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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44; </span></p><p class="elsevierStylePara">We presented the case of a 50 year old woman with terminal chronic renal failure secondary to IgA mesangial glomerulonephritis&#46; She had a Tenckhoff type II peritoneal dialysis catheter &#40;PD&#41; implanted in May 2009&#44; and started the program in September 2009&#46; During the adaptation period she presented abdominal pain&#44; fever of 38&#46;2&#186;C and cloudy peritoneal fluid&#46; Culture samples were taken and a cell count carried out and she started a course of antibiotics according to the our centre&#8217;s protocol&#58; 1g intravenous vancomycin &#40;i&#46;v&#46;&#41; the first and fifth days together with intraperitoneal ceftazidime &#40;i&#46;p&#46;&#41; at a dose of 1g&#47;day distributed during exchanges for 10 days&#46; The physical examination revealed blood pressure &#40;BP&#41; of 165&#47;90mm&#47;Hg and painful abdomen on deep palpation with signs of peritonitis&#46; The catheter exit site had a good appearance&#46; Twenty-four hours after commencing empirical antibiotic treatment&#44; the fever and abdominal pain disappeared&#44; and the peritoneal dialysis was maintained as indicated in the established guideline &#40;four exchanges&#47;day&#41;&#46; <span class="elsevierStyleItalic">Pseudomonas aeruginosa </span>grew in the<span class="elsevierStyleItalic"> </span>peritoneal fluid culture and antibiotic treatment was readjusted according to antibiogram &#40;imipenem i&#46;p&#46; and ciprofloxacin i&#46;v&#46;&#41;&#44; with a good initial response which worsened again 48 hours later&#46; A new culture was taken of peritoneal fluid due to the increase in cell count and reappearance of pain&#46; This new culture grew only O<span class="elsevierStyleItalic">chrobactrum anthropi</span>&#44; with no evidence of <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#46; The antibiotic guideline with imipenem and ciprofloxacin was maintained &#40;for <span class="elsevierStyleItalic">Ochrobactrum anthropi</span>&#41;&#46; Nonetheless&#44; five days later she clinically worsened once more with variable behaviour of the cell count in the drained fluid&#46; The PD catheter was therefore removed after 19 days of antibiotic treatment &#40;Figure 1&#41;&#46; The preventative fungicide treatment was 200mg&#47;24 hours oral fluconazole&#46; The patient evolved favourably and was discharged a few days later&#46;</p><p class="elsevierStylePara">Peritonitis is one of the most frequent complications in PD patients and one of the causes of abandoning the technique&#59;<span class="elsevierStyleSup">1</span>&#160;up to 10&#37; of the cases are polymicrobial&#46; The most frequent bacteria are gram-positive &#40;<span class="elsevierStyleItalic">Staphylococcus epidermidis</span> and <span class="elsevierStyleItalic">aureus</span> and <span class="elsevierStyleItalic">Streptococcus</span>&#41; followed by gram-negative bacteria &#40;<span class="elsevierStyleItalic">E</span>&#46;<span class="elsevierStyleItalic"> coli&#44; Pseudomonas&#44; Klebsiella&#44; Enterobacter </span>and <span class="elsevierStyleItalic">Serratia</span>&#41;&#46; Peritonitis with <span class="elsevierStyleItalic">Pseudomonas</span> and <span class="elsevierStyleItalic">Serratia</span> are difficult to eradicate&#44; they tend to be related with catheter infection and frequently the catheter has to be removed&#46; Fungal peritonitis are less frequent but more severe and are usually associated with previous use of antibiotic therapy&#44; immunosuppression and diabetes&#46;</p><p class="elsevierStylePara">A study performed in Australia with a total of 4&#44;675 PD patients&#44; analysed the polymicrobial peritonitis and the most frequently isolated bacteria in the series were <span class="elsevierStyleItalic">Staphylococcus</span><span class="elsevierStyleItalic"> </span>epidermidis &#40;21&#37;&#41;&#44; methicillin-sensitive <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;10&#37;&#41;&#44; methicillin-resistant Staphylococcus aureus &#40;2&#37;&#41; and <span class="elsevierStyleItalic">Pseudomonas aeruginosa </span>&#40;8&#37;&#41;&#46;<span class="elsevierStyleSup">2</span>&#160;This data has since been confirmed by other groups&#46;<span class="elsevierStyleSup">3&#44;4</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> is an aerobic&#44; mobile and oxidase positive gram-negative bacteria&#46; It is considered an aggressive opportunistic pathogen&#44; with great clinical relevance&#44; and is often resistant to treatment&#46; It mainly affects immunodepressed patients including catheter carriers&#46; Biofilm or cuff catheter-associated peritonitis caused by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> has been reported in patients with terminal renal failure on PD&#46; At times&#44; they are related with exit site infection&#46; It is difficult to eradicate and requires the prolonged use of several antibiotics&#44; and in up to two thirds of cases the catheter has to be removed&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Ochrobactrum anthropi</span> is a non-fermenting aerobic&#44; mobile&#44; oxidase and urease-positive&#44; indole negative gram-negative bacillus&#46;<span class="elsevierStyleSup">5&#44;6</span>&#160;This micro-organism is considered an opportunistic pathogen of low virulence&#59; it is isolated in nature and in the hospital environment it is isolated in water sources&#46; It has also been described as an early coloniser of silicon catheters&#46;<span class="elsevierStyleSup">3</span>&#160;Patients who use connection systems present greater probability of gram-negative bacteria infections&#44; with a drop in the incidence of peritonitis caused by gram-positive bacteria&#46;<span class="elsevierStyleSup">6</span>&#160;<span class="elsevierStyleItalic">Ochrobactrum anthropi</span> infections unrelated to PD were reported in 1980&#46;<span class="elsevierStyleSup">5</span>&#160;They have been isolated in several types of infections&#58; pancreatic abscesses&#44; catheter-related bacteremias&#44; meningitis related with contamination of cadaveric pericardial tissue&#44; endophthalmitis&#44; pacemaker infections and osteochondritis&#46;<span class="elsevierStyleSup">7</span>&#160;They usually occur in immunodepressed patients &#40;haematological&#44; neoplastic or transplant receivers&#41; or in permanent catheter carriers&#46;<span class="elsevierStyleSup">5</span>&#160;</p><p class="elsevierStylePara">Three cases of peritonitis caused by <span class="elsevierStyleItalic">Ochrobactrum anthropi</span> have been reported in relation with the PD&#46; In 2000&#44; a Spanish group published the first case in a diabetic 79-year-old woman on PD&#46; She had suffered two previous episodes of peritonitis over the previous year&#46; Empirical treatment of the peritonitis was commenced with vancomycin and intraperitoneal gentamicin &#40;i&#46;p&#46;&#41;&#46; <span class="elsevierStyleItalic">Ochrobactrum anthropi </span>was isolated in the culture&#44; so the antibiotic was changed to ofloxacin &#40;in accordance with the antibiogram&#41;&#44; with a satisfactory evolution&#46;<span class="elsevierStyleSup">7</span>&#160;The second case appeared in a 39-year-old patient 2 months after inserting the PD catheter&#46; The initial antibiotic treatment consisted of vancomycin i&#46;p&#46; With no improvement on the fifth day&#44; treatment was commenced with imipenem i&#46;p&#46; and i&#46;v&#46;&#44; as well as ceftazidime i&#46;p&#46;&#44; which was also associated with resolving the process&#46;<span class="elsevierStyleSup">6</span>&#160;Another case of <span class="elsevierStyleItalic">Ochrobactrum anthropi </span>peritonitis has been published more recently in a 51-year-old patient&#44; with three previous episodes of negative culture peritonitis&#46; He presented a new symptoms of peritonitis and treatment was commenced with vancomycin and amikacin i&#46;p&#46; Meropenem and amikacin-sensitive <span class="elsevierStyleItalic">Ochrobactrum anthropi </span>grew in the culture&#44; so the antibiotics were changed&#44; resolving the symptoms&#46;<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara">Our patient initially presented a <span class="elsevierStyleItalic">Pseudomonas aeruginosa </span>positive culture that responded well to antibiotic treatment&#44; as shown in the second culture&#46; The catheter did not have to be removed to cure the peritonitis in any of the previous cases&#46; The most relevant aspect of this case&#44; however&#44; was that the catheter had to be removed with the <span class="elsevierStyleItalic">Ochrobactrum anthropi </span>infection&#46; With the atypical behaviour of this peritonitis&#44; we consider it interesting to emphasise that multiple bacteria infection can alter the immunological response of the host and&#44; therefore&#44; the expected virulence of each of these&#44; as well as its response to antibiotic therapy&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10376&#95;108&#95;9215&#95;en&#95;10376&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10376_108_9215_en_10376_f1.jpg" alt="Evolution of peritoneal fluid cell count"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Evolution of peritoneal fluid cell count</p>"
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