Polymicrobial peritonitis including Pantoea agglomerans from teething on a catheter.

To the Editor A 24-month-old female with end-stage renal disease on chronic peritoneal dialysis presented with a 1-day history of cloudy peritoneal fluid without fever or abdominal pain. Her usual medicines included cotrimoxazole, iron, sodium citrate, erythropoietin, and growth hormone.

Her weight was 9.8 kg (<5%) and height was 75 cm (<5%). She had a temperature of 35.9[degrees]C. Heart rate was 137 bpm, respiratory rate was 36 bpm, and blood pressure was 92/38 mm Hg. She was pink on room air and playful. She had a normal ear, eye, nose, and throat examination. Her neck was supple, and there was no lymphadenopathy. Chest and cardiac examinations were normal, and no abdominal mass was found. Her Tenckhoff catheter exit site appeared to be noninfected.

Initial white blood cell count was 10.8 X [10.sup.3]/[mm.sup.3], with normal differential. Electrolytes were within normal limits, with a blood urea nitrogen level of 31 mg/dL and creatinine of 5.8 mg/dL. Peritoneal fluid examination showed a white blood cell count of 20,100/[mm.sup.3], with 80% neutrophils and 0 red cells.

The patient was started on 8 mg/L intraperitoneal gentamicin and 250 mg/L cefotaxime. Peritoneal fluid culture grew Pantoea agglomerans, Stomatococcus species, Viridans streptococci, and Candida lusitaniae. Intravenous amphotericin was given for 14 days. Her Tenckhoff catheter was removed 4 days after admission, and a new catheter was placed after 6 days. She returned to the clinic 2 days after discharge because of maternal concern that she kept chewing on and had made a bite hole in the distal end of her transfer set. The set was changed, and she was sent home with instructions for close monitoring. She was again admitted 3 weeks later, with another episode of peritonitis with Enterobacter cloacae and Acinetobacter calcoaceticus-baumanni complex. She was treated successfully with intraperitoneal cefotaxime and tobramycin and 14-day oral fluconazole.

Although peritonitis is still the most common morbidity in patients receiving peritoneal dialysis, (1) polymicrobial peritonitis is rare, according to a single-center report of Holley et al. (2) Only 9% of peritonitis among adults had polymicrobial involvement. The North American Pediatric Renal Transplant Cooperative Study database report does not mention polymicrobial peritonitis specifically, (3) but the Mid-European Pediatric Peritoneal Dialysis Study Group (MEPPS) group did report that 2.4% of total peritonitis episodes were polymicrobial. (4)

Other than arthritis associated with plant thorn injury, (5) Pantoea infection is rare in clinical practice. Although we did not culture the patient's oral cavity, we concluded that the most likely source of these particular polymicrobial infections was oral contamination because of her behavior of chewing on the dialysis catheter. Multiple organism peritonitis can be caused by simple but unique behavioral habits of children. All health care professionals and parents of patients receiving peritoneal dialysis should be aware of this potential risk for peritonitis.

References

1. Neu AM, Ho PL, McDonald RA, et al. Chronic dialysis in children and adolescents: the 2001 NAPRTCS Annual Report. Pediatr Nephrol 2002;17:656-663.

2. Holley JL, Bernardini J, Piraino B. Polymicrobial peritonitis in patients on continuous peritoneal dialysis. Am J Kidney Dis 1992;19:162-166.

3. Furth SL, Donaldson LA, Sullivan EK, et al. Peritoneal dialysis catheter infections and peritonitis in children: a report of the North American Pediatric Renal Transplant Cooperative Study. Pediatr Nephrol 2000;15:179-182.

4. Schaefer F, Klaus G, Muller-Wiefel DE, et al. Intermittent versus continuous intraperitoneal glycopeptide/ceftazidime treatment in children with peritoneal dialysis-associated peritonitis: the Mid-European Pediatric Peritoneal Dialysis Study Group (MEPPS). J Am Soc Nephrol 1999;10:136-145.

5. Ulloa-Gutierrez R, Moya T, Avila-Aguero ML. Pantoea agglomerans and thorn-associated suppurative arthritis. Pediatr Infect Dis J 2004;23:690.

Keith K. Lau, MD

Bettina H. Ault, MD

Deborah P. Jones, MD

University of Tennessee Health

Science Center

Department of Pediatrics

Children's Foundation Research Center at Le Bonheur Children's Medical Center 

Memphis, TN