Paracoccus yeei
Fosso C1, Maillart E2, Beun
A3, Touzani F1, Mahadeb
B4, Clevenbergh P2
Corresponding author: Dr Clevenbergh Philippe: Infectious Diseases
Department, CHU Brugmann, 4, Place A Van Gehuchten, 1020 Brussels
Belgium, Philippe.CLEVENBERGH@chu-brugmann.be
Key Clinical Message
Peritonitis is a serious problem for patients undergoing peritoneal
dialysis (PD) with incidence varying between centers. Paracoccus
yee i, a soil microorganism with specific virulence factors, is
an opportunistic pathogen. We report a case of CAPD -peritonitisdue to P. yeei . International guidelines exist to decrease
exogenously and endogenously acquired CAPD-peritonitis.
Key words
Paracoccus yee i, peritonitis, peritoneal dialysis, complications,
prevention.
Abstract
We report a case of P. yeei CAPD-peritonitis in a patient
experiencing repeated episodes of peritonitis. P. yeei , an
emerging opportunistic pathogen, takes advantage of specific virulence
factors and peculiar circumstances. We discuss the exogenous or
endogenous microbial source of the peritonitis and guidelines to
decrease its occurrence.
Introduction
Serious complications of peritoneal dialysis are peritonitis, catheter
exit site and tunnel infections. Over 0.5 episodes/patient-year rate of
peritonitis has been reported in some facilities (1) with up to 5%
mortality rate (2). In 10-20%, no etiological organism can be detected.
This rate can be decreased by direct inoculation of dialysate in
blood-culture bottles (3) or amplification and identification of 16S
rRNA. Some peritonitis may be truly aseptic. Skin colonizers such asS. epidermidis and S. aureus , Gram-negative organisms or
even fungus are involved owing to the mode of entry: skin and
catheter-related, gut-associated translocation or hematogenous seeding.
Various unexpected exogenous opportunistic micro-organisms originating
from the patient’s environment have been reported to cause exit site,
tunnel infection and peritonitis (4, 5). Paracoccus yeei is an
aerobic Gram-negative coccobacillus, found in soil and water. It can
develop biofilms on plastic surfaces and has recently been identified as
an opportunistic pathogen in human disease (6). Few cases of P.
yeei -induced peritonitis in patients undergoing CAPD have been
described (7,8, 9, 10). We report such a case successfully treated with
intraperitoneal amoxicillin in a patient experiencing several episodes
of exogenous catheter infections.
Case report
This is the case of a 50-year-old woman. Her medical history reveals
chronic depression, social isolation, linguistic barrier, and
hypertension. She has been treated since December 2011 for end-stage
renal disease of undetermined etiology. Starting by hemodialysis, she
was transferred to PD in July 2012. In PD, she presented several tunnel
infections and two episodes of peritonitis refractory to treatment
requiring removal and reinsertion of PD catheter. In September 2018, she
presented with diffuse abdominal pain with anorexia, diarrhea and
shivering for 4 days although afebrile.
Laboratory analysis revealed: white blood cell count of 9.19
103 /µL with normal differentiation and a C-reactive
protein level of 47.7 mg/L (normal value < 10 mg/L).
Peritoneal fluid analysis revealed a leukocyte count of 346/µL, with
51% monocytes, 41% polymorphonuclear cells and 4% lymphocytes. The
peritoneal catheter exit site was of normal appearance. Empirical
treatment was initiated with intraperitoneal (IP) vancomycin 30 mg/kg
and amikacin 2 mg/kg according to local protocol. Subsequent effluent
dialysate analysis showed an initial rise in WBC count to 2111/µL
(polymorphonuclear predominance of 49%). Direct examination showed
Gram-negative cocci, and culture yielded Paracoccus yeei . Drug
susceptibility was tested for amoxicilline and amoxicilline-clavulanate,
both of which were sensitive. Empiric treatment was discontinued on the
second day of hospitalization and replaced by amoxicillin 150 mg IP per
liter of effluent. The total treatment duration was of 3 weeks with
progressive decline and normalization of effluent cytology on the 9 th
day following diagnosis. However, the patient developed other catheter
infections with S. oralis and P. mirabilis involving the
exit site, later P. putida and C. freundii peritonitis,
and lastly a S. pneumoniae peritonitis in January 2020.
Discussion:
The genus Paracoccus comprises 17 species found in soil and
water. Only P. yeei has been identified as a pathogen causing
disease in humans as it possesses specific genes of virulence (6).
Spectrum of disease includes CAPD-associated peritonitis and bacteremia
associated with cellulitis, myocarditis in a heart-transplant,
bacteremia in a cirrhotic patient, arthritis, and keratitis (11,12,13,
14, 15). Previous reports have demonstrated antibiotic susceptibility to
beta-lactams, fluoroquinolones, and aminoglycosides. Amoxicillin and
other beta-lactams are likely effective treatment options for P. yeei.
Our patient received IP amoxicillin for 3 weeks. IP administration of
antibiotics is the preferred route to treat peritonitis for a duration
of 2 -3 weeks according to the germ identified. IP dosing
recommendations are available for many antibiotics (2). The incidence of
PD peritonitis varies greatly according to the reporting centers and
ranges from 0.2 to over 0.5 episodes per patient/year (1). Various
interventions are recommended to prevent catheter and tunnel infections.
Skin/catheter-related exogenous infections can be prevented by general
hygiene, patient education and training in practicing home CAPD,Staphylococcus aureus decolonization, antibiotic ointment of the
exit site, among others (16). Endogenous, bacterial
translocation-associated peritonitis can be prevented by prevention of
constipation, and antibio-prophylaxis prior to various invasive
endoscopic procedures (17).
Conclusion
Environmental germs of low virulence can cause peritoneal dialysis
catheter-associated peritonitis providing opportunistic circumstances.
We report a case of P. yeei PD peritonitis successfully treated
with intraperitoneal ampicillin in a patient experiencing several
episodes of infections with various germs. P. yeei is an emerging
opportunistic pathogen. Various prophylactic measures can be implemented
to reduce the rate PD peritonitis from both exogenous and endogenous
sources.
Acknowledgement statement
None
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Ethical aspects
The patient provided written informed consent to the publication of her
case. Anonymity has been preserved.
Funding
None
Conflict of Interest
None
Author Contributions
Fosso C: followed the case and reviewed the manuscript
Maillart E: reviewed the manuscript
Beun A: followed the case and reviewed the manuscript
Touzani F: followed the case and reviewed the manuscript
Mahadeb B: identified the germ and reviewed the manuscript
Clevenbergh P: followed the case and organized the case report