Successful treatment with clofazimine for macrolide-resistant Mycobacterium abscessus infection in a peritoneal dialysis patient: A case report and literature review

Nontuberculous mycobacteria are rare but serious pathogens in peritoneal dialysis (PD)-associated infections. Mycobacterium abscessus (M. abscessus) is usually resistant to standard anti-tuberculosis drugs. Macrolide antibiotics are key drugs for treating M. abscessus, but macrolide-resistant strains pose particular challenges, and an optimal antimicrobial treatment strategy or duration has not been established for M. abscessus PD-associated infections. We report a case of a 63-year-old man on PD who developed persistent purulent discharge from his PD catheter exit site. Skin swab culture identified macrolide-resistant M. abscessus, with imaging confirming inflammation along the catheter tunnel. These findings led to the diagnosis of M. abscessus PD catheter tunnel infection, with peritonitis excluded. Initial management included early catheter removal, extensive surgical debridement, and 6 weeks of combination antibiotic therapy, including imipenem-cilastatin, amikacin, and clarithromycin, achieving clinical cure. However, the infection recurred after 5 months, necessitating retreatment with debridement and an antibiotic regimen including imipenem-cilastatin, amikacin, azithromycin, and clofazimine for 4 weeks, followed by a continuation regimen with amikacin, clofazimine, and sitafloxacin for 4 months. This approach achieved sustained clinical cure without recurrence at 14 months of follow-up. Based on a literature review of 67 cases of M. abscessus PD-associated infections, all six cases treated with clofazimine achieved clinical cure, but there were no reports on cases of macrolide-resistant M. abscessus treated with clofazimine. Our case represents the first successful clofazimine treatment of macrolide-resistant M. abscessus PD-associated infection, demonstrating clofazimine as a potentially effective oral antibiotic option in combination therapy, particularly in macrolide-resistant cases with limited therapeutic options.