LETTERS TO EDITOR
Elizabethkingia Meningoseptica Outbreak in Intensive Care Unit Sir, Elizabethkingia meningoseptica is a rare and unusual bacterium causing fulminant hospital infections. It is important to identify E. meningoseptica infections as the bacterium exhibits intrinsic resistance for most antimicrobial agents except quinolones, trimethoprim-sulfamethoxazole, rifampicin, and vancomycin.[1,2] We describe a cluster of four cases, who developed ventilator associated pneumonia (VAP) with E. meningoseptica, in Intensive Care Unit (ICU) of our tertiary care hospital in March, 2013. All were female patients with a mean age of 65.5 years (range: 49-77 years). The mean time of development of VAP due to E. meningoseptica after mechanical ventilation was 12.1 days (range: 3-17 days). Endotracheal aspirates from these patients were collected and sent to the microbiology laboratory for culture and identification of pathogen. Quantitative culture done on MacConkey agar and sheep blood agar showed significant growth of pathogen (≥105 CFU/ml) [Figures 1 and 2]. The biochemical characterization and VITEK identification revealed that the isolate in all four cases was E. meningoseptica (99% probability). Antimicrobial susceptibility testing performed by KirbyBauer disc diffusion method revealed that the bacterium was resistant to penicillins, cephalosporins, aminoglycosides, quinolones and colistin, but was susceptible to trimethoprimsulfamethoxazole, rifampicin, and vancomycin in all four cases [Figure 3]. As there are still no standard guidelines for susceptibility testing of E. meningoseptica, interpretation of trimethoprim-sulfamethoxazole, rifampicin, and vancomycin susceptibility was done in comparison with Staphylococcus aureus (ATCC 25923). The results of susceptibility testing were later confirmed with VITEK 2 automated system. All four patients were treated with rifampicin, vancomycin, and trimethoprim-sulfamethoxazole. Mean duration of antibiotic therapy was 8.7 days. Improvement with therapy was seen in two patients, one patient expired, and one took discharge against advice. To trace the source of infection multiple environmental samples were taken from ventilator machines, humidifier boxes, hospital trolley, AC duct, bed curtains, bed railings, saline bottles, and tap water of the ICU. E. meningoseptica with the same sensitivity pattern was isolated from the humidifier water. Thus, humidifier water was identified as the source of infection. The humidifier boxes in the ventilator circuit of all the four patients were sterilized by
autoclave. Repeat samples taken from the humidifier boxes after sterilization did not yield any bacteria on culture. Our study is the first report of an acute outbreak of VAP with E. meningoseptica in India. Earlier Weaver et al. in 2010 and Güngör et al. in 2003 have reported similar
Figure 1: Blood agar showing growth of Elizabethkingia meningoseptica
Figure 2: MacConkey agar showing growth of Elizabethkingia meningoseptica
Figure 3: Antimicrobial susceptibility testing of Elizabethkingia meningoseptica by Kirby-Bauer disc diffusion method
Journal of Global Infectious Diseases / Jan-Mar 2015 / Vol-7 / Issue-1
43
Letters to Editor
outbreaks.[3,4] The predisposing factors for infection with this pathogen are adults with some underlying severe illness, on life support devices and on prolonged antibiotic treatment.[3] Two out of four patients had predisposing comorbid illness like diabetes and carcinoma breast and all four patients were on a mechanical ventilator. Previous studies have shown that E. meningoseptica is found as colonizer in tap water, tubing of ventilators and in sink basins of the hospital wards.[5] Infections caused by E. meningoseptica have a high mortality rate due to the delay in the administration of appropriate therapy. We stress the importance of awareness of infections caused by E. meningoseptica, and prompt collaborative action by microbiologist and infection control team to control such hospital outbreaks.
Kiran Chawla, Anusha Gopinathan, Muralidhar Varma1, Chiranjay Mukhopadhyay Departments of Microbiology and 1Internal Medicine, Kasturba Medical College, Manipal, Karnataka, India Address for correspondence: Dr. Kiran Chawla, E-mail: [email protected]
REFERENCES 1.
2.
3.
4.
5.
Hsu MS, Liao CH, Huang YT, Liu CY, Yang CJ, Kao KL, et al. Clinical features, antimicrobial susceptibilities, and outcomes of Elizabethkingia meningoseptica (Chryseobacterium meningosepticum) bacteremia at a medical center in Taiwan, 1999-2006. Eur J Clin Microbiol Infect Dis 2011;30:1271-8. Spangler SK, Visalli MA, Jacobs MR, Appelbaum PC. Susceptibilities of non-Pseudomonas aeruginosa gram-negative nonfermentative rods to ciprofloxacin, ofloxacin, levofloxacin, D-ofloxacin, sparfloxacin, ceftazidime, piperacillin, piperacillin-tazobactam, trimethoprim-sulfamethoxazole, and imipenem. Antimicrob Agents Chemother 1996;40:772-5. Weaver KN, Jones RC, Albright R, Thomas Y, Zambrano CH, Costello M, et al. Acute emergence of Elizabethkingia meningoseptica infection among mechanically ventilated patients in a long-term acute care facility. Infect Control Hosp Epidemiol 2010;31:54-8. Güngör S, Ozen M, Akinci A, Durmaz R. A Chryseobacterium meningosepticum outbreak in a neonatal ward. Infect Control Hosp Epidemiol 2003; 24:613-7. Amer MZ, Bandey M, Bukhari A, Nemenqani D. Neonatal meningitis caused by Elizabethkingia meningoseptica in Saudi Arabia. J Infect Dev Ctries 2011;5:745-7.
Access this article online Quick Response Code: Website: www.jgid.org
DOI: 10.4103/0974-777X.150890
44
Elbow Mycobacterium Tuberculosis in America Sir Less than 1% of tuberculosis (TB) cases are specific to the elbow.[1,2] Symptoms often develop insidiously, and in the absence of pulmonary involvement, TB is typically excluded from the differential diagnosis. A 69-year-old man, originally from Pakistan, presented with elbow swelling, pain, and decreased range of motion. His medical history included dengue, entamoeba histolytica, and gout. He reported recent unexplained changes in weight, weakness and fatigue, loss of appetite, changes in skin, blurred vision, coughing, smoking, abdominal pain, frequent diarrhea, and constipation. Vital signs were within normal limits. There was no skin breakdown or lesions. The elbow demonstrated diffuse swelling, but no redness. Radiographs revealed mild osteoarthritis, but no acute fractures. The elbow joint was aspirated without complication. The patient was negative for rheumatoid factor and lyme disease. The C-reactive protein was within normal limits, and the sedimentation rate was 29 mm/h. Despite no trauma, 6 months later, the patient reported increased swelling, pain, and decreased range of motion. The elbow demonstrated moderate effusion and some warmth, but no ecchymosis. Radiographs showed increased erosion of the capitellum and radial head, but no acute fractures or subluxation. The joint was aspirated without complication. No aerobic growth or crystals were seen. Given the worsening symptoms, the patient was admitted for incision and drainage of the right elbow and olecranon bursa. Tissue, bone, and fluid specimens were obtained. Pulmonary TB was ruled out. Acid-fast Bacilli (AFB) cultures were obtained for all surgical specimens. The primary culture media included a Remel Mitchison 7H11 Selective Agar Slant (Thermo Scientific™ Remel™, Waltham, MA) and a VersaTREK® Myco liquid medium (TREK Diagnostic Systems, Oakwood Village, OH). Growth was present on the slant and in the liquid medium. Both the agar slant and the liquid medium were Kinyoun positive.
Journal of Global Infectious Diseases / Jan-Mar 2015 / Vol-7 / Issue-1
Copyright of Journal of Global Infectious Diseases is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Elizabethkingia Meningoseptica Outbreak in Intensive Care Unit Sir, Elizabethkingia meningoseptica is a rare and unusual bacterium causing fulminant hospital infections. It is important to identify E. meningoseptica infections as the bacterium exhibits intrinsic resistance for most antimicrobial agents except quinolones, trimethoprim-sulfamethoxazole, rifampicin, and vancomycin.[1,2] We describe a cluster of four cases, who developed ventilator associated pneumonia (VAP) with E. meningoseptica, in Intensive Care Unit (ICU) of our tertiary care hospital in March, 2013. All were female patients with a mean age of 65.5 years (range: 49-77 years). The mean time of development of VAP due to E. meningoseptica after mechanical ventilation was 12.1 days (range: 3-17 days). Endotracheal aspirates from these patients were collected and sent to the microbiology laboratory for culture and identification of pathogen. Quantitative culture done on MacConkey agar and sheep blood agar showed significant growth of pathogen (≥105 CFU/ml) [Figures 1 and 2]. The biochemical characterization and VITEK identification revealed that the isolate in all four cases was E. meningoseptica (99% probability). Antimicrobial susceptibility testing performed by KirbyBauer disc diffusion method revealed that the bacterium was resistant to penicillins, cephalosporins, aminoglycosides, quinolones and colistin, but was susceptible to trimethoprimsulfamethoxazole, rifampicin, and vancomycin in all four cases [Figure 3]. As there are still no standard guidelines for susceptibility testing of E. meningoseptica, interpretation of trimethoprim-sulfamethoxazole, rifampicin, and vancomycin susceptibility was done in comparison with Staphylococcus aureus (ATCC 25923). The results of susceptibility testing were later confirmed with VITEK 2 automated system. All four patients were treated with rifampicin, vancomycin, and trimethoprim-sulfamethoxazole. Mean duration of antibiotic therapy was 8.7 days. Improvement with therapy was seen in two patients, one patient expired, and one took discharge against advice. To trace the source of infection multiple environmental samples were taken from ventilator machines, humidifier boxes, hospital trolley, AC duct, bed curtains, bed railings, saline bottles, and tap water of the ICU. E. meningoseptica with the same sensitivity pattern was isolated from the humidifier water. Thus, humidifier water was identified as the source of infection. The humidifier boxes in the ventilator circuit of all the four patients were sterilized by
autoclave. Repeat samples taken from the humidifier boxes after sterilization did not yield any bacteria on culture. Our study is the first report of an acute outbreak of VAP with E. meningoseptica in India. Earlier Weaver et al. in 2010 and Güngör et al. in 2003 have reported similar
Figure 1: Blood agar showing growth of Elizabethkingia meningoseptica
Figure 2: MacConkey agar showing growth of Elizabethkingia meningoseptica
Figure 3: Antimicrobial susceptibility testing of Elizabethkingia meningoseptica by Kirby-Bauer disc diffusion method
Journal of Global Infectious Diseases / Jan-Mar 2015 / Vol-7 / Issue-1
43
Letters to Editor
outbreaks.[3,4] The predisposing factors for infection with this pathogen are adults with some underlying severe illness, on life support devices and on prolonged antibiotic treatment.[3] Two out of four patients had predisposing comorbid illness like diabetes and carcinoma breast and all four patients were on a mechanical ventilator. Previous studies have shown that E. meningoseptica is found as colonizer in tap water, tubing of ventilators and in sink basins of the hospital wards.[5] Infections caused by E. meningoseptica have a high mortality rate due to the delay in the administration of appropriate therapy. We stress the importance of awareness of infections caused by E. meningoseptica, and prompt collaborative action by microbiologist and infection control team to control such hospital outbreaks.
Kiran Chawla, Anusha Gopinathan, Muralidhar Varma1, Chiranjay Mukhopadhyay Departments of Microbiology and 1Internal Medicine, Kasturba Medical College, Manipal, Karnataka, India Address for correspondence: Dr. Kiran Chawla, E-mail: [email protected]
REFERENCES 1.
2.
3.
4.
5.
Hsu MS, Liao CH, Huang YT, Liu CY, Yang CJ, Kao KL, et al. Clinical features, antimicrobial susceptibilities, and outcomes of Elizabethkingia meningoseptica (Chryseobacterium meningosepticum) bacteremia at a medical center in Taiwan, 1999-2006. Eur J Clin Microbiol Infect Dis 2011;30:1271-8. Spangler SK, Visalli MA, Jacobs MR, Appelbaum PC. Susceptibilities of non-Pseudomonas aeruginosa gram-negative nonfermentative rods to ciprofloxacin, ofloxacin, levofloxacin, D-ofloxacin, sparfloxacin, ceftazidime, piperacillin, piperacillin-tazobactam, trimethoprim-sulfamethoxazole, and imipenem. Antimicrob Agents Chemother 1996;40:772-5. Weaver KN, Jones RC, Albright R, Thomas Y, Zambrano CH, Costello M, et al. Acute emergence of Elizabethkingia meningoseptica infection among mechanically ventilated patients in a long-term acute care facility. Infect Control Hosp Epidemiol 2010;31:54-8. Güngör S, Ozen M, Akinci A, Durmaz R. A Chryseobacterium meningosepticum outbreak in a neonatal ward. Infect Control Hosp Epidemiol 2003; 24:613-7. Amer MZ, Bandey M, Bukhari A, Nemenqani D. Neonatal meningitis caused by Elizabethkingia meningoseptica in Saudi Arabia. J Infect Dev Ctries 2011;5:745-7.
Access this article online Quick Response Code: Website: www.jgid.org
DOI: 10.4103/0974-777X.150890
44
Elbow Mycobacterium Tuberculosis in America Sir Less than 1% of tuberculosis (TB) cases are specific to the elbow.[1,2] Symptoms often develop insidiously, and in the absence of pulmonary involvement, TB is typically excluded from the differential diagnosis. A 69-year-old man, originally from Pakistan, presented with elbow swelling, pain, and decreased range of motion. His medical history included dengue, entamoeba histolytica, and gout. He reported recent unexplained changes in weight, weakness and fatigue, loss of appetite, changes in skin, blurred vision, coughing, smoking, abdominal pain, frequent diarrhea, and constipation. Vital signs were within normal limits. There was no skin breakdown or lesions. The elbow demonstrated diffuse swelling, but no redness. Radiographs revealed mild osteoarthritis, but no acute fractures. The elbow joint was aspirated without complication. The patient was negative for rheumatoid factor and lyme disease. The C-reactive protein was within normal limits, and the sedimentation rate was 29 mm/h. Despite no trauma, 6 months later, the patient reported increased swelling, pain, and decreased range of motion. The elbow demonstrated moderate effusion and some warmth, but no ecchymosis. Radiographs showed increased erosion of the capitellum and radial head, but no acute fractures or subluxation. The joint was aspirated without complication. No aerobic growth or crystals were seen. Given the worsening symptoms, the patient was admitted for incision and drainage of the right elbow and olecranon bursa. Tissue, bone, and fluid specimens were obtained. Pulmonary TB was ruled out. Acid-fast Bacilli (AFB) cultures were obtained for all surgical specimens. The primary culture media included a Remel Mitchison 7H11 Selective Agar Slant (Thermo Scientific™ Remel™, Waltham, MA) and a VersaTREK® Myco liquid medium (TREK Diagnostic Systems, Oakwood Village, OH). Growth was present on the slant and in the liquid medium. Both the agar slant and the liquid medium were Kinyoun positive.
Journal of Global Infectious Diseases / Jan-Mar 2015 / Vol-7 / Issue-1
Copyright of Journal of Global Infectious Diseases is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
