Infectious Disease Reports 2020; volume 12:8376 Peritonitis from facultative presenting with Citrobacter freundii peri- anaerobic gram-negative bacilli tonitis. Correspondence: Sreedhar Adapa, The Citrobacter freundii (C. freundii) is a Nephrology Group, 568 East Herndon Avenue likely due to translocation of motile, facultative anaerobe, non-sporing #201, Fresno, CA 93720, USA. bacteria from gut in a patient gram-negative bacilli colonize in the gas- Tel.: 5592286600 - Fax: 5592263709. undergoing peritoneal dialysis trointestinal tract of humans and other ani- E-mail: [email protected] mals. It is also found in water, soil, and Key words: Citrobacter freundii, peritonitis, food.1 Werkman and Gillen discovered Sreedhar Adapa,1 Srikanth Naramala,2 SPICE organisms, peritoneal dialysis. 3 genus Citrobacter in 1932 and the organism Harmandeep Singh Tiwana, uses citrate a sole carbon source for the Contributions: All authors contributed equally 4 4 Niraj Patel, Raman Verma, energy source and hence derives its name.2 to the text of the manuscript and the literature 5 Narayana Murty Koduri, Venu Madhav C. freundii is hydrogen sulfide positive, review. SA was responsible for the original Konala6 indole negative, adonitol negative, and mal- diagnosis and treatment. Manuscript prepara- 3 tion and modification by VM. 1The Nephrology group, Fresno, CA; onate negative in character. Peritonitis 2 Department of Rheumatology, from gram-negative organisms frequently Conflict of interest: The authors declare no Adventist Medical Center, Hanford, CA; results in hospitalization, catheter loss, dial- potential conflict of interest. 3 ysis modality change, and mortality. These Department of Internal Medicine, infections are hard to treat because of Funding: None. Adventist Medical Center, Hanford, CA; biofilm formation, which makes them less 4Department of Internal Medicine, susceptible to antibiotics. Availability of data and materials: PubMed Kaweah Delta Medical Center, Visalia, database. The authors declare that data sup- CA; 5Department of Psychiatry, Great porting the findings of the discussion are Plains Health, North Platte, NE; available within the article. 6Ashland Bellefonte Cancer Center, Case Report Ethics approval and consent to participate: Ashland, KY, USA A 42-year-old male on peritoneal dialy- Our institution does not require ethical approvalonly for individual case reports. sis presented with abdominal pain and cloudy effluent of one-day duration. The Informed consent: Verbal informed consent Abstract patient denied any fever and denied any in from the patient has been obtained for their advent breach in the technique while mak- The peritonitis caused by gram-negative useanonymized information to be published in ing peritoneal dialysis connections. this article. organisms is a serious complication Moreover, the patient denied history of diar- encountered in patients undergoing peri- rhea or constipation. The patient has been Received for publication: 10 November 2019. toneal dialysis, often causing high morbidi- on peritoneal dialysis for five years and had Revision received: 5 March 2020. ty and mortality. There has been recognition no prior history of peritonitis. Past medical Accepted for publication: 25 March 2020 of peritonitis caused by uncommon organ- history was signification for diabetes, isms because of improved microbiological This work is licensed under a Creative hypertension, hyperlipidemia, hyper- detection techniques. The healthcare Commons Attribution-NonCommercial 4.0 parathyroidism, end-stage renal disease on providers involved in the management of International License (CC BY-NC 4.0). peritoneal dialysis. Home medications these patients should be very vigilant. We included metoprolol 100 milligrams (mg) © report a rare case of peritonitis caused by Copyright: the Author(s), 2020 twice a day, nifedipine 60 mg extended- Citrobacter freundii. A 42-year-old male on Licensee PAGEPress, Italy release daily, atorvastatin 80 mg daily, seve- Infectious Disease Reports 2020; 12:8376 peritoneal dialysis for five years presented lamer 2400 mg three times a day with doi:10.4081/idr.2020.8376 with abdominal pain and cloudy effluent. meals, calcitriol 0.5 micrograms (mcg) The peritoneal fluid analysis was consistent daily, gabapentin 100 mg daily at bedtime, with peritonitis, and peritoneal fluid culture cinacalcet 30 mg daily, insulin glargine 15 grew Citrobacter freundii. The patient was units daily, insulin sliding scale. 1837 cells/ul with 85% predominant neu- treated with two courses of double antibiot-Non-commercial The vital signs on presentation were the trophils. Peritoneal fluid gram stain ic coverage with intraperitoneal ceftazidime temperature of 36.4 Celsius, pulse rate of 84 revealed >100 WBC, and no organisms and oral ciprofloxacin, which failed to beats per minute, respiratory rate of 16 were seen. The patient was started on resolve the infection and hence resulted in breath per minute, blood pressure of 158/95 empiric treatment for peritonitis with the removal the peritoneal dialysis catheter mm Hg. Physical examination revealed intraperitoneal vancomycin and cef- and dialysis modality change. abdominal tenderness with a peritoneal tazidime. Later on, peritoneal fluid culture dialysis catheter in the right lower quadrant. grew Citrobacter freundii in both aerobic There was no exit site drainage or redness and anaerobic bottles. The sensitivities of Introduction along the tunnel and the rest of the physical Citrobacter freundii were listed in Table 1 Gram-negative organism peritonitis is a examination was nonsignificant. done by VITEK 2 method. severe complication encountered in patients Laboratory analysis showed white The patient was treated with double undergoing peritoneal dialysis, often caus- blood count 10300 mm3, hemoglobin 11.2 antibiotic coverage of intraperitoneal cef- ing high morbidity and mortality. The gm/dl, platelet count 22300 mm3, sodium tazidime and oral ciprofloxacin for three healthcare providers involved in the care of 138 mmol/l, potassium 4.5 mmol/l, bicar- weeks. The repeat peritoneal fluid cultures patients undergoing peritoneal dialysis bonate 22 mmol/l, blood urea nitrogen 58 after finishing the antibiotic course yielded should recognize that unusual organisms mg/dl, creatinine 11.6 mg/dl, albumin 3.3 heavy growth of C. freundii again. The sen- could cause peritonitis. We report the case g/dl. The peritoneal fluid effluent revealed sitivities of Citrobacter freundii are listed in of a 42-year-old male on peritoneal dialysis peritoneal fluid white blood cells (WBC) Table 2 done. Another three weeks course [page 16] [Infectious Disease Reports 2020; 12:8376] Case Report of double antibiotic treatment (intraperi- leads to peritoneal dialysis catheter removal gram-negative bacteria, particularly toneal ceftazidime and intravenous imipen- despite repeated courses of double antibiot- Citrobacter compared to the general popu- em) was given, which failed to clear the ic coverage.4 Dialysis patients are prone to lation. Citrobacter peritonitis tends to be organism. The symptoms resolved when have gastrointestinal colonization from polymicrobial in 10-15% episodes com- peritoneal dialysis catheter was removed after failing two double antibiotic courses. Subsequently, he did not require a further course of antibiotics. The dialysis modality of the patient was then switched to Table 1. Sensitivities of Citrobacter freundii, isolated in our patient with peritonitis. hemodialysis and the patient continues to be Antibiotic Minimum inhibitory concentration Sensitivity result hemodialysis dependent after two years of follow up. Cefazolin ≥64 mcg/ ml Resistant Cefepime ≤1 mcg/ml Sensitive Ceftazidime ≤1 mcg/ml Sensitive Ceftriaxone ≤1 mcg/ml Sensitive Discussion Ciprofloxacin 0.5 mcg/ml Sensitive C. freundii belongs to the Gentamicin ≥16 mcg/ml Resistant Enterobacteriaceae family, which accounts Imipenem 2 mcg/ml Sensitive for more than 10% of cases of peritonitis. Serratia, Pseudomonas/Providencia, indole positive Proteus/Acinetobacter/Morganella, Table 2. Sensitivities of Citrobacter freundii during antibiotic treatment. Citrobacter, Enterobacter, and Hafnia Antibiotic Minimum inhibitory concentration Sensitivity result group of organisms (SPICE) are associated with peritonitis with high mortality, and Cefazolin ≥64 mcg/ ml Resistant morbidity.4 Citrobacter has low virulence only Cefepime ≤1 mcg/ml Sensitive and accounts for 4.8% of all Ceftazidime 1 mcg/ml Sensitive Enterobacteriaceae peritonitis.5 ≤ Ceftriaxone =1 mcg/ml Sensitive C. freundii and C. koseri are the most ≤ pathogenic strains and cause seventy per- Ciprofloxacin use 1 mcg/ml Intermediate cent of human infections among the Gentamicin ≥16 mcg/ml Resistant Citrobacter genus. Other medically impor- Imipenem 1 mcg/ml Sensitive tant species in Citrobacter are C. Levofloxacin 4 mcg/ml Intermediate amalonaticus, C. farmeri, C. braakii, C. Tobramycin 8 mcg/ml Resistant werkmanii, and C. sedlakii.6 Citrobacter is the rare cause of peritonitis, and C. freundii Trimethoprim/Sulfamethoxazole ≥320 mcg/ml Resistant is the common species involved, frequently Piperacillin-tazobactam 16 mcg/ml Sensitive Table 3. Summary all the cases listed as Citrobacter freundii peritonitis with patients on dialysis as per PubMed review of literature. Author Year Age/ Duration Dialysis Polymicrobial Dialysate Treatment Catheter Outcome Gender (months) Mode association culture salvage Dervisoglu et al.8 2008 33/F 96 CAPD No Positive Intravenous No Infection