Peritoneal dialysis-related peritonitis from Burkholderia pseudomallei infection (Melioidosis) of northeast Thailand

INTRODUCTION

Peritonitis is the most common and serious consequence of peritoneal dialysis. More than 15% of patients undergoing peritoneal dialysis die directly or as a result of peritoneal dialysis-related peritonitis.^[1,2] The most common reason for transitioning to long-term hemodialysis is a single episode of severe peritonitis or multiple bouts of peritonitis, both of which typically result in a loss in peritoneal ultrafiltration capacity. Gram-positive cocci, such as Staphylococcus epidermidis and Staphylococcus aureus, are the most common cause of peritoneal dialysis-related peritonitis globally.^[3,4] The variety of organisms associated with peritonitis varies by geography, as does the frequency of episodes with negative cultures. Because 20% of cultures are negative, it is recommended that appropriate laboratory samples be obtained before the introduction of antibiotics.^[5,6] Cloudy effluent in peritoneal dialysis patients should be considered an indication of peritonitis, which should be confirmed by an effluent white blood cell (WBC) count of more than 100/mL, differential count, culture, and Gram staining. Even if the effluent is clear, patients with abdominal pain should always consider peritonitis because it affects only a tiny percentage of patients.^[7]

The etiological agents responsible for peritonitis in tropical regions, such as Thailand, may differ from those in other parts of the world due to differences in climatic and microbiological circumstances. Burkholderia pseudomallei, a Gram-negative bacteria, is native to Southeast Asia and Northern Australia. It is known to cause melioidosis, which can be lethal in people.^[8,9] Melioidosis is typically transmitted through percutaneous injection, inhalation, or ingestion, and it can cause localized or disseminated illnesses.^[10] The bacterium is often found in soil and water, making it a major threat in tropical settings. Peritoneal dialysis-related peritonitis is hypothesized to have an unusual cause of melioidosis.^[11,12] The coexistence of B. pseudomallei and peritoneal dialysis is a concerning situation, as infection with this organism might have disastrous effects on peritoneal dialysis patients. Furthermore, the bacterium’s natural resistance to several antibiotics, as well as its ability to build biofilms, makes eradication difficult. As a result, peritoneal dialysis-related peritonitis caused by B. pseudomallei is a major concern in tropical countries where melioidosis is common. The purpose of this study was to investigate the prevalence and outcome of peritoneal dialysis-related peritonitis caused by B. pseudomallei infection.

MATERIALS AND METHODS

RESULTS

Of the 194 cases diagnosed peritoneal dialysis-related peritonitis, there were only 7 patients (3.6%), four females and three males infected due to B. pseudomallei. These patients ranged in age from 40 to 65. The mean age was 51.1, with a standard deviation of 9.44. 5 of the 7 cases (71.4%) had diabetes, 1 (14.3%) had hypertension, and 1 (14.3%) had renal stone disease as their primary disease. Hypertension (7 cases, 100%), diabetes (5 cases, 71.4%), cardiovascular disease (2 cases, 28.6%), gout (1 case, 14.3%), and neurovascular disease (1 case, 14.3%) were the prevalent concomitant conditions. Clinical presentations included abdominal pain in 7 (100%) cases, fever in 6 (85.7%) cases, and cloudy effluent in 5 (71.4%) cases. Septicemia was identified as being present in the 5 (71.4%) cases. WBC and neutrophil counts were both >100/L and 50%, respectively, in the peritoneal effluent of all seven cases. Prior peritonitis had occurred in 2 (28.6%) cases within a month before and antibiotics had been used. However, medication for prophylaxis was not given to these patients [Table 1].

The result of laboratory data is shown in Table 2.

The discovered microorganisms in bacterial culture included all B. pseudomallei. While the finding of the antibiotic susceptibility tests was sensitive to ceftazidime and carbapenems from all samples; however, one sample developed trimethoprim-sulfamethoxazole (TMP/SMX) resistance. Except for three cases, all hospitalized patients were given antibiotics for a period of 2 weeks. Ceftazidime was given to 6 (85.7%) cases and meropenem was given to 1 (14.3%) case. In 6 (85.7%) cases, the administrations of the antibiotics were done intravenously, whereas in 1 case used an early intraperitoneal route and then shifted intravenously later during the induction phase. Five (71.4%) cases switched to hemodialysis mode after the catheters were removed. The hemodialysis mode was changed permanently in 3 (42.8%) cases later. In 1 (14.3%) case, peritoneal dialysis was resumed after a brief period of hemodialysis. However, finally 3 (42.8%) patients died while receiving antibiotic treatments. For all alive patients, TMP/SMX was administered for 20 weeks during the eradication phase. After 6 months of follow-up period, there were no recurrent infections.

A comparison of risk factors in the survivor and non-survivor group is shown in Table 3. The result was no related factors impacting in survival of both patient groups significantly (P > 0.05).

DISCUSSION

The current study’s participants all complained of stomach pain, with other symptoms such as fever and unclear effluent. Diabetes (71.4%) was the most common primary condition, with hypertension being the most common comorbid disease in all cases. Adults with underlying medical conditions that increase risk were classified as high-risk categories, which was consistent with earlier studies; diabetes was the most common cause of these disorders, accounting for around 50% of instances.^[14,15] The majority of cases appeared between June and October, reflecting the previously found link to the wet season.^[16] The majority of situations required significant involvement. This highlighted the disease’s seriousness from the start.^[17] The treatment consisted of an inductive phase that included intravenous meropenem in one case and ceftazidime in six. Because the ISPD recommendations lack a unified therapy prescription, there were few therapeutic options available for melioidosis peritonitis. As long as there were no systemic sepsis signs, intraperitoneal antibiotic injection was the suggested treatment.^[18] However, when there is an unavoidable delay in administering intraperitoneal antibiotics, the intravenous route must be used as a stopgap to ensure timely therapy.^[19] The drug sensitivity pattern seen in this study was consistent with previous findings; nonetheless, there was little medication resistance discovered.^[20] If intravenous antibiotics did not treat the peritonitis, the next logical step would be to remove the catheter as soon as feasible. Five patients’ catheters were removed prematurely due to severe septicemia, and hemodialysis was performed in place of peritoneal dialysis. Despite the removal of catheters in two individuals, the outcomes were still unsuccessful, and the same was true for another who did not have the catheter removed. Following 2 weeks of induction, we administered oral co-trimoxazole for 20 weeks as eradication therapy. Other medications, such as doxycycline and amoxicillinclavulanic acid, can be used instead during the eradication phase and as post-exposure prophylaxis.^[21] According to the treatment summary, three patients died of septicemia and septic shock despite receiving adequate antibiotic treatment. Diabetes, chronic kidney illness, thalassemia, and immunocompromised states were all associated with higher mortality rates.^[22] Unfortunately, the number of patients in this study limited the ability to determine the association between impact factors and infection survival. No statistical significance was determined between the survivor and non-survivor groups. Finally, among the patients who remained alive, one continued peritoneal dialysis, whereas three went to hemodialysis permanently.

The first attempt to evaluate the global burden of human melioidosis was made in 2016, with forecasts of 165,000 cases and 89,000 fatalities each year.^[23] Melioidosis is found in all tropical locations, however, it is most common in Southeast Asia and Northern Australia.^[24] In Northeast Thailand, a 40.0% case mortality rate and around 2,000 culture-confirmed melioidosis cases were reported per year.^[25] Because melioidosis is a disease that must be recorded under Thai law, current official data appear to underestimate disease-related mortality dramatically. Furthermore, a serological study in Northeast Thailand found an age- related increase in seroprevalence, with more than 80% of individuals over the age of four testing positive.^[26] When these data are expanded to include all melioidosis cases, the annual incidence is expected to be 10 cases per 100,000 individuals. The severity of this disease serves as a reminder to increase staff knowledge, keep a high level of suspicion, and improve microbiological methods. Early treatment with melioidosis can enhance outcomes. At the same time, further research is needed to create vaccinations, therapeutic procedures that reduce treatment time, and serological tests for diagnosis.

CONCLUSION

Melioidosis-related peritonitis linked with peritoneal dialysis is uncommon, however, it may be accompanied by catheter loss and could be lethal if untreated as systemic melioidosis. Early clinical diagnosis and the start of antibiotic therapy are essential for effective treatment.