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Nontuberculous mycobacteria (NTM) are uncommon but important causes of peritoneal dialysis (PD) catheter exit‑site infection and tunnel infection (ESI/TI), often leading to catheter loss or peritonitis. Early suspicion, acid‑fast testing, and species‑level identification are crucial, as rapidly growing NTM differ in macrolide susceptibility and outcomes. Refractory ESI should prompt evaluation for NTM, and salvage options such as an exit‑site relocation are now recognized in guidance. The most frequent PD‑related NTM species are M. abscessus, M. fortuitum, and M. chelonae. We report a salvage‑focused success where PD continuation was imperative due to severe left‑ventricular dysfunction with LVEF of 23% and obesity with BMI of 30.8 kg/m2, which limited transition to hemodialysis or transplantation.
A 63-year-old male with a 4-year history of peritoneal dialysis presented on Day -29 with purulent discharge from the catheter exit site. Despite topical gentamicin, the discharge worsened. On Day -8, ultrasound showed a peri‑catheter hypoechoic area consistent with TI, a swab for culture was obtained, and oral cefaclor was started. On Day -1, 7 days later, the acid-fast bacilli (AFB) culture from Day -8 turned positive. He was admitted on Day 0 for suspected NTM ESI/TI. Empiric therapy with linezolid, amikacin, and clarithromycin was started on Day 1. On Day 4, surgical drainage, removal of the infected catheter remnant and exit‑site relocation was performed. The Day -8 culture eventually grew M. chelonae. Amikacin was discontinued after the second dose due to high serum trough levels. Linezolid was replaced with sitafloxacin on Day 14 due to thrombocytopenia. He was discharged on Day 30 on clarithromycin and sitafloxacin to complete a total 4 months of therapy.
The case highlights the importance of early AFB testing in refractory ESI and performing prompt surgical source control to avoid cuff involvement and peritonitis. Species confirmation of M. chelonae supported a macrolide‑based regimen, while toxicity required an aminoglycoside‑sparing, oral combination. M. abscessus often carries erm(41)-mediated macrolide resistance, whereas M. chelonae is usually susceptible, though emerging erm(55)‑variants warrant susceptibility‑guided therapy. Combination regimens with 2 or more active agents for 4–6 months with source control are advised for extrapulmonary rapidly growing mycobacteria infections. Current guidance highlights NTM among atypical causes of refractory ESI, encourages individualized salvage strategies including exit‑site relocation
In PD patients with refractory ESI/TI, clinicians should obtain early AFB cultures and species identification to guide management. Early exit‑site revision/debridement with an oral dual regimen of clarithromycin and sitafloxacin can salvage the catheter and maintain PD when cardiac dysfunction and obesity limit alternatives, demonstrating a practicalt success where evidence remains limited.
