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Simultaneous catheter removal and reinsertion, is it acceptable in M. abscessus exit site infection?
Gajapathiraju Chamarthi1, Dhruv Modi1, Kenneth Andreoni2
1Division of Nephrology, Hypertension and Transplantation, University of Florida, 1600 Archer Road, Gainesville, FL, 32610, USA.
Abstract:
In recent times, increasing reports of exit site infections (ESI) in peritoneal dialysis (PD) patients related to environmentally acquired atypical organisms, such as nontuberculous mycobacterium (NTM), have been reported in the literature. Among these NTM, Mycobacterium abscessus (M. abscessus) is unique and is associated with high morbidity and treatment failure rates. The international society of PD guidelines suggests individualizing therapeutic options for NTM-related ESI. Moreover, the guidelines encourage simultaneous catheter removal and reinsertion (SCRR) in isolated ESI, not responding to antimicrobial therapy to avoid PD interruptions. Physicians should be aware of the limitations of such approaches as delay in appropriate PD catheter intervention can be fraught with complications in patients with M. abscessus ESI. We report an M. abscessus ESI in a PD patient who underwent SCRR in conjunction with targeted antimicrobial therapy, and developed M. abscessus peritonitis requiring PD catheter removal and conversion to hemodialysis. The patient also developed ESI at the new exit site long after the PD catheter was removed, requiring prolonged antimicrobial therapy. Our case, taken together with available published case reports, highlights the futility of the SCRR approach towards the M. abscessus ESI and makes the cases for early PD catheter removal in these patients.
Insights
Simultaneous catheter removal and reinsertion (SCRR) is often ineffective for Mycobacterium abscessus exit site infections in peritoneal dialysis patients. Early catheter removal is recommended to prevent complications like peritonitis.
Area of Science:
- Nephrology
- Infectious Diseases
- Microbiology
Background:
- Exit site infections (ESI) in peritoneal dialysis (PD) patients are increasingly linked to atypical organisms like nontuberculous mycobacteria (NTM).
- Mycobacterium abscessus (M. abscessus) is a particularly challenging NTM strain associated with severe outcomes and treatment resistance.
- Current guidelines suggest individualized therapy and simultaneous catheter removal and reinsertion (SCRR) for NTM-related ESI unresponsive to antibiotics.
Observation:
- This case report details an M. abscessus ESI in a PD patient treated with SCRR and antimicrobials.
- The patient subsequently developed M. abscessus peritonitis, necessitating catheter removal and transition to hemodialysis.
- The patient experienced a new ESI at the reinsertion site even after the catheter's definitive removal, requiring extended treatment.
Findings:
- The SCRR approach proved futile in managing M. abscessus ESI, leading to severe complications.
- Delayed PD catheter intervention in M. abscessus ESI poses significant risks.
- This case underscores the limitations of SCRR and highlights the need for prompt PD catheter removal.
Implications:
- Physicians must recognize the inefficacy of SCRR for M. abscessus ESI and consider early PD catheter removal.
- Aggressive management strategies are crucial to prevent treatment failure and serious complications in PD patients with M. abscessus infections.
- Further research into optimal therapeutic strategies for NTM-related PD infections is warranted.
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