Case report and review of a novel cause of peritoneal dialysis peritonitis in the United Kingdom

Abstract

Peritoneal dialysis (PD) peritonitis poses a significant healthcare problem. Most cases are caused by Gram-positive organisms. Newer molecular diagnostic techniques have now enabled identification of previously unrecognized organisms, fully characterizing disease. We present the first case of Paracoccus yeei PD peritonitis reported in the United Kingdom (UK). A 70-year-old woman with chronic renal failure requiring PD presented with abdominal pain and cloudy dialysate. She was systemically well, with a normal white cell count and elevated C-reactive protein at 176. PD fluid was remarkable for 4495 polymorphonuclear leukocytes, 107 monocytes, and 10 red blood cells/cm3. No organisms were seen on microscopy. She was diagnosed with PD peritonitis and treated empirically with intraperitoneal vancomycin and oral levofloxacin. After two days, small, nonhemolytic gray-white colonies grew on blood agar. Gram stain of culture showed Gram-negative cocco-bacilli with O-shaped morphology. Phenotypic identification using matrix-assisted laser desorption ionization-time of flight mass spectrometry (Biomerieux) identified P. yeei (identification probability 99.9%). The isolate was sent to the reference laboratory for confirmation and antimicrobial susceptibility testing (AST). At present, there are no European Committee on Antimicrobial Susceptibility Testing (EUCAST) clinical breakpoints to guide AST. Proposed minimum inhibitory concentration (MIC) values were determined using broth dilution method interpreted using EUCAST nonspecies-specific PK-PD breakpoints (where available). The isolate was reported as sensitive to quinolones (ciprofloxacin MIC 0.25 mg/L), piperacillin-tazobactam (MIC 2 mg/L), and meropenem (MIC 0.008 mg/L). P. yeei is an aerobic environmental organism found in soil. It has been associated with PD peritonitis in immunosuppressed patients, although this is the first case in the UK. It is possible that true burden of disease is under-represented, and novel molecular techniques have now enabled identification of this previously unknown organism. In this case, her dog