Vol. 2 5 No. 1 I N F E C T I O N C O N T R O L AND HOSPITAL EPIDKMIOLOC;Y Letter t o t h e E d i t o r Pasteurella multocida Peritonitis: Another Risk of Animal-Assisted Therapy To the Editor: Pasteurella multocida is primari- ly a pathogen of animals but has been implicated in a range of human dis- eases. It has been estimated that as many as 66% of dogs and 90% of cats are colonized with this organism, typ- ically in the respiratory and gastroin- testinal tracts. The most common method of zoonotic transmission is via a bite from an infected dog or cat. Infection leads to an acute onset of redness, swelling, and pain within hours of the bite. Infection of peri- toneal fluid has been described in the nephrology literature, usually as a result of a cat licking or biting the tubing of a patient on continu- ous ambulatory peritoneal dialysis (CAPD).110 A 48-year-old woman presented to the emergency department with a 1-day history of fever and chills accompanied by general abdominal discomfort without nausea or vomit- ing. She had end-stage renal failure on maintenance peritoneal dialysis for 3 years. Her blood pressure was 89/48 mm Hg, her pulse rate was 99 beats per minute, her respiratory rate was 18 breaths per minute, and her body temperature was 38.2° C. On physical examination, her liver and spleen were normal, there was no lymphadenopathy noted, and there was no evidence of any rash, scratches, or bites. The abdomen was not distended but was diffusely tender to light palpation with dimin- ished bowel sounds noted. There was rebound tenderness. A complete blood cell count revealed the follow- ing: white blood cell count, 16.9 x 109/L with 93% neutrophils; hemo- globin, 15.0 mg/dL; hematocrit, 46%; and platelet count, 200 x 109/L. The peritoneal dialysis fluid was cloudy with 4,450 white blood cells/uL (100% neutrophils) and 150 red blood cells/uL. Gram stain of the dialysis fluid revealed many white blood cells and no organisms. The patient was admitted to the hospital for management of suspected peritonitis. Empiric antibiotic therapy, consisting of intraperitoneal cefazolin and gentamicin, was initiated with no improvement. P. multocida was isolat- ed from the peritoneal fluid on day 4 and found to be sensitive to gentam- icin, ciprofloxacin, and trimetho- prim-sulfamethoxazole, and the patient responded to intravenous ampi- cillin. The patient reported that she had a cat, which was, for her, an important source of psychosocial sup- port. She admitted to frequent breaks in handwashing technique, with her cat frequently licking her hands before and during fluid cycling. The cat also displayed his curious nature by habitually investigating the tubing and fluid bags during the cycling process. P. multocida is a gram-negative coccobacillus with bipolar staining properties. It is most frequently asso- ciated with cat and dog bites. The organism grows readily on standard laboratory media with the exception of bile-containing media such as MacConkey agar. First-generation cephalosporins, clindamycin, and erythromycin are generally regarded as ineffective in the treatment of infections caused by P. multocida and susceptibility should not be report- ed.11 At a minimum, antimicrobial susceptibility testing is performed with penicillin (the drug of choice), with consideration of testing other antibiotics such as ampicillin, second- generation cephalosporins, trimetho- prim-sulfamethoxazole, tetracycline, and ciprofloxacin. Given the polymi- crobial nature of the typical animal bite,12 therapy is often initiated with amoxicillin-clavulanate or cefurox- ime. This case illustrates the poten- tial for zoonotic transmission of dis- eases to humans undergoing CAPD. With the number of patients using at- home cyclers increasing and the num- bers of dogs or cats in the home burgeoning, the clinician must be sus- picious of a pet-acquired illness in a patient with peritonitis. Given the proximity of pets to their owners and the natural attraction of a carnivorous animal to human body fluid, it is clear that the supposedly healing touch of a dog's or cat's tongue could be fatal for a patient undergoing CAPD. This case emphasizes the importance of thorough handwashing and the exclu- sion of pets from the room where CAPD is performed, as there was no reported damage by the cat to the tubing or bags. With the advent of pet therapy in many hospitals and extended-care facilities, an additional concern has arisen for patients exposed to these animals while undergoing CAPD. The patient and any caregivers who handle the animal should promptly wash their hands after doing so. Many extended-care facilities also allow a dog or cat to live permanent- ly among the residents. Clinicians must be mindful of the possibility of zoonotic transmission in patients liv- ing in such an environment. Certainly clinicians caring for patients undergoing CAPD must weigh the risks and benefits of plac- ing a patient in a facility with an adopted pet. R E F E R E N C E S 1. Paul RV, Rostand SG. Cat-bite peritonitis: Pasteurella multocida peritonitis following feline contamination of peritoneal dialysis tubing. Am J Kidney Dis 1987;10:318-319. 2. Frankel AH, Cassidy MJ. Pasteurella multo- cida peritonitis in CAPD: beware of the cats. Pent Dial Int 1991;11:184-185. 3. London RD, Bottone EJ. Pasteurella multo- cida: zoonotic cause of peritonitis in a patient undergoing peritoneal dialysis. Am] Med 1991;91:202-204. 4. Kitching AR, Macdonald A, Hatfield PJ. Pasteurella multocida infection in continu- ous ambulatory peritoneal dialysis. NZMed J 1996;109:59. 5. Uribarri J, Bottone EJ, London RD. Pasteurella multocida peritonitis: are peri- toneal dialysis patients on cyclers at increased risk? Pent Dial Int 1996; 16:648- 649. Downloaded from https://www.cambridge.org/core. 06 Apr 2021 at 01:19:05, subject to the Cambridge Core terms of use. https://www.cambridge.org/core 6 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY January 2004 6. LoghmanAdham M. Pasteurella multocida peritonitis in patients undergoing peri- toneal dialysis. Pediatr Nephrol 1997;11:353- 354. 7. MacKay K, Brown L, Hudson F. Pasteurella multocida peritonitis in peritoneal dialysis patients: beware of the cat. Petit Dial Int 1997;17:608-610. 8. Joh J, Padmanabhan R, Bastani B. Pasteurella multocida peritonitis following cat bite of peritoneal dialysis tubing: with a brief review of the literature. Am J Nephrol 1998;18:258-259. 9. Musio F, Tiu A. Pasteurella multocida peri- tonitis in peritoneal dialysis. Clin Nephrol 1998;49:258-261. 10. Van Langenhove G, Daelemans R, Zachee P, Lins RL. Pasteurella multocida as a rare cause of peritonitis in peritoneal dialysis. Nephron 2000;85:283-284. 11. Gilbert DN, Moellering RC, Sande MA The Sanford Guide to Antimicrobial Therapy 2002, ed. 32. Hyde Park, VT: Antimicrobial Therapy; 2002. 12. Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ. Bacteriologic analysis of infected dog and cat bites. N Engl J Med 1999;340:85-92. John Sillery University of North Dakota School of Medicine J a m e s Hargreaves, DO Infectious Disease Altru Health System Philip Marin, MD Edgar Lerma, MD Nephrology Altru Health System Cathy Kuznia, SM (ASCP) Claudette Abbe, MT (ASCP) Clinical Laboratory Altru Health System Grand Forks, North Dakota Downloaded from https://www.cambridge.org/core. 06 Apr 2021 at 01:19:05, subject to the Cambridge Core terms of use. https://www.cambridge.org/core