Nontuberculous mycobacteria infections of peritoneal dialysis patients: A multicenter study

Abstract

Objectives: Nontuberculous mycobacteria (NTM) infections pose a diagnostic challenge in peritoneal dialysis (PD) patients. In this study, we sought to identify findings that are suggestive of NTM infection in PD adult patients. Methods: All patients with NTM exit-site infection (ESI) with/without tunnel infection and peritonitis identified during the last decade in eight medical centers in Israel were included. Clinical, microbiological, and outcome data were collected and analyzed. Results: Thirty patients were identified; 16 had ESI (53%) and 14 had peritonitis (47%). Median age was 65 years (interquartile range 52–76). Abdominal pain and cloudy PD fluid were reported in all patients with peritonitis, whereas exit-site discharge and granulation tissue were common in patients with ESI. Fourteen patients (47%) had negative cultures prior NTM diagnosis, and isolation of diphtheroids or Corynebacterium spp. was reported in 9 of 30 patients (30%). Antimicrobial treatment prior to diagnosis was documented in 13 of 30 patients (43%). Delayed diagnosis was frequent. Treatment regimens and duration of therapy varied widely. In 26 of 30 (87%) patients, catheter was removed and 19 of 30 patients (63%) required permanent transition to hemodialysis. Two patients with peritonitis (2 of 14, 14%) and seven with ESI (7 of 16, 44%) were eligible for continuation of PD. Conclusions: Culture negative peritonitis, isolation of diphtheroids or Corynebacterium spp., previous exposure to antibiotics, and/or a refractory infection should all prompt consideration of PD-related NTM infection and timely workup. Catheter removal is recommended aside prolonged antimicrobial therapy. In select patients with ESI, continuation of PD may be feasible.

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment

“…In addition to our suggestion to remove PD catheters for the treatment of NTM, previous studies showed that less than 20% of patients could be resumed on PD. 383 –386,390…”

“…[383][384][385] Published case series have highlighted the pitfall of late NTM diagnosis, with a median delay ranging from 6 to 30 days. 384,386 Given the chance for these organisms to be mistaken for diphtheroids or Corynebacterium species on Gram stain, examination for acid-fast bacilli by Ziehl-Neelsen staining should be requested on peritoneal dialysate fluid. Negative cultures with persistent symptoms of peritonitis, often with concomitant exit-site infection, should also raise concern for the possibility of NTM infection.…”

Mycobacteria avium-related peritonitis in a patient undergoing peritoneal dialysis: case report and review of the literature

“…In majority of the cases, the PD effluent WCC at peritonitis onset was slightly elevated. At least half of the patients showed a polymorphonuclear predominance, which is in accordance with the manifestation of other PD-related NTM peritonitis [ 4 ] and may distinguish from tuberculous peritonitis [ 16 ]. AFB smear was positive in 6 patients.…”

“…Data on PD-related NTM peritonitis is increasing, however, majority of the cases are caused by rapidly growing mycobacteria such as M. fortuitum and M. abscessus , etc. [ 4 , 5 ], while MAC and other slowly growing NTM-related peritonitis in PD population has rarely been reported. Song et al reviewed 57 episodes of PD-associated NTM peritonitis, and found that MAC was responsible for only 6 episodes [ 6 ].…”

Clinical course of peritoneal dialysis-related peritonitis due to non-tuberculosis mycobacterium – A single centre experience spanning 20 years

“…Present series Bnaya et al 11 Washida and Itoh 12 Jiang et al 13 Song et al subsequent peritonitis. The ever-increasing age, medical complexity and frailty of the patient cohort may also contribute to the increased risk for exit site infection.…”