Nocardia Peritonitis: Satisfactory Response to Intraperitoneal Trimethoprim-Sulfamethoxazole

Abstract

Nocardia peritonitis is an uncommon infection complicating peritoneal dialysis (PD). Because of the rarity of data, there is no consensus on the optimal choice of antibiotics and duration of treatment. We report here a case of Nocardia nova peritonitis in a Chinese continuous ambulatory peritonitis dialysis (CAPD) patient.A 68-year-old Chinese CAPD patient was hospitalized because of a 2-day history of abdominal pain and turbid PD effluent. She suffered from end-stage renal disease of unknown etiology. Self-CAPD was commenced March 1999. She enjoyed reasonably good health with no prior episodes of peritonitis. Six months before this admission, she was hospitalized for pseudomonas pneumonia. Computerized tomogram (CT) scan of the thorax showed a 1 ∞2-cm subpleural mass with contrast enhancement. There were fibrotic changes over both right upper lobes and middle lobe. She was treated with oral ciprofloxacin and intravenous gentamicin. Subsequent CT-guided aspiration of the pleural mass was aborted because the mass had disappeared on followup thoraxCT .Concerning the current admission, a preliminary diagnosis of CAPD-related peritonitis was established due to suggestive signs and symptoms and a PD effluent polymorph-predominating cell count of > 250/mm 3 . Intraperitoneal cefazolin and netilmycin were given immediately. No response was observed after 48 hours and intraperitoneal ceftazidime was substituted for netilmycin.Four days after admission, culture of the PD fluid specimen showed scanty growth of gram-positive rods suggestive of Nocardia species. The antibiotic regimen was then changed to intraperitoneal amikacin and imipenem. There was minimal abdominal pain but the PD effluent was persistently cloudy. The patient remained afebrile.No clinical improvement was seen 5da ys after the change in antibiotics. We stopped imipenem and started intraperitoneal trimethoprim-sulfamethoxazole. Three days later, we received the formal bacteriological report: Nocardia nova was identified and it was resistant to trimethoprim-sulfamethoxazole and sensitive to imipenem, amikacin, and ceftriaxone. However, the cell

Intra-Abdominal Nocardiosis—Case Report and Review of the Literature

“…Presumably, respiratory acquisition of Nocardia in immunosuppressed patients is followed by hematologic dissemination, eventually allowing infection at distant sites [ 22 , 38 ]. Additionally, direct peritoneal inoculation has been reported in 12 cases of Nocardia peritonitis in patients on peritoneal dialysis [ 8 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 ].…”

“…Nocardia species is a rare cause of peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD), with 12 published cases in the literature, which we summarize in Table 4 [ 8 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 ]. Peritonitis is an important complication leading to technique failure, hospitalization and even mortality in CAPD patients [ 53 ].…”

“…Extending the incubation time of the dialysate to a minimum of 10 days should be considered in cases of culture-negative and antibiotic-non-responsive peritonitis in CAPD-patients [ 8 ]. The finding of slow growing gram-positive rods in dialysate culture should raise the suspicion of Nocardia peritonitis [ 49 ]. Trimethoprim-sulfamethoxazole (TMP/SMX), often in combination with other antimicrobial agents, appears to be the treatment of choice [ 50 , 51 ].…”

“…Here, we report the second case, to our knowledge, of isolated abdominal nocardiosis due to Nocardia paucivorans . We also provide a comprehensive review of the literature, summarizing the information on 39 previously published cases of intra-abdominal and retroperitoneal nocardiosis and 12 cases of peritoneal dialysis-related nocardia peritonitis [ 2 , 5 , 6 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 ]. Finally, we will review published cases of infection with Nocardia paucivorans , a rare nocardial species.…”

Fatal Nocardia cyriacigeorgica spontaneous bacterial peritonitis

“…Other reports of Nocardia spp. peritonitis are caused by other species and have only been described following iatrogenic surgical procedures or secondary dissemination .…”