Successful treatment of Nocardia asteroides peritonitis in a patient undergoing automated peritoneal dialysis and receiving immunosuppressive therapy
Ortiz, A.M.; Rabagliati, R.; Machuca, E.
Advances in Peritoneal Dialysis. Conference on Peritoneal Dialysis 21: 66-68
2005
ISSN/ISBN: 1197-8554 PMID: 16686287 Document Number: 588269
Nocardiosis is an opportunistic infection especially in patients with underlying chronic debilitating disease or immunodeficiency. Nocardia peritonitis is an uncommon infection in peritoneal dialysis patients. Here, we report a case of peritonitis by Nocardia asteroides during automated peritoneal dialysis in a 35-year-old male patient who had prolonged immunosuppressive therapy to treat acute rejection of a nonfunctioning kidney allograft. The patient presented at our outpatient clinic with typical symptoms of acute peritonitis. The peritoneal fluid leukocyte count was 20,500 cells/microL, with 90% neutrophils. Gram staining showed gram-positive filamentous bacilli later identified as N. asteroides. After bacterial identification, the patient received trimethoprim 320 mg and sulfamethoxazole 3200 mg intravenously every 48 hours (TMP-SMX), plus amikacin 100 mg intraperitoneally daily. The immunosuppressive therapy was reduced. Peritoneal fluid cultures became negative after 1 week of treatment, concomitant with clinical improvement. Unfortunately, after 5 weeks of therapy, the patient developed hematologic side effects attributable to the TMP-SMX treatment. The TMP-SMX was suspended at that time, and the patient then received cefuroxime 500 mg by mouth and amikacin 100 mg intraperitoneally daily for a total of 12 weeks. The patient recovered completely and was discharged 3 months after onset of the peritonitis. Prolonged antibiotic therapy without catheter removal has not been previously described in immunosuppressed patients with APD peritonitis. The combination of amikacin and TMP-SMX may be safe and effective in APD patients who develop N. asteroides peritonitis.