increase the peritonitis rates. Although modification of these factors may not be possible, we believe that more frequent and careful education of the patient and the family members under such conditions can improve patient care.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Changes in the organisms of resistant peritonitis in patients on continuous ambulatory peritoneal dialysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "H. Nakamoto" 1 => "Y. Hashikita" 2 => "A. Itabashi" 3 => "T. Kobayashi" 4 => "T. 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| 2019 January | 35 | 20 | 55 |
| 2018 December | 104 | 45 | 149 |
| 2018 November | 184 | 22 | 206 |
| 2018 October | 139 | 16 | 155 |
| 2018 September | 72 | 20 | 92 |
| 2018 August | 78 | 18 | 96 |
| 2018 July | 45 | 18 | 63 |
| 2018 June | 72 | 14 | 86 |
| 2018 May | 85 | 17 | 102 |
| 2018 April | 137 | 12 | 149 |
| 2018 March | 66 | 10 | 76 |
| 2018 February | 74 | 9 | 83 |
| 2018 January | 65 | 7 | 72 |
| 2017 December | 67 | 6 | 73 |
| 2017 November | 55 | 16 | 71 |
| 2017 October | 33 | 13 | 46 |
| 2017 September | 34 | 7 | 41 |
| 2017 August | 23 | 5 | 28 |
| 2017 July | 42 | 17 | 59 |
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