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Abstract: FR-PO563

Treating Resistant Mycobacterium abscessus in Peritoneal Dialysis-Associated Infection

Session Information

Category: Trainee Case Report

  • 703 Dialysis: Peritoneal Dialysis

Authors

  • Jespersen, Tiana, University of California Davis, Sacramento, California, United States
  • Wani, Priyanka, University of California Davis, Sacramento, California, United States
  • Syed, Wahid N., UC Davis Medical Center, Sacramento, California, United States
  • Young, Brian Y., University of California Davis, Sacramento, California, United States
Introduction

Mycobacteria-associated peritoneal dialysis (PD) infections should be considered in culture-negative or refractory cases. Non-tuberculous mycobacteria (NTM) are abundant in soil and water, and can rarely cause PD infections. NTM are associated with high rates of catheter loss and hemodialysis (HD) conversion. Of the NTM, Mycobacterium abscessus grows rapidly and is resistant to standard therapies. We present a challenging case of an exit site infection (ESI) due to multidrug-resistant M. abscessus that progressed to peritonitis despite antibiotics and PD catheter revision.

Case Description

An 80-year-old man on PD was treated for ESI and a culture collected by his dialysis unit showed gram-variable bacilli requiring outside lab send out for identification. On day 8, he developed a tunnel track abscess necessitating drainage and catheter revision. On day 15, abscess cultures grew acid-fast bacilli (AFB), thus doxycycline was added. On day 21, M. abscessus was identified from the original ESI culture. Antibiotics were broadened to clarithromycin and moxifloxacin. PD fluid analyses were previously negative. However, by day 33, the patient developed recurrent tunnel infection and cloudy PD fluid with AFB. The PD catheter was removed, and he transitioned to HD. On day 41, the original culture finally reported that the M. abscessus was resistant to multiple antibiotics including aminoglycosides, cephalosporins, doxycycline, and fluoroquinolones. A four-drug treatment regimen of eravacycline, imipenem, clarithromycin, and linezolid was ultimately selected.

Discussion

PD-associated infections due to NTM are difficult to distinguish from more common organisms, with our patient initially showing gram-variable bacilli. A delay in appropriate treatment occurs frequently because a minimum of 3-5 days on special medium is necessary for NTM to grow and speciation lags for weeks, as was seen in our case. M. abscessus causes less than 10% of PD-associated NTM infections, thus therapy guidelines are based on limited experience. Macrolides are the most reliable option and should be combined with a parenteral antibiotic tailored to susceptibility data. Our case highlights the difficulty faced with very resistant strains. A high index of suspicion and early catheter removal remain the cornerstone for successful management of M. abscessus and other NTM infections.