Recurrent Polymicrobial Bloodstream Infection in End-Stage Renal Disease: Co-Infection with Klebsiella pneumoniae, Enterobacter cloacae, Achromobacter xylosoxidans, and Achromobacter denitrificans in a Hemodialysis Patient.

Polymicrobial infections in hemodialysis contribute to increased morbidity and mortality. We report a patient who was readmitted due to infection with multiple pathogens and was treated with favorable outcomes. A 51-year-old male with diabetes mellitus, hypertension, and end-stage renal disease was evaluated in the emergency room following fever and chills observed during hemodialysis via a right chest tunneled catheter 2 days before admission. Two months prior, a left forearm arteriovenous graft had been placed. Initial blood cultures at his dialysis center grew Gram-negative bacilli. Empiric vancomycin and gentamicin were initiated to cover both Gram-positive and Gram-negative pathogens commonly associated with catheter-related infections. When contacted, the dialysis center reported cultures had revealed Klebsiella pneumoniae and Enterobacter cloacae complex. Chest imaging suggested pneumonia, and antibiotics were changed to vancomycin and piperacillin-tazobactam. Blood cultures obtained at admission subsequently identified ESBL-producing Klebsiella pneumoniae, prompting escalation to meropenem. Following tunneled dialysis catheter removal and placement of a right femoral central venous catheter, subsequent cultures identified Achromobacter xylosoxidans sensitive to meropenem. He was discharged 3 weeks after negative cultures. One month later, he was readmitted with fever and worsening hypoxemia requiring oxygen supplementation. Hospital course was complicated by diarrhea, with stool analysis confirming Clostridioides difficile infection. Symptoms resolved with oral vancomycin. Blood cultures identified A. xylosoxidans, leading to meropenem treatment. The left internal jugular tunneled dialysis catheter was removed. He experienced spontaneous bleeding at the graft site. Angiography showed no pseudoaneurysm. An urgent graft excision revealed A. xylosoxidans in the resected arteriovenous graft, along with A. denitrificans in blood cultures. Antibiotics were switched to ceftazidime due to suspected meropenem-induced transaminitis and confirmed susceptibility of the organism. Following negative cultures, a left chest tunneled dialysis catheter was placed, and he was discharged. Infections with multiple microorganisms in hemodialysis require prompt and targeted antimicrobial therapy for favorable outcomes.