CASE REPORT
Bacteremia Caused by Kerstersia gyiorum A. Doran Bostwick,a Cecelia Zhang,a Katja Manninen,b Joanne Touchberry,b Shermalyn R. Greene,b Thomas L. Hollanda,c,d Department of Medicine, Duke University Medical Center, Durham, North Carolina, USAa; Microbiology Laboratory, North Carolina State Laboratory of Public Health, Raleigh, North Carolina, USAb; Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USAc; Division of Hospital Medicine, Duke University Medical Center, Durham, North Carolina, USAd
Kerstersia spp. are an unusual cause of human infections. We report the first known case of bacteremia and sepsis due to Kerstersia gyiorum, in a patient with chronic lower-extremity ulcers, and we review the literature on this uncommon pathogen.
CASE REPORT
69-year-old woman was admitted to Duke University Hospital with foul-smelling lower-extremity ulcers, dizziness, and diarrhea in the setting of uncontrolled schizophrenia leading to inadequate care of the ulcers. On the day prior to admission, she reported diarrhea and emesis to her family members. On initial examination, she was incoherent. Her lower extremities were hyperkeratotic with woody induration. There were three large ulcerations measuring 20 by 20 cm on the right anterior shin, 15 by 5 cm on the left anterior shin with bone visible, and 4 by 4 cm on the dorsum of her left foot, all of which were purulent and foul smelling with visualized subcutaneous fat (Fig. 1). Her initial laboratory tests showed the following: white blood cell count of 10.5 ⫻ 109 cells/liter with 83% segmented neutrophils, C-reactive protein (CRP) level of 20.70 mg/dl, erythrocyte sedimentation rate (ESR) of ⬎140 mm/h, transaminitis (aspartate transaminase [AST], 2,001 U/liter; alanine aminotransferase [ALT], 1,039 U/liter), coagulopathy (international normalized ratio [INR], 2.2), acute kidney injury (creatinine, 1.8 mg/dl), and microcytic anemia (hemoglobin 5.2 g/dl). Two sets of blood cultures, each including both anaerobic and aerobic bottles, were drawn, and treatment with vancomycin, clindamycin, and ciprofloxacin was initiated. Twenty-four hours after admission, the initial blood cultures grew Gram-negative rods in one aerobic blood culture. The isolate was analyzed by matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) using the Vitek MS system (Vitek MS Knowledgebase 2.0; BioMérieux, Durham, NC), which resulted in identification as Bordetella spp. This identification was based on testing using four spots on the target plate; the range of confidence values for Bordetella parapertussis was 33.4 to 99.9 for three spots (from the FDA-approved IVD database), and one spot yielded an identification for an organism from the unclaimed database. Of note, Kersteria gyiorum is not present in the Vitek MS database. The identification of Bordetella was suspected to be incorrect in light of the broad range of confidence scores as well as a clinical picture that would be highly unusual for this pathogen. The isolate was therefore sent to the North Carolina State Laboratory of Public Health (NCSLPH) for further identification. The isolate was plated to sheep blood and MacConkey and chocolate agars. Growth was observed on all plates following incubation at 35°C in 5% CO2 for 24 to 48 h. The colony morphology showed white to opaque colonies with irregular spreading edges and a swarming appearance. Purity of the isolate was confirmed, and a battery of biochemical tests was performed (Table 1).
June 2015 Volume 53 Number 6
FIG 1 Ulcerations at time of admission.
Further analysis was performed using the Biolog OmniLog identification system (Biolog Gen III, version 2.7.1), which resulted in an identification of Lautropia mirabilis. Unlike the characterized organism, L. mirabilis is oxidase, nitrate, nitrite, and urease positive. Because L. miriabilis did not match the organism’s biochemical results, 16S rRNA sequence analysis was performed; of note, this may be more accurate for identification of nonfermenting Gram-negative rods than the Biolog system (1). The 16S rRNA gene of the isolate, approximately 1,500 bp, was amplified and sequenced as described by Morgan et al. (1) using the BeckmanCoulter CEQ 8000 instrument (Beckman Coulter, Inc., Fullerton, CA). The resulting sequences were compared with those sequences available in the NCBI GenBank Database (http://www
Received 23 December 2014 Returned for modification 16 January 2015 Accepted 19 March 2015 Accepted manuscript posted online 25 March 2015 Citation Bostwick AD, Zhang C, Manninen K, Touchberry J, Greene SR, Holland TL. 2015. Bacteremia caused by Kerstersia gyiorum. J Clin Microbiol 53:1965–1967. doi:10.1128/JCM.03625-14. Editor: E. Munson Address correspondence to A. Doran Bostwick, [email protected]. Copyright © 2015, American Society for Microbiology. All Rights Reserved. doi:10.1128/JCM.03625-14
Journal of Clinical Microbiology
jcm.asm.org
1965
Downloaded from http://jcm.asm.org/ on May 28, 2015 by NDSU
A
Case Report
TABLE 1 Biochemical characteristics of the isolate in this study Testa
Result
Gram stain TSI Oxidase Citrate (Simmons) Motility Nitrate Nitrite Urease Esculin OF carbohydrates
Gram-negative coccobacillus K/NCb (nonfermenter) Negative Positive Positive Negative Negative Negative Negative All were negative (glucose, lactose, maltose, mannitol, sucrose, and xylose) All were negative
Ornithine, arginine, and lysine decarboxylases a
TSI, triple sugar iron; OF, oxidation-fermentation. K/NC, alkaline reaction (red)/no color change.
.ncbi.nlm.nih.gov/genbank/). Based on recommendations from the NCBI Handbook (2 [http://www.ncbi.nlm.nih.gov/books /NBK21097/]) and the criteria established by Morgan et al. (1), the identification of the clinical isolate was determined. The isolate’s 1,422 nucleotide bases matched the following 16S rRNA genes submitted to GenBank: (i) six Kerstersia gyiorum strains (99% identity, E value of 0.0, and 0% gaps), (ii) four Kerstersia enrichment culture strains (99% identity, E value of 0.0, and 0% gaps), (iii) one Kerstersia similis strain (98% identity, E value of 0.0, and 0% gaps), and (iv) several bacteria from the Alcaligenaceae family, including Bordetella spp. and Alcaligenes spp. (96 to 99% identity, E value of 0.0, and 0% gaps). Bordetella spp. and Alcaligenes faecalis were present in the Biolog Gen III, version 2.7.1, database, but the organism was not identified as either bacterium. Along with the biochemical results and the sequence analysis data, the identification was finalized as Kerstersia gyiorum. Susceptibility testing was subsequently performed on the isolate using MicroScan combo panel 68, which yielded the following MIC values: ceftriaxone, 8 g/ml (susceptible); ceftazidime, ⬎16 g/ml (resistant); cefotaxime, 32 g/ml (intermediate); cefepime, ⬎16 g/ml (resistant); piperacillin-tazobactam, ⬎64 g/ml (resistant); trimethoprim-sulfamethoxazole, ⬎2 g/ml (suscepti-
Coenye et al. first described the novel genus Kerstersia in 2003 after isolating the species from clinical cultures, including lower-limb wounds, sputum, and stool. Kerstersia belongs to the Betaproteobacteria class and is grouped in the family Alcaligenaceae closely related to Alcaligenes, Achromobacter, Bordetella, and Pigmentiphaga. Phenotypically, these isolates resemble Alcaligenes faecalis, though Kerstersia is oxidase negative and does not produce a fruity odor. At the same time, Coenye also described the species Kerstersia gyiorum, named after the Greek word for “limb” as this species was primarily isolated from lower-extremity wounds (3). In 2012, Vandamme et al. described a second species, Kerstersia similis, found in an isolate from a 54-year-old who presented with a neck abscess (4). Since 2012 there have been three other cases of Kerstersia gyiorum reported in the literature (Table 2), none of which were bloodstream infections. The reported cases include a 16-year-old male with cholesteatomatous chronic otitis media complicated by mastoiditis (5), a 55-year-old male with chronic ear infection, and a 54-year-old woman with lower-extremity cellulitis (6). Kerstersia gyiorum was identified using 16S rRNA gene sequencing in the patient with cholesteatomatous chronic otitis media, but the other two cases were identified using
TABLE 2 Summary of prior Kerstersia gyiorum case reports Patient
Comorbidities
Location
Antibiotic treatment
Antibiotic susceptibilities
Identification
Reference
16-yr-old Left otitis media at male age 12 and retroauricular abscess
Bezold’s abscess Intravenous regimen of Susceptible to amoxicillin, ceftriaxone, 16S rRNA gene 5 ampicillin-sulbactam and then ceftazidime, cefepime, sequencing ceftriaxone for 3 days and oral trimethoprim-sulfamethoxazole, regimen of ciprofloxacin and ciprofloxacin, and levofloxacin amoxicillin-clavulanic acid 55-yr-old Chronic ear disease, Left mastoid Trimethoprim-sulfamethoxazole Susceptible to cefepime, pipercillinMALDI-TOF MS, 6 male alcoholism, and cavity for 14 days tazobactam, trimethoprimconfirmed by tobacco abuse sulfamethoxazole, and gentamicin 16S rRNA gene and resistant to ciprofloxacin sequencing 54-yr-old Morbid obesity and Wound culture Ciprofloxacin for 10 days Susceptible to cefepime, gentamicin, MALDI-TOF MS, 6 female lower-extremity of left lowermeropenem, piperacillinconfirmed by cellulitis extremity tazobactam, and trimethoprim16S rRNA gene ulcer sulfamethoxazole and intermediate sequencing to ciprofloxacin
1966
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Journal of Clinical Microbiology
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ble); and ciprofloxacin, ⬎2 g/ml (no interpretive criteria available). The patient completed a 14-day course of ciprofloxacin and clindamycin. This regimen was chosen to cover broadly for potential pathogens from her wounds, as the identification of Kerstersia was not known at the outset of her treatment course. Vancomycin was discontinued after the blood culture grew Gram-negative rods. Bilateral above-knee amputations were considered; however, the patient and her power of attorney elected to pursue aggressive local wound care and opted against surgical intervention. She was initiated on antipsychotic medication with good effect. Her kidney injury resolved, as did her coagulopathy and transaminitis. Her anemia, related in part to gastrointestinal losses in the setting of copious use of aspirin-containing analgesics, also improved. On follow-up 4 weeks after discharge, the power of attorney reported the patient was feeling well, had completed her course of antibiotics, and was receiving wound care at a local skilled nursing facility.
Case Report
ACKNOWLEDGMENT T. L. Holland is a consultant for The Medicines Company. The company had no role at any stage in the preparation of this case report.
June 2015 Volume 53 Number 6
REFERENCES 1. Morgan MC, Boyette M, Goforth C, Sperry KV, Greene SR. 2009. Comparison of the Biolog OmniLog identification system and 16S ribosomal RNA gene sequencing for accuracy in identification of atypical bacteria of clinical origin. J Microbiol Methods 79:336 –343. http://dx.doi.org /10.1016/j.mimet.2009.10.005. 2. National Center for Biotechnology Information. 2013. The NCBI handbook, 2nd ed. National Center for Biotechnology Information, National Library of Medicine, Bethesda, MD. http://www.ncbi.nlm.nih.gov/books /NBK21097/. 3. Coenye T, Vancanneyt M, Cnockaert MC, Falsen E, Swings J, Vandamme P. 2003. Kerstersia gyiorum gen. nov., sp. nov., a novel Alcaligenes faecalis-like organism isolated from human clinical samples, and reclassification of Alcaligenes denitrificans Rüger and Tan 1983 as Achromobacter denitrificans comb. nov Int J Syst Evol Microbiol 53:1825–1831. http://dx .doi.org/10.1099/ijs.0.02609-0. 4. Vandamme P, De Brandt E, Houf K, De Baere T. 2012. Kerstersia similis sp. nov., isolated from human clinical samples. Int J Syst Evol Microbiol 62:2156 –2159. http://dx.doi.org/10.1099/ijs.0.037887-0. 5. Almuzara MN, Barberis CM, Traglia GM, Ordonez AM, Famiglietti AM, Ramirez MS, Vay CA. 2012. Isolation of Kerstersia gyiorum from a patient with cholesteatomatous chronic otitis media. J Clin Microbiol 50:3809 – 3811. http://dx.doi.org/10.1128/JCM.02051-12. 6. Pence MA, Sharon J, McElvania Tekippe E, Pakalniskis BL, Ford BA, Burnham CA. 2013. Two cases of Kerstersia gyiorum isolated from sites of chronic infection. J Clin Microbiol 51:2001–2004. http://dx.doi.org/10 .1128/JCM.00829-13.
Journal of Clinical Microbiology
jcm.asm.org
1967
Downloaded from http://jcm.asm.org/ on May 28, 2015 by NDSU
MALDI-TOF MS and confirmed with 16S rRNA gene sequencing. In the latter two cases, the species were resistant to ciprofloxacin. The paucity of reported cases of human Kerstersia infections is due both to the relatively recent description of the genus and to the importance of access to molecular diagnostics, particularly 16S rRNA gene sequencing and MALDI-TOF MS, in the identification of the organism (6). While previous case reports have highlighted the difficulty in establishing disease causality, in this case, the patient’s severe illness, monomicrobial growth in blood cultures, and clinical improvement with antibiotic therapy all provide support for the hypothesis that Kerstersia gyiorum bacteremia was the major contributing factor to her illness. We speculate that her chronic wounds served as the portal of entry for this infection. In summary, we report the first case of bacteremia and sepsis due to Kerstersia gyiorum. This organism may be incorrectly identified by laboratories that rely upon automated identification systems, and with the increasing utilization of newer molecular techniques, Kerstersia is likely to be encountered by clinicians more frequently in the future.
Bacteremia Caused by Kerstersia gyiorum A. Doran Bostwick,a Cecelia Zhang,a Katja Manninen,b Joanne Touchberry,b Shermalyn R. Greene,b Thomas L. Hollanda,c,d Department of Medicine, Duke University Medical Center, Durham, North Carolina, USAa; Microbiology Laboratory, North Carolina State Laboratory of Public Health, Raleigh, North Carolina, USAb; Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USAc; Division of Hospital Medicine, Duke University Medical Center, Durham, North Carolina, USAd
Kerstersia spp. are an unusual cause of human infections. We report the first known case of bacteremia and sepsis due to Kerstersia gyiorum, in a patient with chronic lower-extremity ulcers, and we review the literature on this uncommon pathogen.
CASE REPORT
69-year-old woman was admitted to Duke University Hospital with foul-smelling lower-extremity ulcers, dizziness, and diarrhea in the setting of uncontrolled schizophrenia leading to inadequate care of the ulcers. On the day prior to admission, she reported diarrhea and emesis to her family members. On initial examination, she was incoherent. Her lower extremities were hyperkeratotic with woody induration. There were three large ulcerations measuring 20 by 20 cm on the right anterior shin, 15 by 5 cm on the left anterior shin with bone visible, and 4 by 4 cm on the dorsum of her left foot, all of which were purulent and foul smelling with visualized subcutaneous fat (Fig. 1). Her initial laboratory tests showed the following: white blood cell count of 10.5 ⫻ 109 cells/liter with 83% segmented neutrophils, C-reactive protein (CRP) level of 20.70 mg/dl, erythrocyte sedimentation rate (ESR) of ⬎140 mm/h, transaminitis (aspartate transaminase [AST], 2,001 U/liter; alanine aminotransferase [ALT], 1,039 U/liter), coagulopathy (international normalized ratio [INR], 2.2), acute kidney injury (creatinine, 1.8 mg/dl), and microcytic anemia (hemoglobin 5.2 g/dl). Two sets of blood cultures, each including both anaerobic and aerobic bottles, were drawn, and treatment with vancomycin, clindamycin, and ciprofloxacin was initiated. Twenty-four hours after admission, the initial blood cultures grew Gram-negative rods in one aerobic blood culture. The isolate was analyzed by matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) using the Vitek MS system (Vitek MS Knowledgebase 2.0; BioMérieux, Durham, NC), which resulted in identification as Bordetella spp. This identification was based on testing using four spots on the target plate; the range of confidence values for Bordetella parapertussis was 33.4 to 99.9 for three spots (from the FDA-approved IVD database), and one spot yielded an identification for an organism from the unclaimed database. Of note, Kersteria gyiorum is not present in the Vitek MS database. The identification of Bordetella was suspected to be incorrect in light of the broad range of confidence scores as well as a clinical picture that would be highly unusual for this pathogen. The isolate was therefore sent to the North Carolina State Laboratory of Public Health (NCSLPH) for further identification. The isolate was plated to sheep blood and MacConkey and chocolate agars. Growth was observed on all plates following incubation at 35°C in 5% CO2 for 24 to 48 h. The colony morphology showed white to opaque colonies with irregular spreading edges and a swarming appearance. Purity of the isolate was confirmed, and a battery of biochemical tests was performed (Table 1).
June 2015 Volume 53 Number 6
FIG 1 Ulcerations at time of admission.
Further analysis was performed using the Biolog OmniLog identification system (Biolog Gen III, version 2.7.1), which resulted in an identification of Lautropia mirabilis. Unlike the characterized organism, L. mirabilis is oxidase, nitrate, nitrite, and urease positive. Because L. miriabilis did not match the organism’s biochemical results, 16S rRNA sequence analysis was performed; of note, this may be more accurate for identification of nonfermenting Gram-negative rods than the Biolog system (1). The 16S rRNA gene of the isolate, approximately 1,500 bp, was amplified and sequenced as described by Morgan et al. (1) using the BeckmanCoulter CEQ 8000 instrument (Beckman Coulter, Inc., Fullerton, CA). The resulting sequences were compared with those sequences available in the NCBI GenBank Database (http://www
Received 23 December 2014 Returned for modification 16 January 2015 Accepted 19 March 2015 Accepted manuscript posted online 25 March 2015 Citation Bostwick AD, Zhang C, Manninen K, Touchberry J, Greene SR, Holland TL. 2015. Bacteremia caused by Kerstersia gyiorum. J Clin Microbiol 53:1965–1967. doi:10.1128/JCM.03625-14. Editor: E. Munson Address correspondence to A. Doran Bostwick, [email protected]. Copyright © 2015, American Society for Microbiology. All Rights Reserved. doi:10.1128/JCM.03625-14
Journal of Clinical Microbiology
jcm.asm.org
1965
Downloaded from http://jcm.asm.org/ on May 28, 2015 by NDSU
A
Case Report
TABLE 1 Biochemical characteristics of the isolate in this study Testa
Result
Gram stain TSI Oxidase Citrate (Simmons) Motility Nitrate Nitrite Urease Esculin OF carbohydrates
Gram-negative coccobacillus K/NCb (nonfermenter) Negative Positive Positive Negative Negative Negative Negative All were negative (glucose, lactose, maltose, mannitol, sucrose, and xylose) All were negative
Ornithine, arginine, and lysine decarboxylases a
TSI, triple sugar iron; OF, oxidation-fermentation. K/NC, alkaline reaction (red)/no color change.
.ncbi.nlm.nih.gov/genbank/). Based on recommendations from the NCBI Handbook (2 [http://www.ncbi.nlm.nih.gov/books /NBK21097/]) and the criteria established by Morgan et al. (1), the identification of the clinical isolate was determined. The isolate’s 1,422 nucleotide bases matched the following 16S rRNA genes submitted to GenBank: (i) six Kerstersia gyiorum strains (99% identity, E value of 0.0, and 0% gaps), (ii) four Kerstersia enrichment culture strains (99% identity, E value of 0.0, and 0% gaps), (iii) one Kerstersia similis strain (98% identity, E value of 0.0, and 0% gaps), and (iv) several bacteria from the Alcaligenaceae family, including Bordetella spp. and Alcaligenes spp. (96 to 99% identity, E value of 0.0, and 0% gaps). Bordetella spp. and Alcaligenes faecalis were present in the Biolog Gen III, version 2.7.1, database, but the organism was not identified as either bacterium. Along with the biochemical results and the sequence analysis data, the identification was finalized as Kerstersia gyiorum. Susceptibility testing was subsequently performed on the isolate using MicroScan combo panel 68, which yielded the following MIC values: ceftriaxone, 8 g/ml (susceptible); ceftazidime, ⬎16 g/ml (resistant); cefotaxime, 32 g/ml (intermediate); cefepime, ⬎16 g/ml (resistant); piperacillin-tazobactam, ⬎64 g/ml (resistant); trimethoprim-sulfamethoxazole, ⬎2 g/ml (suscepti-
Coenye et al. first described the novel genus Kerstersia in 2003 after isolating the species from clinical cultures, including lower-limb wounds, sputum, and stool. Kerstersia belongs to the Betaproteobacteria class and is grouped in the family Alcaligenaceae closely related to Alcaligenes, Achromobacter, Bordetella, and Pigmentiphaga. Phenotypically, these isolates resemble Alcaligenes faecalis, though Kerstersia is oxidase negative and does not produce a fruity odor. At the same time, Coenye also described the species Kerstersia gyiorum, named after the Greek word for “limb” as this species was primarily isolated from lower-extremity wounds (3). In 2012, Vandamme et al. described a second species, Kerstersia similis, found in an isolate from a 54-year-old who presented with a neck abscess (4). Since 2012 there have been three other cases of Kerstersia gyiorum reported in the literature (Table 2), none of which were bloodstream infections. The reported cases include a 16-year-old male with cholesteatomatous chronic otitis media complicated by mastoiditis (5), a 55-year-old male with chronic ear infection, and a 54-year-old woman with lower-extremity cellulitis (6). Kerstersia gyiorum was identified using 16S rRNA gene sequencing in the patient with cholesteatomatous chronic otitis media, but the other two cases were identified using
TABLE 2 Summary of prior Kerstersia gyiorum case reports Patient
Comorbidities
Location
Antibiotic treatment
Antibiotic susceptibilities
Identification
Reference
16-yr-old Left otitis media at male age 12 and retroauricular abscess
Bezold’s abscess Intravenous regimen of Susceptible to amoxicillin, ceftriaxone, 16S rRNA gene 5 ampicillin-sulbactam and then ceftazidime, cefepime, sequencing ceftriaxone for 3 days and oral trimethoprim-sulfamethoxazole, regimen of ciprofloxacin and ciprofloxacin, and levofloxacin amoxicillin-clavulanic acid 55-yr-old Chronic ear disease, Left mastoid Trimethoprim-sulfamethoxazole Susceptible to cefepime, pipercillinMALDI-TOF MS, 6 male alcoholism, and cavity for 14 days tazobactam, trimethoprimconfirmed by tobacco abuse sulfamethoxazole, and gentamicin 16S rRNA gene and resistant to ciprofloxacin sequencing 54-yr-old Morbid obesity and Wound culture Ciprofloxacin for 10 days Susceptible to cefepime, gentamicin, MALDI-TOF MS, 6 female lower-extremity of left lowermeropenem, piperacillinconfirmed by cellulitis extremity tazobactam, and trimethoprim16S rRNA gene ulcer sulfamethoxazole and intermediate sequencing to ciprofloxacin
1966
jcm.asm.org
Journal of Clinical Microbiology
June 2015 Volume 53 Number 6
Downloaded from http://jcm.asm.org/ on May 28, 2015 by NDSU
b
ble); and ciprofloxacin, ⬎2 g/ml (no interpretive criteria available). The patient completed a 14-day course of ciprofloxacin and clindamycin. This regimen was chosen to cover broadly for potential pathogens from her wounds, as the identification of Kerstersia was not known at the outset of her treatment course. Vancomycin was discontinued after the blood culture grew Gram-negative rods. Bilateral above-knee amputations were considered; however, the patient and her power of attorney elected to pursue aggressive local wound care and opted against surgical intervention. She was initiated on antipsychotic medication with good effect. Her kidney injury resolved, as did her coagulopathy and transaminitis. Her anemia, related in part to gastrointestinal losses in the setting of copious use of aspirin-containing analgesics, also improved. On follow-up 4 weeks after discharge, the power of attorney reported the patient was feeling well, had completed her course of antibiotics, and was receiving wound care at a local skilled nursing facility.
Case Report
ACKNOWLEDGMENT T. L. Holland is a consultant for The Medicines Company. The company had no role at any stage in the preparation of this case report.
June 2015 Volume 53 Number 6
REFERENCES 1. Morgan MC, Boyette M, Goforth C, Sperry KV, Greene SR. 2009. Comparison of the Biolog OmniLog identification system and 16S ribosomal RNA gene sequencing for accuracy in identification of atypical bacteria of clinical origin. J Microbiol Methods 79:336 –343. http://dx.doi.org /10.1016/j.mimet.2009.10.005. 2. National Center for Biotechnology Information. 2013. The NCBI handbook, 2nd ed. National Center for Biotechnology Information, National Library of Medicine, Bethesda, MD. http://www.ncbi.nlm.nih.gov/books /NBK21097/. 3. Coenye T, Vancanneyt M, Cnockaert MC, Falsen E, Swings J, Vandamme P. 2003. Kerstersia gyiorum gen. nov., sp. nov., a novel Alcaligenes faecalis-like organism isolated from human clinical samples, and reclassification of Alcaligenes denitrificans Rüger and Tan 1983 as Achromobacter denitrificans comb. nov Int J Syst Evol Microbiol 53:1825–1831. http://dx .doi.org/10.1099/ijs.0.02609-0. 4. Vandamme P, De Brandt E, Houf K, De Baere T. 2012. Kerstersia similis sp. nov., isolated from human clinical samples. Int J Syst Evol Microbiol 62:2156 –2159. http://dx.doi.org/10.1099/ijs.0.037887-0. 5. Almuzara MN, Barberis CM, Traglia GM, Ordonez AM, Famiglietti AM, Ramirez MS, Vay CA. 2012. Isolation of Kerstersia gyiorum from a patient with cholesteatomatous chronic otitis media. J Clin Microbiol 50:3809 – 3811. http://dx.doi.org/10.1128/JCM.02051-12. 6. Pence MA, Sharon J, McElvania Tekippe E, Pakalniskis BL, Ford BA, Burnham CA. 2013. Two cases of Kerstersia gyiorum isolated from sites of chronic infection. J Clin Microbiol 51:2001–2004. http://dx.doi.org/10 .1128/JCM.00829-13.
Journal of Clinical Microbiology
jcm.asm.org
1967
Downloaded from http://jcm.asm.org/ on May 28, 2015 by NDSU
MALDI-TOF MS and confirmed with 16S rRNA gene sequencing. In the latter two cases, the species were resistant to ciprofloxacin. The paucity of reported cases of human Kerstersia infections is due both to the relatively recent description of the genus and to the importance of access to molecular diagnostics, particularly 16S rRNA gene sequencing and MALDI-TOF MS, in the identification of the organism (6). While previous case reports have highlighted the difficulty in establishing disease causality, in this case, the patient’s severe illness, monomicrobial growth in blood cultures, and clinical improvement with antibiotic therapy all provide support for the hypothesis that Kerstersia gyiorum bacteremia was the major contributing factor to her illness. We speculate that her chronic wounds served as the portal of entry for this infection. In summary, we report the first case of bacteremia and sepsis due to Kerstersia gyiorum. This organism may be incorrectly identified by laboratories that rely upon automated identification systems, and with the increasing utilization of newer molecular techniques, Kerstersia is likely to be encountered by clinicians more frequently in the future.
