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Extended-spectrum beta-lactamase-producing klebsiella pneumoniae causing peritonitis in a patient on continuous ambulatory peritoneal dialysis.

There are very few reported cases of peritonitis caused by extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumonia, and as such there is no standard protocol for its treatment in patients on continuous ambulatory peritoneal dialysis (CAPD). The International Society for Peritoneal Dialysis (ISPD) recommends the use of intra-peritoneal (IP) cephalosporin or aminoglycosides to cover gram negative bacteria. A 65-year-old man was on CAPD for two years because of end-stage renal diseases resulting from diabetes mellitus and presented with pain abdomen, vomiting, fever and cloudy effluent fluid. The effluent fluid cell count was 1800/μL (90% neutrophils, 10% lymphocytes). Gram stain showed capsulated gram negative cocco-bacili. A patient was empirically started on vancomycin and ceftazidime IP; however, after two days of antibiotics, there was no relief from peritonitis. The effluent peritoneal fluid culture was positive for ESBL-producing K. pneumonia, which was sensitive to carbapenem (imipenem); the antibiotic was changed to imipenem/cilastatin 2 g IP daily. The repeat effluent cell count was 100/μL, gram stain was negative and the culture of peritoneal fluid was sterile. The patient fully recovered after three weeks of imipenem/cilastatin. Because the production of ESBL enzyme by the bacterial pathogens is the most commonly encountered mechanism of resistance to βlactam antibiotics, the hydrolysis of broadspectrum oxyimino-cephalosporins renders these antibiotics ineffective. The propensity of ESBL-producing organisms to be concomitantly resistant to other classes of antibiotics greatly limits the choice of antibiotics that can be used for treatment. Infections caused by ESBL-producing organisms such as K. pneumonae and Eshcherichia coli are associated with adverse clinical outcomes and significantly higher mortility. The ESBL-producing pathogens should be suspected in patients who have recently received broad-spectrum antibiotics, with age older than 60 years, those with other comorbid conditions and those who underwent recent hospital and intensive care unit admissions and were treated with invasive devices. Carbapenems are the most reliable antimicrobial agents against ESBL isolates. With increasing prevalence of ESBL infections, higher incidences of ESBL peritonitis are likely to be encountered in CAPD patients. Although the current ISPD recommendations have not yet discussed the issue, the clinician should be aware of these emerging and difficult-to-treat bacteria in CAPD patients with peritonitis. Further studies are needed to identify effective IP antibiotics for peritonitis caused by ESBL.