2001/09/01 by Pierre‐Marie Roger, Hélène Sichez-Com, Jacques Ollier +3 · 1 voice
Biochemistry, Genetics and Molecular Biology · Engineering · Medicine · Social Sciences · #Botulinum Toxin and Related Neurological Disorders #Clostridium difficile and Clostridium perfringens research #Diphtheria, Corynebacterium, and Tetanus #Legal and Regulatory Analysis #Linguistic, Cultural, and Literary Studies #Military Technology and Strategies
paper · doi:10.1093/jacamr/dlae128
openalex publication_date 2001/09/01 · openalex created_date 2016/06/24 · openalex updated_date 2026/04/28
Peritonitis is a complication of peritoneal dialysis (PD), and most bacteria isolated from dialysis effluent are either Staphylococcus spp. or Pseudomonas aeruginosa.1,2 Therefore, intraperitoneal vancomycin and ceftazidime are recommended as empirical therapy. Definitive treatment should be based on bacterial identification and determination of susceptibilities, but relapses or recurrences are observed due to the maintenance of a peritoneal catheter.3 We report two cases of relapsing peritonitis due to unusual bacteria successfully treated by oral clindamycin. A 75-year-old man with stage 5 chronic kidney disease due to nephrosclerosis began continuous ambulatory PD in November 2018. In June 2023, he presented with abdominal pain and cloudy effluent, but no evidence of exit site or tunnel infection. No recent contamination or accidental disconnection was noted. Analysis of dialysis effluent showed a white cell count (WCC) of 2300/μL including 55% neutrophils, but no bacteria were identified by Gram staining or culture. Empirical intraperitoneal antibiotic therapy with vancomycin 1500 mg every 4 days plus ceftazidime 1500 mg once a day was prescribed for 14 days, allowing a clinical and biological improvement. In August 2023, he presented a relapse of the infection, and analysis of the effluent identified Brevibacterium casei using MALDI-TOF MS (identification scores between 1.89 and 2.11). Susceptibility to antibiotics tested by the disc diffusion method on Mueller–Hinton Fastidious agar (BD, le Pont de Claix, France) according to the 2021 guidelines of the Comité des Antibiogrammes de la Société Française de Microbiologie/EUCAST,4 showed a vancomycin-susceptible bacteria. Vancomycin alone was prescribed with similar dosage for 3 weeks with good efficacy. Finally, a third episode was observed by the end of September 2023 with analysis of the effluent still showing B. casei. At that time, the PD catheter was removed and oral clindamycin 600 mg, three times a day, was prescribed for 14 days. The patient started haemodialysis on a tunnelled dialysis catheter. The outcome was favourable, with the resumption of PD by the end of November 2023 without relapse. A 77-year-old man with stage 5 chronic kidney disease due to nephrosclerosis began continuous ambulatory PD in June 2022. In April 2023, he presented with fever and cloudy effluent. The patient described an accidental disconnection of the PD catheter while gardening 1 week before. Microbial analysis showed a WCC of 1250/μL including 55% neutrophils, but no bacteria were identified by Gram staining or culture. Empirical intraperitoneal antibiotic therapy with vancomycin plus ceftazidime was administered for 14 days, allowing a significant improvement. Late in May 2023, he presented a relapse of the infection, and analysis of the cloudy effluent showed Bacillus cereus using MALDI-TOF MS (identification scores between 1.90 and 2.03). Susceptibility to antibiotics tested by the disc diffusion method revealed vancomycin susceptibility. Thus, vancomycin alone was prescribed with similar dosage for 3 weeks with a good clinical efficacy. Finally, we observed a third episode by the end of June 2023, still with a culture of the effluent positive for B. cereus. At that time, the PD catheter was removed and oral clindamycin 600 mg, three times a day, was prescribed for 14 days. The outcome was favourable with the resumption of PD by the end of September 2023 without relapse. We report two cases of peritonitis during PD due to Gram-positive bacilli for which intraperitoneal vancomycin treatment failed twice in both cases, but which were thereafter successfully treated by oral clindamycin for 14 days. As we concomitantly removed the peritoneal catheter and introduced clindamycin, the specific role of each intervention is difficult to assess. However, removing the peritoneal catheter implied administration of the antibiotic therapy by IV infusion or the oral route. As both patients experienced a failure of two courses of at least 14 days of vancomycin treatment, we chose oral clindamycin. Vancomycin failure for peritonitis due to B. casei or B. cereus has already been reported, leading to the removal of the peritoneal catheter.5–7 Furthermore, after the latter, all reports indicated a parenteral and sometimes combination antibiotic therapy. Concepts of antibiotic therapy have evolved towards administration by the oral route as soon as possible. We chose oral clindamycin as a definitive antibiotic treatment as its efficacy was established from first isolations. Clindamycin is adapted for patients with end-stage chronic kidney disease, with high bioavailability by the oral route, avoiding parenteral administration and catheter manipulation, achieving significant intracellular concentration with bioactivity, and excretion through the biliary tract allowing a full dosage despite kidney disease. It is a well-tolerated compound with a low level of drug–drug interactions.8,9 Intraperitoneal clindamycin has also been proposed to treat susceptible bacterial peritonitis in PD, 600 mg per bag, with stable intraperitoneal concentrations for at least 24 h in glucose-based solutions.10 In conclusion, oral clindamycin was an efficient therapy for our two cases of recurrent peritonitis due to Gram-positive bacteria. Because its antimicrobial spectrum includes a broad range of the bacteria involved in PD-related peritonitis, further studies should determine the place of clindamycin in these infections. We acknowledge the patients for providing their consent for the publication. This report was conducted in accordance with French legislation: patients or their relatives provide written consent for computerization of their anonymized personal data and must declare their opposition to using the latter for retrospective studies. The data are available from the corresponding author on reasonable request. The report was done as part of routine work, and no specific funding has been received for this study, including no internal funding. All authors declare that they have no relevant financial or non-financial interests to disclose. All authors contributed significantly to the report, and all have read and consented to this submission.