Peritoneal Dialysis-Associated Peritonitis with Kytococcus schroeteri

Introduction: Peritonitis is a known complication of PD and common organisms include gram-positive cocci such as Staphylococcus epidermidis, Staphylococcus aureus and enteric Gram negative bacilli. We present a case of peritonitis in a PD patient with a rare gram-positive organism, Kytococcus schroeteri. Case Description: 50-year-old male with ESRD due to diabetes mellitus and hypertension on peritoneal dialysis was noted to have signs and symptoms of peritonitis and peritoneal effluent culture grew Kytococcus schroeteri. Initial fluid was milky with PD fluid WBC count was 16686 predominantly(80%) neutrophils and it came down to 81 on day 6, <50 on day 11, 65 on day 15 and 99 on day 21 after starting intraperitoneal vancomycin. He received intraperitoneal gentamicin during the first 5 days. Rifampin had to be stopped due to allergic reaction to it. Intraperitoneal tPA was given to break the fibrin in the peritoneum and 2 additional weeks of intraperitoneal vancomycin was given with improvement in the PD WBC count to <10 and effluent culture remained negative. Staining and culture for acid fast bacilli and fungal cultures were negative. Proper hygiene and techniques were reinforced. Discussion: Kytococcus organisms are rare causes of bacteremia in the immunosuppressed and device related infection. This is the first case of PD related peritonitis caused by K.schroeteri based on our literature search even though there is one published case report of PD peritonitis from Kytococcus sedentarius. K. schroeteri is resistant to penicillin, cephalosporin, erythromycin and clindamycin and sensitive to vancomycin, rifampin, daptomycin and linezolid. Generally dual therapy is needed and rifampin is an important component associated with successful outcome. Since Kytococcus is a skin organism, root cause analysis should include assessment of dialysis technique to prevent future episodes. ISPD has no specific suggestions on treatment of Kytococcus peritonitis, but 3-4 weeks of treatment with two antibiotics seems reasonable along with fungal prophylaxis.