Dr Julien Nithianandan1
1Bendigo Health, , Australia
Biography:
Julien is a nephrology advanced trainee who has worked in Victoria and the Northern Territory. His interests include chronic disease management, lupus nephritis, and the health of Aboriginal and Torres Strait Islander peoples.
Background:
Peritonitis is a significant complication that affects patients with end-stage kidney disease (ESKD) on peritoneal dialysis (PD). Enterococci are facultative anaerobes that form part of the normal flora of the human gastrointestinal tract. Enterococcus gallinarum is a rare cause of PD-peritonitis. We present the fourth case of Enterococcus gallinarum PD-peritonitis in the literature, and the first case of successful treatment with intraperitoneal teicoplanin.
Case Report:
A man in his 50s with ESKD on PD was commenced on empirical intraperitoneal cefazolin and gentamycin for cloudy effluent. His native disease was pauci-immune necrotising crescentic glomerulonephritis, managed with cyclophosphamide, steroids and azathioprine. He had no abdominal pain or other gastrointestinal symptoms. He was afebrile and haemodynamically stable. Abdomen was soft and non-tender, with no signs of exit-site infection. Investigations showed: WCC 7.3×10^9/L, CRP 29.1mg/L, and normal LFTs.
Day 1 PD fluid analysis showed: 1960×10^6/L leucocytes, 54% neutrophils. Day 2 PD fluid analysis showed: 5040×10^6/L leucocytes, 70% neutrophils, gram positive cocci resembling Streptococcus or Enterococcus on gram stain. There was subsequent Enterococcus gallinarum isolation on culture, with resistance to ampicillin/amoxicillin and vancomycin, and sensitivity to teicoplanin. Intraperitoneal teicoplanin 15mg/Kg was administered every five days, for four doses on days six, eleven, sixteen, and twenty-one. Subsequent PD fluid analyses normalised. The Tenckhoff catheter did not require removal.
Conclusion:
In a world of rising antibiotic-resistance, clinicians should be cognisant of multi-drug resistant organisms such as vancomycin-resistant enterococci causing PD-peritonitis, particularly in patients who do not respond to conventional, empirical antibiotics. Enterococcus gallinarum is intrinsically resistant to vancomycin, mediated by the chromosomally-integrated vanC gene. As such, especially in the event of early clinical deterioration, consideration may be given to escalating therapy whilst awaiting sensitivity results.