NEPHROLOGY - CASE REPORT

Micrococcus species-related peritonitis in patients receivingperitoneal dialysis

Chih-Chin Kao • Chih-Kang Chiang •

Jenq-Wen Huang

Received: 21 May 2012 / Accepted: 15 September 2012

� Springer Science+Business Media Dordrecht 2012

Abstract Peritonitis is a major complication of

peritoneal dialysis (PD) and remains the most com-

mon cause of PD failure. Micrococci are catalase-

positive, coagulase-negative, and gram-positive cocci

that are spherical, often found in tetrad, and belong to

the family Micrococcaceae. Micrococcus species are

commonly found in the environment, and it is now

recognized that Micrococcus species can be opportu-

nistic pathogens in immunocompromised patients.

The only consistent predisposing factor for Micrococ-

cus infection is an immunocompromised state. We

report three cases of Micrococcus PD peritonitis.

Improper practice of PD may have been the causative

factor. Although Micrococcus species are low-viru-

lence pathogens, infection could result in refractory

peritonitis and subsequent PD failure. Intraperitoneal

administration of vancomycin for at least 2 weeks is

recommended for Micrococcus peritonitis.

Keywords Micrococcus � Peritoneal dialysis �Peritonitis

Introduction

Peritonitis is a major complication of peritoneal

dialysis (PD) and remains the most common cause

of PD failure [1]. Most cases of peritonitis caused by

contamination during exchange procedures are due to

gram-positive cocci. Micrococcus species are com-

mon gram-positive aerobic cocci present in soil, water,

dust, and the skin of humans and animals; these cocci

are generally considered nonpathogenic. However, it

is now recognized that Micrococcus species can be

opportunistic pathogens in immunocompromised

patients [2, 3].

We describe the cases of three patients with

Micrococcus-related PD peritonitis. Of them, two

were switched to hemodialysis (HD) because of

refractory relapsing/repeat peritonitis.

Case reports

Patient 1

A 54-year-old man had a 5-year history of end-stage

renal disease (ESRD) due to chronic glomerulone-

phritis (CGN). He began HD as renal replacement

therapy and switched to PD 1 year later. Three

C.-C. Kao � C.-K. Chiang � J.-W. Huang (&)

Division of Nephrology, Department of Internal

Medicine, National Taiwan University Hospital,

No. 7, Chung-Shan South Road, Taipei 100,

Taiwan, R.O.C.

e-mail: 007378@nuth.gov.tw

C.-K. Chiang

Integrated Diagnostics and Therapeutics, National Taiwan

University Hospital, National Taiwan University College

of Medicine, Taipei, Taiwan, R.O.C.

123

Int Urol Nephrol

DOI 10.1007/s11255-012-0302-1

episodes of PD peritonitis occurred before the present

peritonitis episode. Two episodes were due to Staph-

ylococcus aureus and the third due to Corynebacte-

rium. One month after the third peritonitis episode,

turbid effluent was observed and abdominal pain

developed. The total nuclear cell count (TNC) of the

effluent was 2,800/lL, with 90 % neutrophils. Empir-

ical antibiotic therapy was administered with intra-

peritoneal (IP) vancomycin at an initial dose of

1,000 mg, followed by 500 mg every 3 days accord-

ing to previous two Gram (?) pathogens. Micrococcus

and Kocuria species grew in the effluent. The perito-

nitis was cured after a total of eight doses of IP

vancomycin.

Patient 2

A 40-year-old man with a history of CGN-related

ESRD received a living donor kidney transplantation.

Unfortunately, acute rejection with graft failure

occurred 2 years later, and PD was initiated. There

were no peritonitis episodes in the first 3 years of PD;

however, relapsing and repeat peritonitis occurred in

the following 2 years. The causative pathogens

included M. luteus, Pseudomonas oryzihabitans (two

times), coagulase-negative staphylococci (two times),

nonfermentative GNB for once and culture negative

for once. Micrococcus-related peritonitis was identi-

fied in 7 of 13 episodes of peritonitis. He reported

turbid dialysate and mild abdominal pain in all

peritonitis episodes, without spiking fever. In the first

episode of M. luteus peritonitis, the TNC of the

effluent was 9,500/lL, with 95 % neutrophils. Treat-

ment with IP cefazolin (1 g daily) and Ceftazidime

(1 g daily) at first, and it changed to Cefazolin 1 g

daily as the culture reported Micrococcus. Two-week

treatment was effective for this peritonitis episode and

for the following six Micrococcus peritonitis episodes.

For the rest peritonitis episodes caused by other

pathogens, we followed the International Society for

Peritoneal Dialysis (ISPD) guidelines [4]. Because of

relapsing and repeat episodes of peritonitis, PD was

finally replaced with HD.

Patient 3

A 63-year-old man with a history of ESRD caused by

hypertension underwent PD for 1 year. Intermittent,

dull abdominal pain; turbid effluent; and mild fever

(BT, 38 �C) were present for 2 days. TNC of the

effluent was 4,000/lL, with 98 % neutrophils. Empir-

ical antibiotic therapy was initiated with daily IP

administration of cefazolin (1 g) and Ceftazidime

(1 g). The culture yielded Micrococcus species;

however, the effluent was not clear and had a TNC

of 400/lL with 75 % neutrophils after 4 days of

antibiotic therapy. The patient was administered IP

vancomycin at an initial dose of 1,000 mg and

followed by 500 mg every 3 days. However, turbid

dialysate persisted after 7 days of vancomycin ther-

apy, and the Tenckhoff catheter was removed because

of refractory peritonitis. Subsequently, PD was per-

manently replaced with HD.

Discussion

Micrococci are catalase-positive, coagulase-negative,

and gram-positive cocci that are often found as tetrad

and belong to the family Micrococcaceae [5]. There

are currently seven known species: M. luteus, M. lylae,

M. antarcticus, M. endophyticus, M. flavus, M. terreus,

and M. yunnanensis. They are often pigmented,

especially M. luteus, which is characterized by the

production of yellow, water-insoluble pigments, and

are generally considered nonpathogenic. Micrococcus

species are commonly found in the environment, and it

is now recognized they can be opportunistic pathogens

in immunocompromised patients. Cases of bactere-

mia, endocarditis, ventriculitis, peritonitis, pneumo-

nia, endophthalmitis, keratolysis, and septic arthritis

caused by Micrococcus species have been documented

[2, 3, 6–11]. There are only a few case reports of

Micrococcus species-related peritonitis in PD patients

[3, 12]. The genus Micrococcus is classified into the

genera Kocuria, Micrococcus, Kytococcus, Nest-

erenkonia, and Dermacoccus based on phylogenetic

and chemotaxonomic analysis [13]. Genome-based

typing is required to exactly characterize Kocuria

species [14]. However, the high cost and intensive

labor required in molecular typing may limit the use of

such methodologies in routine practice. The only

consistent predisposing factor for Micrococcus infec-

tion is an immunocompromised state. Intermittent

flushing with extraneous fluids and repeated and

complex handling procedures contribute to Micrococ-

cus entry and subsequent peritonitis in PD patients [3].

Other possible contributing factors to Micrococcus

Int Urol Nephrol

123

infection are an invasive procedure (transhepatic

cholangiography) with bacteremia and septic shock

[8], carious teeth with brain abscess [7], a metallic

foreign body with endophthalmitis [9], or Corynebac-

terium group JK with M. pneumonia [2]. Infection in

Patient 1 and Patient 2 may be attributable to improper

management of PD. Patient 1 reported to change the

dialysate in the company’s warehouse, and he some-

times did not wear a mask and wash his hand as the

standard protocol. Patient 2 often had several times of

disconnection of the lines between the Tenckhoff

catheter and automated peritoneal dialysis (APD)

machine during an APD cycle. It put him on a higher

risk of contamination. Infection in Patient 3 may be

attributable to a long thumb knuckle, which provides a

good milieu for Micrococcus colonization in an

individual who had daily contact with plants.

The mean age of these patients was 52 years

(Table 1). They all developed Micrococcus perito-

nitis while receiving APD. Among their clinical

presentations, there were no gastrointestinal symp-

toms, exit-site infection, or tunnel infection. All the

three patients showed turbid effluent and abdominal

tenderness after the occurrence of Micrococcus

peritonitis. They did not show systemic signs such

as bacteremia or sepsis. This may be due to the low

virulence of Micrococcus species. For two of our

patients, PD was replaced with HD. We initiated IP

antibiotics as soon as possible, according to ISPD

guidelines [4]; however, low-virulence pathogens

like Micrococcus species can cause refractory peri-

tonitis and subsequent PD failure.

Two episodes of Micrococcus peritonitis slowly

responded to empirical treatment. Vancomycin was

administered during these episodes, but only one

episode of peritonitis was cured. Although National

Committee for Clinical Laboratory Standards

(NCCLS) do not include disk diffusion susceptibility

standards for Micrococcus species, most isolates are

susceptible to a wide range of antibiotics. However,

pathogens resistant to penicillin and oxacillin have

been reported [8, 15]. In our experience, vancomycin

is the preferred agent. We recommend IP administra-

tion of vancomycin for at least 2 weeks.

In summary, we reported three cases of Micrococ-

cus PD peritonitis. Micrococcus species caused PD

failure in two patients. We recommend at least

2 weeks of IP vancomycin for treating Micrococcus

peritonitis.Ta

ble

1C

lin

ical

char

acte

rist

ics

of

thre

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ith

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eal

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itis

Pt

no.

Age

(yea

rs)

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orb

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(yea

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Occ

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ng

risk

fact

or

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trophil

s(%

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icro

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isep

isode(

s)

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PD

fail

ure

154

CG

NH

TN

,hyper

lipid

emia

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old

CV

A5

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cedure

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00

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n

240

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Int Urol Nephrol

123

Conflict of interest None.

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