Journal Information
Vol. 37. Issue. 1.January - February 2017
Pages 1-114
Vol. 37. Issue. 1.January - February 2017
Pages 1-114
Letter to the Editor
DOI: 10.1016/j.nefroe.2017.01.021
Open Access
Peritonitis caused by Pantoea agglomerans in peritoneal dialysis
Peritonitis causada por Pantoea agglomerans en diálisis peritoneal
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Aránzazu Sastre
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aranchasastre@hotmail.com

Corresponding author.
, Jose E. González-Arregoces, Igor Romainoik, Santiago Mariño, Cristina Lucas, Elena Monfá, George Stefan, Benjamin de León, Mario Prieto
Servicio de Nefrología, Complejo Asistencial Universitario de León, León, Spain
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Dear Editor,

Pantoea agglomerans is a germ that infrequently causes peritonitis in peritoneal dialysis patients. Let us look at the case of a peritoneal dialysis patient who presented with peritonitis due to this germ.

The patient was an 83-year-old man living in an urban environment, who carried out basic daily activities independently and who had been on outpatient peritoneal dialysis with 4 daily exchanges for 4 years. The cause of the chronic kidney disease was nephroangiosclerosis, with no other comorbidity. The patient was well adapted to the dialysis and had no adequacy, ultrafiltration or fluid overload problems. However, he had suffered 6 episodes of peritonitis. Peritonitis is defined as peritoneal inflammation caused by microorganisms, with the presence of cloudy peritoneal fluid, a count of more than 100leukocytes/μl with more than 50% polymorphonuclear cells. It remains the most significant complication deriving from the dialysis technique itself. It is generally caused by Gram-positive skin bacteria such as Staphylococcus epidermidis and Staphylococcus aureus, or by enterobacteria and fungi. Prevention is the fundamental weapon, acting on the routes by which microorganisms enter the peritoneal cavity: peritoneal access, connection systems, dialysis solutions and examinations that enable infection. The germs identified in the previous peritonitis episodes were gram-positive. The patient had been retrained in the performance of the dialysis technique on multiple occasions to try to prevent new episodes and it had been proven that he was not a nasal carrier of Staphylococcus aureus.

The patient came to the dialysis unit complaining of abdominal pain and with a cloudy peritoneal effluent, detected in the last exchange. He had not had fever, nausea, or intestinal transit alterations. His count was 560leukocytes/μl with 80% polymorphonuclear cells. Examination revealed signs of peritoneal irritation. Gram stain and cultures were taken. Treatment was started with intraperitoneal cefazolin and tobramycin. Since the patient's condition was unchanged, he was monitored as an outpatient. At the 48-h follow-up, he showed a clinical improvement with clear peritoneal fluid, a peritoneal count below 100leukocytes/μl, and the culture received tested positive for Pantoea agglomerans.

Pantoea agglomerans (formerly known as Enterobacter agglomerans and previously as Erwinia agglomerans) is a gram-negative bacillus from the Enterobacteriaceae family which basically causes nosocomial infections in immunocompromised patients,1 our elderly patient and in dialysis.

Species of the Pantoea genus are generally isolated from soil, plants, fruits and vegetables, but they have also been found in human and animal faeces. In our case, there is no evidence of contact with plants or animals, but it is possible that there were deficiencies in washing hands and making connections after touching fruit.

As a pathogen, it has traditionally been described as a causative factor of localised infections such as synovitis, post-traumatic arthritis2 due to plant thorns or splinters, as well as cases of peritonitis in dialysis patients, since it can grow in glucose-rich media (gardener's peritonitis?)3–5 and in carriers of invasive devices, in the paediatric population it can cause sepsis6 and it has also been cultivated in bile samples from patients with cholangitis and choledocholithiasis.7

The patient was kept on tobramycin treatment for 14 days, showing an excellent sensitivity to cephalosporins, aminoglycosides and ciprofloxacin.

Following this new peritonitis episode, after identifying errors in performing the exchange during retraining sessions and due to his advanced age, we decided to transfer the patient to carer-assisted automated peritoneal dialysis.

References
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Bacteriemia por Pantoea agglomerans.
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[2]
A. Kratz, D. Greenberg, Y. Barki, E. Cohen, M. Lifshitz.
Pantoea agglomerans as a cause of septic arthritis after palm thorn injury; case report and literature review.
Arch Dis Child, 88 (2003), pp. 542-544
[3]
P.S. Lim, S.L. Chen, C.Y. Tsai, M.A. Pai.
Pantoea peritonitis in a patient receiving chronic ambulatory peritoneal dialisis.
[4]
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An unusual cause of peritonitis in peritoneal dialysis patients: Pantoea agglomerans.
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Pantoea agglomerans: the gardener's peritonitis?.
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Pantoea agglomerans: a new pathogen at the neonatal intensive care unit?.
Arch Argent Pediatr, 110 (2012), pp. 77-79
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Please cite this article as: Sastre A, González-Arregoces JE, Romainoik I, Mariño S, Lucas C, Monfá E, et al. Peritonitis causada por Pantoea agglomerans en diálisis peritoneal. Nefrologia. 2017;37:108–109.

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