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Intraleukocytic sequestration as a cause of persistent Staphylococcus aureus peritonitis in continuous ambulatory
Abstract:
Peritonitis caused by Staphylococcus aureus in four patients undergoing continuous ambulatory peritoneal dialysis failed to respond to, or relapsed immediately after cessation of, intraperitoneal antibiotic therapy with vancomycin or cephalothin and tobramycin. Sequestration of viable staphylococci within polymorphonuclear leukocytes in the peritoneal fluid was suspected for two reasons: (1) staphylococci could still be grown after treatment of the dialysate cell fraction with lysostaphin, a procedure that kills only extracellular staphylococci, and (2) diminished polymorphonuclear leukocyte bactericidal activity was demonstrated in peritoneal dialysis effluent. Addition of rifampin, which readily penetrates polymorphonuclear leukocytes, to the treatment regimen of all patients led to prompt resolution of peritonitis without relapse.
Insights
Staphylococcus aureus peritonitis in peritoneal dialysis patients resistant to standard antibiotics suggests intracellular bacteria. Rifampin effectively treated these infections by penetrating white blood cells.
Area of Science:
- Nephrology
- Infectious Diseases
- Microbiology
Background:
- Peritonitis is a serious complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).
- Staphylococcus aureus is a common pathogen causing CAPD-associated peritonitis.
- Standard intraperitoneal antibiotic regimens (vancomycin, cephalothin, tobramycin) can be ineffective.
Observation:
- Four CAPD patients presented with S. aureus peritonitis unresponsive to conventional intraperitoneal antibiotics.
- Viable S. aureus were recovered from the peritoneal fluid's cellular fraction even after treatment with lysostaphin, indicating intracellular sequestration.
- Reduced bactericidal activity of polymorphonuclear leukocytes (PMNs) in peritoneal dialysis effluent was observed.
Findings:
- Intracellular sequestration of Staphylococcus aureus within polymorphonuclear leukocytes was identified as a mechanism of treatment failure.
- Addition of rifampin, an antibiotic known to penetrate host cells, to the treatment regimen led to prompt resolution of peritonitis.
- No relapses occurred after rifampin was included in the treatment protocol.
Implications:
- Rifampin should be considered as an adjunctive therapy for refractory or relapsing S. aureus peritonitis in CAPD patients.
- Understanding intracellular bacterial reservoirs is crucial for effective management of certain infectious complications in immunocompromised patients.
- This finding highlights the importance of antibiotic penetration into host cells for treating intracellular pathogens.