456
Indian Journal of Medical Microbiology
suggesting presence of different lineages of NDM positive MDR Acinetobacter CBC strains. There is an immense public health importance of antibiotic resistance, which transcends national borders.[1] The clock is ticking and the time is not too far when there will be no drug available to treat serious infections, lest we enhance our infection control practices and implement the use of strong antibiotic policies urgently.
4. Kaase M, Nordmann P, Wichelhaus TA, Gatermann SG, Bonnin RA, Poirel L. NDM‑2 carbapenemase in Acinetobacter baumannii from Egypt. J Antimicrob Chemother 2011;66:1260‑2. 5. Misbah S, AbuBakar S, Hassan H, Hanifah YA, Yusof MY. Antibiotic susceptibility and REP‑PCR fingerprints of Acinetobacter spp. isolated from a hospital ten years apart. J Hosp Infect 2004;58:254‑61.
V Gautam, A Mewara, A Raj, V Gupta, N Singla, *P Ray
Acknowledgement The authors are thankful to Dr Camilla Rodrigues, Department of Microbiology, Research Laboratories, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, for providing us blaNDM and blaNDM‑1 positive K. pneumoniae strain.
Department of Medical Microbiology (VG, AM, AR, PR), Postgraduate Institute of Medical Education and Research, Chandigarh, Department of Microbiology (VG, NS), Government Medical College and Hospital, Chandigarh, Punjab, India
References 1. Johnson AP, Woodford N. Global spread of antibiotic resistance: The example of New Delhi metallo‑β‑lactamase (NDM)‑mediated carbapenem resistance. J Med Microbiol 2013;62:499‑513. 2. Carvalhaes CG, Picao RC, Nicoletti AG, Xavier DE, Gales AC. Cloverleaf test (modified Hodge test) for detecting carbapenemase production in Klebsiella pneumoniae: Be aware of false positive results. J Antimicrob Chemother 2010;65:249‑51. 3. Deshpande P, Rodrigues C, Shetty A, Kapadia F, Hedge A, Soman R. New Delhi Metallo‑beta lactamase (NDM‑1) in Enterobacteriaceae: Treatment options with carbapenems compromised. J Assoc Physicians India 2010;58:147‑9.
vol. 32, No. 4
*Corresponding author (email: ) Received: 11-07-2013 Accepted: 15-02-2014 Access this article online Quick Response Code:
Website: www.ijmm.org PMID: *** DOI: 10.4103/0255-0857.142231
Kocuria kristinae, an unusual pathogen causing opportunistic infections in patients with malignancy Dear Editor, Kocuria kristinae is a Gram‑positive bacterium normally residing on human skin and oral cavity, but it can be pathogenic in immune‑compromised hosts. Kocuria belongs to the family Micrococcaceae, having 17 species, of which K. kristinae has been reported to cause human infections.[1‑3] We present here five instances where K. kristinae was isolated from different clinical specimens of cancer patients undergoing treatment, who were having leukocytosis with neutrophillia. K. kristinae was isolated from sputum samples of three patients suffering from small cell carcinoma of lung, carcinoma soft palate and carcinoma of lip and gingivo‑buccal sulcus; and pus samples of two patients suffering from ductal carcinoma of breast and squamous cell carcinoma of buccal mucosa as shown in Table 1. These samples were processed
and after overnight incubation at 37ºC, blood agar showed non‑haemolytic 0.5‑1‑mm diameter colonies, which were creamish‑white, opaque, round‑convex with well‑defined edges and matted texture; growth on Mac‑Conkey agar showed 0.25‑0.5‑mm diameter, light pink, opaque, round colonies with well‑defined edges [Figure 1]. Gram‑stained smear from the growth revealed Gram‑positive cocci, which were catalase‑positive and slide coagulase negative. The growth was identified as Kocuria kristinae by automated VITEKR 2 Compact (C) (Biomeriux, North Carolina/USA) using Gram‑positive GP REF 21342 identification (GPID) card. The pathogen in all cases was confirmed by promptly culturing a repeat sample from the patients. As there was no database for MIC calculation for Kocuria spp. in the Vitek system, the antimicrobial susceptibility testing (AST) was done using database of Coagulase‑negative Staphylococcus, and interpretation was done according to the criteria of the
www.ijmm.org
October - December 2014
Correspondences
457
Table 1: Details of the patients and the isolates of Kocuria kristinae obtained from their sputum/pus samples Case Age Sex Medical Sample Complete Differential Gram stain Antimicrobial Treatment no. (years) condition blood count count appearance susceptibility given 3 1 65 Male Small cell Sputum 19140/ml N75L12M12E0.3B0.1 25‑30 pus Resistant to P, Intravenous carcinoma cells/10x, OX, G, FLUO, vancomycin of lung 0‑1 epithelial ERY, CL. 1g 12 cells/10x, gram sensitive to V, hourly X positive cocci in LIN, TIG 10 days tetrads, pairs/100x 2 65 Male Carcinoma Sputum 14720/ml3 N84L5M10E0.1B0.2 Plenty of pus Resistant to P, Intravenous soft palate cells/10x, OX, G, FLUO, vancomycin 1‑2 epithelial ERY, CL. 1g 12 cells/10x, gram sensitive to hourly X positive cocci in V, LIN, TIG, 7 days pairs, singly/100x QUIN 3 41 Female Carcinoma Sputum 14900/ml3 N75L20M9E0.06B0.01 15‑20 pus Resistant to P, Intravenous lip and cells/10x, OX, ERY, CL, levofloxacin gingival 2‑4 epithelial QUIN. 500mg once sulcus cells/10x, gram sensitive to daily X positive cocci G, FLUO, V, 7 days in tetrads, pairs, LIN, TIG singly/100x 4 39 Male Squamous Pus 71550/ml3 N56L25M6E0.14B0.01 10‑12 Pus Resistant to P, Oral cell cells/10x, gram OX, G, FLUO, linezolid carcinoma positive cocci ERY, CL. 600mg 12 of buccal in tetrads, sensitive to V, hourly X mucosa clusters/100x LIN, TIG 14 days 5 42 Female Ductal Pus 12,260 N71L22M10E0.08B0.01 Few pus cells/10x, Resistant to P, Intravenous carcinoma gram positive OX, G, FLUO, vancomycin of breast cocci in tetrads, ERY, CL. 1g 12 clusters/100x sensitive to V, hourly X LIN, TIG 5 days P: Penicillin, OX: Oxacillin, G: Gentamicin, FLUO: Fluoroquinolones, ERY: Erythromycin, CL: Clindamycin, V: Vancomycin, LIN: Linezolid, TIG: Tigecycline, QUIN: Quinupristin
subsided and their haematological parameters returned to normal.
a
b
Figure 1: Colonies of Kocuria kristinae on Blood agar (a) and MacConkey agar (b)
Clinical Laboratory Standards Institute M100‑ S23, 2013.[4] All the isolates were resistant to all first‑line antibiotics except the one isolated from lip and gingivo‑buccal sulcus which was sensitive to gentamicin and fluoroquinolones. All the isolates were susceptible to vancomycin, linezolid and tigecycline. The patients were successfully treated with intravenous vancomycin or oral linezolid; the one with carcinoma of lip and gingivo‑buccal sulcus was treated with intravenous levofloxacin. Following treatment, the patients’ symptoms
Cancer patients have a deficit of immunity due to the malignancy per se, long duration of treatment with cytotoxic drugs, immune‑suppression and radiotherapy. Although K. kristinae is mainly a commensal of skin and oral cavity, it can be an opportunistic pathogen in such patients. This organism is very difficult to identify by conventional microbiological techniques, but can be recognised by modern automated identification systems.[5] Monotherapy with oxacillin, vancomycin, piperacillin/tazobactam and ciprofloxacin; and combination therapy with teicoplanin and vancomycin, ciprofloxacin and clindamycin as well as ceftriaxone and ofloxacin have been used successfully in the reported cases.[1] To the best of our knowledge, this is the first case series of infections caused by K. kristinae in patients with underlying malignancy. This case‑series expands the
www.ijmm.org
458
Indian Journal of Medical Microbiology
existing clinical spectrum of diseases caused by this unusual pathogen around the world and adds to the growing body of literature documenting the virulence of these organisms in humans.
impact of members of the genus Kocuria. J Med Microbiol 2010;59:1395‑402.
*NH Ahmed, I Biswal, P Roy, RK Grover Department of Laboratory Medicine (NHA, IB, PR), Department of Clinical Oncology, Director and Chief Executive Officer (RKG), Delhi State Cancer Institute, Delhi, India
References 1. Martinaud C, Gaillard T, Brisou P, Gisserot O, de Jaureguiberry JP. Bacteraemia caused by Kocuria kristinae in a patient with acute leukaemia. Med Mal Infect 2008;38:165‑6. 2. Basaglia G, Carretto E, Barbarini D, Moras L, Scalone S, Marone P, et al. Catheter‑related bacteremia due to Kocuria kristinae in a patient with ovarian cancer. J Clin Microbiol 2002;40:311‑3. 3. Ma ES, Wong CL, Lai KT, Chan EC, Yam WC, Chan AC. Kocuria kristinae infection associated with acute cholecystitis. BMC Infect Dis 2005;5:60. 4. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing; Twenty first Informational supplement. CLSI document M100‑S23 ; 2013;3. 5. Savini V, Catavitello C, Masciarelli G, Astolfi D, Balbinot A, Bianco A, et al. Drug sensitivity and clinical
vol. 32, No. 4
*Corresponding author ( email: [email protected]>) Received: 02‑09‑2013 Accepted: 06‑02‑2014 Access this article online Quick Response Code:
Website: www.ijmm.org PMID: *** DOI: 10.4103/0255-0857.142232
Role of cold agglutination test in the diagnosis Mycoplasma pneumoniae infection in HIV infected children Dear Editor, Studies have shown that CD4 depletion may enhance M. pneumoniae infection in human immunodeficiency virus (HIV)‑infected patient.[1] Diagnosis of M. pneumoniae infection is mostly based on serology as isolation of bacterium in sputum is insensitive, whereas polymerase chain reaction (PCR) lacks clinical relevance. Cold agglutination test is convenient and inexpensive serological test for this purpose. We have evaluated the reliability of Quantitative cold agglutination test and Rapid bed side cold agglutination test in diagnosis of M. pneumoniae infection in HIV‑infected children. Serum samples of 90 HIV proven children presenting with recent pulmonary complaints were subjected to Quantitative cold agglutination test, Rapid cold agglutination test using the standard procedure.[5] M. pneumoniae IgM Enzyme Linked Immunosorbant Assay (IgM ELISA) was performed as the gold standard test and the results were compared. Of the total 90 cases tested, 29 (32.2%) were tested positive by Quantitative cold agglutination test of which 19 (65.5%) correlated with positive IgM ELISA test. Among positive cases, titres of ≥1:64 were observed in 21 (72.4%)
and 1:32 in 8 (27.5%). Rapid bed side cold agglutination test was found positive among 28 (31%) of which 15 (53.5%) correlated with positive IgM ELISA. A total of 29 (32.2%) cases tested were positive for IgM ELISA. Results concerning Reliability of cold agglutination test when compare to IgM- ElSA is given in Table 1. Shankar et al. reported sensitivity, specificity, positive and negative predictive values of 100%, 84%, 62% and 100%, respectively, for Quantitative cold agglutination test compared with IgM ELISA in HIV‑infected patients.[3] Ching YT et al. reported sensitivity and specificity of 78.3% and 41.3% and positive and negative predictive values of 43.4% and 76.7%, respectively, for Rapid cold agglutination test when compared with IgM ELISA in asthmatic children .[4] Kwan et al. reported sensitivity and specificity of 46% and 95% for Conventional Quantitative cold agglutination test .[5] According to the results obtained in our study, Cold agglutination test lacks sensitivity and specificity, hence IgM ELISA should be considered in diagnosis of M. pneumoniae infection in case of HIV‑infected children. Acknowledgement Mr. Kiran B and Mr. Rajesh M Technicians KIMS Hubli for their overwhelming technical support.
www.ijmm.org
Copyright of Indian Journal of Medical Microbiology 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.
Indian Journal of Medical Microbiology
suggesting presence of different lineages of NDM positive MDR Acinetobacter CBC strains. There is an immense public health importance of antibiotic resistance, which transcends national borders.[1] The clock is ticking and the time is not too far when there will be no drug available to treat serious infections, lest we enhance our infection control practices and implement the use of strong antibiotic policies urgently.
4. Kaase M, Nordmann P, Wichelhaus TA, Gatermann SG, Bonnin RA, Poirel L. NDM‑2 carbapenemase in Acinetobacter baumannii from Egypt. J Antimicrob Chemother 2011;66:1260‑2. 5. Misbah S, AbuBakar S, Hassan H, Hanifah YA, Yusof MY. Antibiotic susceptibility and REP‑PCR fingerprints of Acinetobacter spp. isolated from a hospital ten years apart. J Hosp Infect 2004;58:254‑61.
V Gautam, A Mewara, A Raj, V Gupta, N Singla, *P Ray
Acknowledgement The authors are thankful to Dr Camilla Rodrigues, Department of Microbiology, Research Laboratories, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, for providing us blaNDM and blaNDM‑1 positive K. pneumoniae strain.
Department of Medical Microbiology (VG, AM, AR, PR), Postgraduate Institute of Medical Education and Research, Chandigarh, Department of Microbiology (VG, NS), Government Medical College and Hospital, Chandigarh, Punjab, India
References 1. Johnson AP, Woodford N. Global spread of antibiotic resistance: The example of New Delhi metallo‑β‑lactamase (NDM)‑mediated carbapenem resistance. J Med Microbiol 2013;62:499‑513. 2. Carvalhaes CG, Picao RC, Nicoletti AG, Xavier DE, Gales AC. Cloverleaf test (modified Hodge test) for detecting carbapenemase production in Klebsiella pneumoniae: Be aware of false positive results. J Antimicrob Chemother 2010;65:249‑51. 3. Deshpande P, Rodrigues C, Shetty A, Kapadia F, Hedge A, Soman R. New Delhi Metallo‑beta lactamase (NDM‑1) in Enterobacteriaceae: Treatment options with carbapenems compromised. J Assoc Physicians India 2010;58:147‑9.
vol. 32, No. 4
*Corresponding author (email: ) Received: 11-07-2013 Accepted: 15-02-2014 Access this article online Quick Response Code:
Website: www.ijmm.org PMID: *** DOI: 10.4103/0255-0857.142231
Kocuria kristinae, an unusual pathogen causing opportunistic infections in patients with malignancy Dear Editor, Kocuria kristinae is a Gram‑positive bacterium normally residing on human skin and oral cavity, but it can be pathogenic in immune‑compromised hosts. Kocuria belongs to the family Micrococcaceae, having 17 species, of which K. kristinae has been reported to cause human infections.[1‑3] We present here five instances where K. kristinae was isolated from different clinical specimens of cancer patients undergoing treatment, who were having leukocytosis with neutrophillia. K. kristinae was isolated from sputum samples of three patients suffering from small cell carcinoma of lung, carcinoma soft palate and carcinoma of lip and gingivo‑buccal sulcus; and pus samples of two patients suffering from ductal carcinoma of breast and squamous cell carcinoma of buccal mucosa as shown in Table 1. These samples were processed
and after overnight incubation at 37ºC, blood agar showed non‑haemolytic 0.5‑1‑mm diameter colonies, which were creamish‑white, opaque, round‑convex with well‑defined edges and matted texture; growth on Mac‑Conkey agar showed 0.25‑0.5‑mm diameter, light pink, opaque, round colonies with well‑defined edges [Figure 1]. Gram‑stained smear from the growth revealed Gram‑positive cocci, which were catalase‑positive and slide coagulase negative. The growth was identified as Kocuria kristinae by automated VITEKR 2 Compact (C) (Biomeriux, North Carolina/USA) using Gram‑positive GP REF 21342 identification (GPID) card. The pathogen in all cases was confirmed by promptly culturing a repeat sample from the patients. As there was no database for MIC calculation for Kocuria spp. in the Vitek system, the antimicrobial susceptibility testing (AST) was done using database of Coagulase‑negative Staphylococcus, and interpretation was done according to the criteria of the
www.ijmm.org
October - December 2014
Correspondences
457
Table 1: Details of the patients and the isolates of Kocuria kristinae obtained from their sputum/pus samples Case Age Sex Medical Sample Complete Differential Gram stain Antimicrobial Treatment no. (years) condition blood count count appearance susceptibility given 3 1 65 Male Small cell Sputum 19140/ml N75L12M12E0.3B0.1 25‑30 pus Resistant to P, Intravenous carcinoma cells/10x, OX, G, FLUO, vancomycin of lung 0‑1 epithelial ERY, CL. 1g 12 cells/10x, gram sensitive to V, hourly X positive cocci in LIN, TIG 10 days tetrads, pairs/100x 2 65 Male Carcinoma Sputum 14720/ml3 N84L5M10E0.1B0.2 Plenty of pus Resistant to P, Intravenous soft palate cells/10x, OX, G, FLUO, vancomycin 1‑2 epithelial ERY, CL. 1g 12 cells/10x, gram sensitive to hourly X positive cocci in V, LIN, TIG, 7 days pairs, singly/100x QUIN 3 41 Female Carcinoma Sputum 14900/ml3 N75L20M9E0.06B0.01 15‑20 pus Resistant to P, Intravenous lip and cells/10x, OX, ERY, CL, levofloxacin gingival 2‑4 epithelial QUIN. 500mg once sulcus cells/10x, gram sensitive to daily X positive cocci G, FLUO, V, 7 days in tetrads, pairs, LIN, TIG singly/100x 4 39 Male Squamous Pus 71550/ml3 N56L25M6E0.14B0.01 10‑12 Pus Resistant to P, Oral cell cells/10x, gram OX, G, FLUO, linezolid carcinoma positive cocci ERY, CL. 600mg 12 of buccal in tetrads, sensitive to V, hourly X mucosa clusters/100x LIN, TIG 14 days 5 42 Female Ductal Pus 12,260 N71L22M10E0.08B0.01 Few pus cells/10x, Resistant to P, Intravenous carcinoma gram positive OX, G, FLUO, vancomycin of breast cocci in tetrads, ERY, CL. 1g 12 clusters/100x sensitive to V, hourly X LIN, TIG 5 days P: Penicillin, OX: Oxacillin, G: Gentamicin, FLUO: Fluoroquinolones, ERY: Erythromycin, CL: Clindamycin, V: Vancomycin, LIN: Linezolid, TIG: Tigecycline, QUIN: Quinupristin
subsided and their haematological parameters returned to normal.
a
b
Figure 1: Colonies of Kocuria kristinae on Blood agar (a) and MacConkey agar (b)
Clinical Laboratory Standards Institute M100‑ S23, 2013.[4] All the isolates were resistant to all first‑line antibiotics except the one isolated from lip and gingivo‑buccal sulcus which was sensitive to gentamicin and fluoroquinolones. All the isolates were susceptible to vancomycin, linezolid and tigecycline. The patients were successfully treated with intravenous vancomycin or oral linezolid; the one with carcinoma of lip and gingivo‑buccal sulcus was treated with intravenous levofloxacin. Following treatment, the patients’ symptoms
Cancer patients have a deficit of immunity due to the malignancy per se, long duration of treatment with cytotoxic drugs, immune‑suppression and radiotherapy. Although K. kristinae is mainly a commensal of skin and oral cavity, it can be an opportunistic pathogen in such patients. This organism is very difficult to identify by conventional microbiological techniques, but can be recognised by modern automated identification systems.[5] Monotherapy with oxacillin, vancomycin, piperacillin/tazobactam and ciprofloxacin; and combination therapy with teicoplanin and vancomycin, ciprofloxacin and clindamycin as well as ceftriaxone and ofloxacin have been used successfully in the reported cases.[1] To the best of our knowledge, this is the first case series of infections caused by K. kristinae in patients with underlying malignancy. This case‑series expands the
www.ijmm.org
458
Indian Journal of Medical Microbiology
existing clinical spectrum of diseases caused by this unusual pathogen around the world and adds to the growing body of literature documenting the virulence of these organisms in humans.
impact of members of the genus Kocuria. J Med Microbiol 2010;59:1395‑402.
*NH Ahmed, I Biswal, P Roy, RK Grover Department of Laboratory Medicine (NHA, IB, PR), Department of Clinical Oncology, Director and Chief Executive Officer (RKG), Delhi State Cancer Institute, Delhi, India
References 1. Martinaud C, Gaillard T, Brisou P, Gisserot O, de Jaureguiberry JP. Bacteraemia caused by Kocuria kristinae in a patient with acute leukaemia. Med Mal Infect 2008;38:165‑6. 2. Basaglia G, Carretto E, Barbarini D, Moras L, Scalone S, Marone P, et al. Catheter‑related bacteremia due to Kocuria kristinae in a patient with ovarian cancer. J Clin Microbiol 2002;40:311‑3. 3. Ma ES, Wong CL, Lai KT, Chan EC, Yam WC, Chan AC. Kocuria kristinae infection associated with acute cholecystitis. BMC Infect Dis 2005;5:60. 4. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing; Twenty first Informational supplement. CLSI document M100‑S23 ; 2013;3. 5. Savini V, Catavitello C, Masciarelli G, Astolfi D, Balbinot A, Bianco A, et al. Drug sensitivity and clinical
vol. 32, No. 4
*Corresponding author ( email: [email protected]>) Received: 02‑09‑2013 Accepted: 06‑02‑2014 Access this article online Quick Response Code:
Website: www.ijmm.org PMID: *** DOI: 10.4103/0255-0857.142232
Role of cold agglutination test in the diagnosis Mycoplasma pneumoniae infection in HIV infected children Dear Editor, Studies have shown that CD4 depletion may enhance M. pneumoniae infection in human immunodeficiency virus (HIV)‑infected patient.[1] Diagnosis of M. pneumoniae infection is mostly based on serology as isolation of bacterium in sputum is insensitive, whereas polymerase chain reaction (PCR) lacks clinical relevance. Cold agglutination test is convenient and inexpensive serological test for this purpose. We have evaluated the reliability of Quantitative cold agglutination test and Rapid bed side cold agglutination test in diagnosis of M. pneumoniae infection in HIV‑infected children. Serum samples of 90 HIV proven children presenting with recent pulmonary complaints were subjected to Quantitative cold agglutination test, Rapid cold agglutination test using the standard procedure.[5] M. pneumoniae IgM Enzyme Linked Immunosorbant Assay (IgM ELISA) was performed as the gold standard test and the results were compared. Of the total 90 cases tested, 29 (32.2%) were tested positive by Quantitative cold agglutination test of which 19 (65.5%) correlated with positive IgM ELISA test. Among positive cases, titres of ≥1:64 were observed in 21 (72.4%)
and 1:32 in 8 (27.5%). Rapid bed side cold agglutination test was found positive among 28 (31%) of which 15 (53.5%) correlated with positive IgM ELISA. A total of 29 (32.2%) cases tested were positive for IgM ELISA. Results concerning Reliability of cold agglutination test when compare to IgM- ElSA is given in Table 1. Shankar et al. reported sensitivity, specificity, positive and negative predictive values of 100%, 84%, 62% and 100%, respectively, for Quantitative cold agglutination test compared with IgM ELISA in HIV‑infected patients.[3] Ching YT et al. reported sensitivity and specificity of 78.3% and 41.3% and positive and negative predictive values of 43.4% and 76.7%, respectively, for Rapid cold agglutination test when compared with IgM ELISA in asthmatic children .[4] Kwan et al. reported sensitivity and specificity of 46% and 95% for Conventional Quantitative cold agglutination test .[5] According to the results obtained in our study, Cold agglutination test lacks sensitivity and specificity, hence IgM ELISA should be considered in diagnosis of M. pneumoniae infection in case of HIV‑infected children. Acknowledgement Mr. Kiran B and Mr. Rajesh M Technicians KIMS Hubli for their overwhelming technical support.
www.ijmm.org
Copyright of Indian Journal of Medical Microbiology 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.
