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the incidence of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis ( capd ) has significantly decreased recently compared to rates in the past because of the development of peritoneal dialysis methods and catheter - related techniques , continuous patient education , and the establishment of antibiotic treatment guidelines ; however , peritonitis remains an important cause of peritoneal dialysis failure .
in peritonitis induced by a single microorganism strain , coagulase - negative staphylococcus was the most common cause of peritonitis ( 24.3% ) , followed by streptococcus , staphylococcus , escherichia coli , and pseudomonas aeruginosa .
pseudomonas stutzeri was first isolated from human spinal fluid as a gram - negative motile organism with a single polar flagella .
p. stutzeri is widely distributed in the environment and rarely causes infections , but it has been isolated as an opportunistic pathogen in clinical conditions .
stutzeri - induced peritonitis in patients with capd was reported by ceri et al .   overseas , but
no cases have so far been reported in korea . with regard to inflammatory diseases other than peritonitis ,
only one case of choroid plexitis has been reported domestically . in this report , we present a case of peritonitis by an uncommon pathogen , p. stutzeri , in a patient undergoing capd treated without catheter removal .
an 82-year - old woman who had undergone capd for 1 year for the treatment of end - stage renal disease secondary to hypertension was hospitalized for a cloudy peritoneal dialysis effluent for 1 day before admission .
physical examination on admission revealed abdominal distension , decreased bowel sounds , and mild diffuse abdominal tenderness .
the patient s vital signs were as follows : body temperature , 36.8  c ; blood pressure , 185/88  mmhg ; and heart rate , 78/min in sinus rhythm .
laboratory analysis revealed the following : white blood cell count of 10.410/mm with 89% polymorphonucleocytes ; hemoglobin , 11.1  g / dl ; platelet count , 30410/mm ; erythrocyte sedimentation rate , 64  mm / h ; c - reactive protein level , 2.92  mg / dl .
the patient s blood chemistries were normal except for a creatinine level of 6.33  mg / dl , blood urea nitrogen level of 56.7  mg / dl , and albumin level of 2.8  g / dl .
chest radiography showed mild pulmonary congestion with cardiomegaly , whereas abdominal radiography revealed a mild paralytic ileus ( fig .
1 ) . peritoneal fluid analysis revealed a leukocyte count of 9.9210/mm ( polymorphonuclear leukocytes , 84% ; lymphocytes , 4% ) .
empirical therapy was initiated with intraperitoneal cefazolin ( dong - a pharmaceutical company limited , seoul , korea ) and isepamicin .
because p.stutzeri grew in the culture of the peritoneal effluent performed on admission , cefazolin was discontinued from the 9 day of peritonitis , and ciprofloxacin was administered orally in addition to the initial treatment .
the white blood cell count of the peritoneal fluid decreased from 9,920/mm on admission to 6/mm on the 19 day of peritonitis , and the dialysate effluent that was cloudy on admission drained clear from the 3 day of peritonitis .
there were no other complications , and the patient is currently undergoing capd through the outpatient nephrology service without recurrent peritonitis .
identifying the causative microorganism is important for antibiotic selection and the determination of a treatment strategy in the management of capd peritonitis .
approximately 72% of capd peritonitis cases can be treated with antibiotics , but the catheter must be removed in the other 28% of cases because of recurrent and intractable peritonitis such as fungal infections .
. cases of p. stutzeri have been reported in the form of osteomyelitis , arthritis , endocarditis , meningitis , pneumonia , empyema , skin infections , eye infections , urinary tract infections , and diverticulitis , and susceptibility tests for several antibiotics have been performed in epidemiological and case reports .
nearly all studies involving several antibiotics and bacterial species have shown that p. stutzeri is sensitive to many more antibiotics than p. aeruginosa , its most closely related species and a well - known human pathogen .
the higher sensitivity of p. stutzeri can be explained by its reduced exposure to antibiotics because of its low incidence rate in clinical environments . despite these results , when isolated in immunocompromised hosts , p. aeruginosa and other pseudomonas spp . , including p. stutzeri ,
this finding implies that p. stutzeri has a range of antibiotic resistance mechanisms , such as changes in outer membrane proteins and lipopolysaccharide , and the presence of -lactamase has been described .
siva et al .   reported that pseudomonas is associated with a higher catheter removal rate and conversion to hemodialysis compared to general microorganisms , and immediate removal of the peritoneal catheter and treatment with two types of antipseudomonal antibiotics decreased mortality through a meta - analysis of 191 cases of peritonitis by pseudomonas that occurred in 20032006 in australia .
p. stutzeri was identified in 15 ( 8% ) of a total of 191 cases .
treated the patients with refractory capd peritonitis due to p. stutzeri with susceptible antibiotics and catheter removal .
tan et al .   described p. stutzeri as one of the causative pathogens of recurrent peritonitis in pediatric patients undergoing capd .
however , no case has yet been reported in korea . in this case , the patient was treated with antibiotics without catheter removal because the isolated bacterium was susceptible to ciproflocaxin and isepamicin ( table 1 ) , there was no evidence of an exit site infection or tunnel infection , and her clinical symptoms improved after antibiotic administration ( table 2 ) . according to the recommendations of the international society for peritoneal dialysis , catheter removal with antibiotic treatment
is recommended because peritonitis by pseudomonas species , which has the capacity to generate biofilm , is commonly associated with catheter - related infection , .
in addition , like p. aeruginosa , p. stutzeri has a variety of antibiotic resistance mechanisms .
thus , the administration of two susceptible antibiotics with different mechanisms of action is required . in conclusion ,
management of p. stutzeri - induced peritonitis should be the same as that with p. aeruginosa .
however , careful deliberation is necessary upon capd catheter removal because p. stutzeri infection progresses according to host immunity and antibiotic exposure as shown in this case .
pseudomonas stutzeri is a gram - negative , rod - shaped , motile , single polar - flagellated , soil bacterium that was first isolated from human spinal fluid and is widely distributed in the environment . 
 it was isolated as an uncommon opportunistic pathogen from humans , and a few cases of p. stutzeri - induced peritonitis have been reported in patients undergoing continuous ambulatory peritoneal dialysis ( capd ) . 
 catheter removal with antibiotic treatment is generally recommended because peritonitis by pseudomonas species is commonly associated with catheter - related infection . 
 here , we describe the first case of p. stutzeri - induced peritonitis in an 82-year - old woman in korea . 
 she had received two antipseudomonal antibiotics , an aminoglycoside ( isepamicin , yuhan corporation , seoul , korea ) and a fluoroquinolone ( ciprofloxacin ) , and was successfully treated without removal of the capd catheter .