Pets are ‘Risky Business’ for Patients undergoing Continuous Ambulatory Peritoneal Dialysis

case rePort Pets are ‘risky business’ for patients undergoing continuous ambulatory peritoneal dialysis Yahya Salim Yahya Al-Fifi MD1, Chris Sathianathan MD2, Brenda-Lee Murray MSc3, Michelle J Alfa PhD3 YSY Al-Fifi, C Sathianathan, B-L Murray, MJ Alfa. Pets are ‘risky business’ for patients undergoing continuous ambulatory peritoneal dialysis. Can J Infect Dis Med Microbiol 2013;24(3):e96-e98. Les animaux de compagnie sont dangereux pour les patients sous dialyse péritonéale continue ambulatoire The authors report the first case in Manitoba of a patient undergoing continuous ambulatory peritoneal dialysis who experienced three successive infections with Pasteurella multocida and Capnocytophaga species over an eight-month period. These zoonotic infections were believed to originate from contact with the patient’s household pets. To prevent such infections, the authors recommend the development and implementation of hygiene guidelines outlining the risks associated with owning domestic pets for continuous ambulatory peritoneal dialysis patients. Les auteurs rendent compte du premier cas manitobain d’un patient sous dialyse péritonéale continue ambulatoire (DPCA) qui a subi trois infections successives par les espèces de Pasteurella multocida et de Capnocytophaga sur une période de huit mois. On croit que ces zoonoses étaient attribuables au contact avec les animaux domestiques du patient. Pour les prévenir, les auteurs recommandent d’élaborer et de mettre en œuvre des directives d’hygiène liées à la propriété d’animaux domestiques pour les patients sous DPCA. Key Words: CAPD; Capnocytophaga; Hand hygiene; Pasteurella multocida; Pets; Zoonotic infections CASE PrESEntAtIon A 49-year-old man with end-stage renal failure secondary to type I diabetes undergoing continuous ambulatory peritoneal dialysis (CAPD) since August 2010 presented to the emergency room with severe abdominal pain in October 2011. Several days before presentation to the emergency room, the patient had been feeling unwell; this developed into localized, dull pain at the centre of the abdomen that extended to the flanks. Approximately 24 h to 48 h before presentation, the pains became sharp and diffuse throughout the abdomen; the pain escalated gradually and then became constant. The pain was aggravated by movement and eased by lying down on one side, but it did not radiate. The patient complained of fever, chills and rigors that were occasionally associated with nausea, vomiting and night sweats. No other notable symptoms were reported. On physical examination, the patient was oriented and alert, with a blood pressure of 150/80 mmHg and a regular heart rate of 84 beats/min. He was pale but not jaundiced, and there was no sign of lymphadenopathy. His peritoneal dialysis (PD) catheter was in place and showed no signs of redness, discharge or leakage. Five months earlier, in May 2011, the patient experienced similar symptoms and was diagnosed with PD-related peritonitis. Culture analysis of the PD fluid revealed Pasteurella multocida, a normal oropharyngeal flora of cats and dogs (1,2) (Table 1). This strain of P multocida was sensitive to numerous antibiotics (Table 2). The patient was treated empirically with vancomycin and tobramycin for two days followed by cefazolin for four days, and then given intraperitoneal (IP) ceftazidime for seven days and, finally, oral amoxicillin-clavulanate for seven days. Further questioning revealed that the patient had a dog and a cat at home; however, the patient was adamant that the animals were never in the vicinity while he was performing his dialysis. He did not recall any breaks or leaks in the dialysis tubing, although he did admit that he did not always use adequate hand hygiene when handling his catheter. In August 2011, the patient acquired a PD infection secondary to Enterobacter cloacae (Table 1), which was characterized by cloudy dialysate and abdominal pain. The source of the infection was not likely zoonotic because this pathogen is commonly found in the human gastrointestinal tract. The patient was successfully treated with IP cefazolin and tobramycin for three days followed by IP ceftazidime and ciprofloxacin orally for 14 days. Analysis of the dialysate in October 2011 (Table 1) revealed an elevated white blood cell (WBC) count of 13,631×106cells/L with 89% polymorphonuclear neutrophils and 11% monocytes. Due to the patient’s history and the fact that he owned household pets, this PD infection was suspected to be zoonotic in origin. The initial Gram stain revealed no bacteria; however, several days later, Capnocytophaga was recovered from liquid media that had been inoculated with PD fluid. Bacterial 16S ribosomal DNA (rDNA) sequencing was performed to determine the species, but was unable to differentiate between Capnocytophaga cynodegmi and Capnocytophaga canimorsus (both normal flora of domestic pets). Antibiotic treatment was initiated with IP cefazolin and tobramycin for 14 days. The patient responded to antibiotic treatment and all subsequent CAPD bags were clear post-therapy until January 2012 when he presented again with cloudy dialysate and abdominal pain. As shown in Table 1, his CAPD fluid grew Capnocytophaga species. Bacterial 16S rDNA sequencing identified this isolate as C canimorsus. He was treated with IP cefazolin and tobramycin for three days followed by IP cefazolin and ciprofloxacin to complete 21 days of antibiotic therapy. It is possible that the same strain of Capnocytophaga was responsible for both infections; however, the second infection most likely occurred separately and was not a continuation of the first infection. In March 2012, the patient developed a PD catheter exit site infection that grew Corynebacterium jeikeium and manifested as a 2 cm × 4 cm area of induration over the catheter tunnel. He was treated with IP cefazolin and the catheter was removed in April 2012. The exit site infection and the previous E cloacae CAPD infection are not likely related to the zoonotic infections, but they do further attest to the consequences of poor hand and catheter hygiene. In view of the patient’s history of multiple CAPD infections, in addition to his exit site infection, he was switched to hemodialysis after removal of his PD catheter. Since being switched, he has experienced no further issues and continues to do well. 1Department of Medicine, University of Manitoba; 2Department of Nephrology, St Boniface Hospital; 3Diagnostic Services of Manitoba, Winnipeg, Manitoba Correspondence: Dr Michelle J Alfa, Diagnostic Services of Manitoba, St Boniface General Hospital, 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6. Telephone 204-237-2105, fax 204-237-7678, e-mail e96 ©2013 Pulsus Group Inc. All rights reserved Can J Infect Dis Med Microbiol Vol 24 No 3 Autumn 2013 Risks of owning pets while undergonig CAPD TAble 1 History of Infection Date May 14, 2011 Peripheral WbC count*, ×109/l 19.1 Continuous ambulatory peritoneal (...truncated)