Infection DOI 10.1007/s15010-015-0722-9
CASE REPORT
Nosocomial pneumonia caused by carbapenem‑resistant Raoultella planticola: a case report and literature review M. Xu · W. Xie · Y. Fu · H. Zhou · J. Zhou
Received: 18 September 2014 / Accepted: 6 January 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract Raoultella planticola is a rare opportunistic pathogen usually invaded immunocompromised patients and sometimes even causes fatal infections. Recently, there is growing concern about the emergence of carbapenem resistance in this species. Here, we describe one case of hospital-acquired pneumonia due to a carbapenem-resistant R. planticola (CRRP) co-producing Klebsiella pneumoniae carbapenemase and extended-spectrum β-lactamase. A literature review was performed to indicate the microbiological and clinical features of infections caused by CRRP.
et al. first reported septicemia due to this organism in 1984 [2]. Though the literatures about infections caused by R. planticola are increasing during past three decades, R. planticola is still rare in clinical specimens. Here, we present a case of nosocomial pneumonia due to a carbapenemresistant R. planticola (CRRP). The microbiological and clinical features of CRRP were reviewed.
Keyword Raoultella planticola · carbapenem resistant · KPC · Neutropenia
A 60-year-old male with no special past medical history was admitted to our hospital for newly diagnosed acute myeloid leukemia (M5b, FAB classification). The standard 7-day IA scheme (idarubicin plus cytarabine) was applied for induction chemotherapy. Before chemotherapy, he was afebrile. The laboratory evaluation was as follows: white blood cell (WBC) 3,700 cell/mm3 with neutrophil 1,300 cell/mm3, normal C-reaction protein and negative sputum culture. The patient developed a fever of 38.5 °C on day 5. WBC decreased to 1,500 cell/mm3 with 100 cell/mm3 neutrophil. He was assessed as high-risk level of severe infection and treated with cefoperazone/sulbactam empirically (2.0 g Q8H). However, fever did not improve in the following three days. Imipenem/cilastatin (1.0 g Q8H) replaced cefoperazone/sulbactam on day 7. Skin and soft tissue infection was suspected since a tender subcutaneous mass presented on medial side of the left lower leg. Therefore, teicoplanin (0.4 g Q12H for the initial 24 h, then 0.4 g QD) was added. Itraconazole (0.2 g Q12H for the initial 48 h, then 0.2 g QD) was also given intravenously for antifungal prophylaxis. The temperature dropped to normal in 24 h after antibiotic change. Cultures of blood and sputum were negative.
Introduction The genus Raoultella, in the family Enterobacteriaceae, was proposed to divide from the genus Klebsiella based on phylogenetic analysis of 16S rDNA and rpoB sequences in 2001 [1]. Its most important representative, R. planticola, had been considered as a harmless environment bacterium usually recovered from water, soil and plants until Freney M. Xu Department of Clinical Laboratory, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China W. Xie Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China Y. Fu · H. Zhou · J. Zhou (*) Department of Respiratory Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou 31003, China e-mail: [email protected]
Case report
13
M. Xu et al. Table 1 Results of microbiology tests and important imaging in chronological order Time
Test
Result
Day 1 Day 1 Day 5 Day 8
Sputum culture Lung CT Sputum and blood culture Lung CT
Negative Chronic infection in lower lobe of right lung Negative Similar to that of day1
Day 15 Day 22 Day 31
Sputum and blood culture Lung CT Sputum culture
Negative Bilateral lower lobes infiltrates and pleural effusions
Day 32 Day 33
Lung CT Sputum culture
Day 33 Day 40 Day 44 Day 46 Day 46 Day 52 Day 58
Pleural fluid culture Sputum culture Transthoracic echocardiography Pleural fluid culture Lung CT Sputum and blood culture Sputum culture
Day 58 Day 59
Lung CT Brain CT
Moderate amount of R. planticola Obvious progression of lung infection with multifocal opacities and consolidation Multiple cerebral infarctions and bleedings
Day 59
Blood culture
E. coli
small amount of Candida albicans Progress of pulmonary infiltrates and pleural effusions compared with that of day 22 Small amount of Candida albicans Negative Negative No valve vegetation Negative Pulmonary infiltrates similar to that of day 32 Negative
Fever around 38 °C was recurrent since day 13. Bone marrow examination on day 15 showed residual of 44 % monoblasts plus promonocytes. An additional 14-day CAG chemotherapy scheme (cytarabine, aclacinomycin and G-CSF) was initiated on day 17 when WBC recovered to 3,600 cell/mm3. Antimicrobial agent was de-escalated to cefoperazone/sulbactam (2.0 g Q8H) on day 21 after 14-day usage of imipenem/cilastatin. The patient was afebrile during day 23 to day 29. Recurrent fever of 38 °C occurred on day 30. The persistent profound neutropenia (neutrophil
CASE REPORT
Nosocomial pneumonia caused by carbapenem‑resistant Raoultella planticola: a case report and literature review M. Xu · W. Xie · Y. Fu · H. Zhou · J. Zhou
Received: 18 September 2014 / Accepted: 6 January 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract Raoultella planticola is a rare opportunistic pathogen usually invaded immunocompromised patients and sometimes even causes fatal infections. Recently, there is growing concern about the emergence of carbapenem resistance in this species. Here, we describe one case of hospital-acquired pneumonia due to a carbapenem-resistant R. planticola (CRRP) co-producing Klebsiella pneumoniae carbapenemase and extended-spectrum β-lactamase. A literature review was performed to indicate the microbiological and clinical features of infections caused by CRRP.
et al. first reported septicemia due to this organism in 1984 [2]. Though the literatures about infections caused by R. planticola are increasing during past three decades, R. planticola is still rare in clinical specimens. Here, we present a case of nosocomial pneumonia due to a carbapenemresistant R. planticola (CRRP). The microbiological and clinical features of CRRP were reviewed.
Keyword Raoultella planticola · carbapenem resistant · KPC · Neutropenia
A 60-year-old male with no special past medical history was admitted to our hospital for newly diagnosed acute myeloid leukemia (M5b, FAB classification). The standard 7-day IA scheme (idarubicin plus cytarabine) was applied for induction chemotherapy. Before chemotherapy, he was afebrile. The laboratory evaluation was as follows: white blood cell (WBC) 3,700 cell/mm3 with neutrophil 1,300 cell/mm3, normal C-reaction protein and negative sputum culture. The patient developed a fever of 38.5 °C on day 5. WBC decreased to 1,500 cell/mm3 with 100 cell/mm3 neutrophil. He was assessed as high-risk level of severe infection and treated with cefoperazone/sulbactam empirically (2.0 g Q8H). However, fever did not improve in the following three days. Imipenem/cilastatin (1.0 g Q8H) replaced cefoperazone/sulbactam on day 7. Skin and soft tissue infection was suspected since a tender subcutaneous mass presented on medial side of the left lower leg. Therefore, teicoplanin (0.4 g Q12H for the initial 24 h, then 0.4 g QD) was added. Itraconazole (0.2 g Q12H for the initial 48 h, then 0.2 g QD) was also given intravenously for antifungal prophylaxis. The temperature dropped to normal in 24 h after antibiotic change. Cultures of blood and sputum were negative.
Introduction The genus Raoultella, in the family Enterobacteriaceae, was proposed to divide from the genus Klebsiella based on phylogenetic analysis of 16S rDNA and rpoB sequences in 2001 [1]. Its most important representative, R. planticola, had been considered as a harmless environment bacterium usually recovered from water, soil and plants until Freney M. Xu Department of Clinical Laboratory, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China W. Xie Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China Y. Fu · H. Zhou · J. Zhou (*) Department of Respiratory Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou 31003, China e-mail: [email protected]
Case report
13
M. Xu et al. Table 1 Results of microbiology tests and important imaging in chronological order Time
Test
Result
Day 1 Day 1 Day 5 Day 8
Sputum culture Lung CT Sputum and blood culture Lung CT
Negative Chronic infection in lower lobe of right lung Negative Similar to that of day1
Day 15 Day 22 Day 31
Sputum and blood culture Lung CT Sputum culture
Negative Bilateral lower lobes infiltrates and pleural effusions
Day 32 Day 33
Lung CT Sputum culture
Day 33 Day 40 Day 44 Day 46 Day 46 Day 52 Day 58
Pleural fluid culture Sputum culture Transthoracic echocardiography Pleural fluid culture Lung CT Sputum and blood culture Sputum culture
Day 58 Day 59
Lung CT Brain CT
Moderate amount of R. planticola Obvious progression of lung infection with multifocal opacities and consolidation Multiple cerebral infarctions and bleedings
Day 59
Blood culture
E. coli
small amount of Candida albicans Progress of pulmonary infiltrates and pleural effusions compared with that of day 22 Small amount of Candida albicans Negative Negative No valve vegetation Negative Pulmonary infiltrates similar to that of day 32 Negative
Fever around 38 °C was recurrent since day 13. Bone marrow examination on day 15 showed residual of 44 % monoblasts plus promonocytes. An additional 14-day CAG chemotherapy scheme (cytarabine, aclacinomycin and G-CSF) was initiated on day 17 when WBC recovered to 3,600 cell/mm3. Antimicrobial agent was de-escalated to cefoperazone/sulbactam (2.0 g Q8H) on day 21 after 14-day usage of imipenem/cilastatin. The patient was afebrile during day 23 to day 29. Recurrent fever of 38 °C occurred on day 30. The persistent profound neutropenia (neutrophil
