The Eurasian

EAJM 2013; 45:60-1

Journal of Medicine

Case Report

Recurrent Port Infection Due to Chryseobacterium Indologenes Chryseobacterium Indologenes'e Bagli Tekrarlayan Port Enfeksiyonu Sibel Islak Mutcali, Mucahit Yemisen, Hikmet Soylu, Ilker Inane Balkan, Bilgul Mete, Nese Saltoglu,

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Department of Infectious Diseases, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey

Abstract

Ozet

Infections due to Chryseobacterium indologenes (C indologenes) are Chryseobacterium indologenes ile enfeksiyon gelijimi nadirdir ve gerare and generally associated with immunosupression and indwellnellikle immun baskilanma ve kalici kateterler ile iliçkilidir. Bu yaziing catheters. We report a recurrent port infection caused by C. inmizda C indotogenes'e baglr geli§en port enfeksiyonu sunmaktayiz. dologenes. In the first bacteremia episode we did not remove the port ilk bakteremi ataginda port çikarilmadi ve sadece antibiyotik tedavisi and only applied antibiotherapy. However, the patient presented verildi. Ancak, hasta ayni mikroorganizma ile yeni bir bakteremi atagi with bacteremia with the same bacteria and successfully treated with geçirdi ve portun çikanlmasi ve uygun antibiyoterapi ile baçanli bir antibiotherapy and removal of the port. çekilde tedavi edildi. Key Words: Chryseobacterium indologenes, Port infection

Anahtar Kelimeler: Chryseobacterium indologenes. Port enfeksiyonu

Introduction

cultures yielded extended-spectrum beta-lactamase-producing Klebsiella pneumoniae, and we switched the patient to Chryseobacterium indologenes is a non-motile, catalase-, ertapenem therapy (1x1 gr). On the seventh day of ertapenem treatment, the patient's body temperature increased oxidase- and indole-positive, non-fermentative, gram-negto over 38°C, and we obtained new cultures. Blood cultures ative bacillus [1]. It rarely causes human infections, and from the port and periphery yielded gram-negative, nonmost develop in immunocompromised patients with medical fermentative, oxidase-positive, slow-growing bacilli. The isodevice implants [2]. Herein, we report a recurrent port infeclated strain was identified as Chryseobacterium indologenes tion caused by C. indologenes. by the API-20NE (bioMérieux, France) identification systeni. Antibiotic susceptibility testing was performed using the Case Report disc diffusion method, and the isolate was sensitive to vancomycin, cefaperozone-sulbactam, ciprofloxacin, ceftazidime A 66-year-old female patient was admitted to our hospiand piperacillin-tazobactam. The therapy was switched to tal due to fever and worsening of her general condition. The ceftazidime (2x2 g) for two weeks. The patient improved and patient had been followed for one year due to an esophagus was discharged from hospital. Because of the rapid respond carcinoma CA. She had a port catheter and had undergone to antibiotic treatment, we did not remove the port. several rounds of chemotherapy and radiotherapy. A physical examination revealed only purulent discharge around Eleven days after discharge, the patient was readmitted the gastrostomy. Her blood pressure was normal, her body to the hospital with fever and a poor general condition. We temperature was 38.5°C, and her laboratory results were as obtained blood cultures from the port and periphery and follows: leukocytes, 17,500/mm^ C-reactive protein, 184 mg/ initiated therapy with meropenem (3x1 gr) and teicoplanin dL (normal < 5 mg/dL); urea, 65 mg/dl; creatinine, 1.4 mg/dL. (1x400 mg), and due to the suspicion of C indologenes, All other results were within normal range. We initiated cefciprofloxacin (2x400 mg) was also administered. One day triaxon therapy (1 x2 gr) and performed cultures of her blood, later, the blood culture obtained from the port yielded gramurine and the discharge around the gastrostomy. The blood negative, non-fermentative, oxidase-positive bacilli 10 hours (BacT/ALERT® 3D, bioMérieux, France) and purulent discharge earlier than the periphery. It was identified as C. indologenes

Received: December 21,2011 / Accepted: September 4,2012 Correspondence to: Sibel Islak Mutcali, Department of Infectious Diseases, Cerrahpasa Medical School, Istanbul university, Kocamustafapasa Fatih, 63520, Istanbul, Turkey Phone: +90 533 426 70 16 e-mail: [email protected] doi:10.5152/eajm.2013.11

EAJM 2013; 45:60-1

Islak Muteali et al. Recurrent Port Infection due to Chryseobacterium Indologenes

by the API-20NE identification system. We removed the port and continued ciprofloxacin treatment. After two weeks, the patient was doing well and was discharged from the hospital.

Discussion C indologenes, formerly known as Flavobacterium CDC group lib, is rarely isolated from clinical specimens and may cause primary bacteremia, catheter-related bacteremia, wound sepsis, cellulitis, pyonephrosis, peritonitis, biliary tract infection and ventilator-associated pneumonia [3-8]. A standardized method of susceptibility testing for C indologenes does not exist. However, the broth dilution method is the preferred method. Although CLSI did not establish the MIC breakpoints for C indologenes, the MIC breakpoints for Enterobacteriaceae or Pseudomonas spp. are generally used for the susceptibility tests [7]. C. indologenes is resistant to many antibiotics, including aminoglycosides, penicillins, aztreonam and first-, second- and third-generation cephalosporins (except for ceftazidime) and demonstrates variable resistance to carbapenems. Kirby et al. [2] (SENTRY Antimicrobial Surveillance Program) has reported that fluoroquinolones, piperacillin/tazobactam, cefepime and trimethoprim/sulfamethoxazole are the most active antibiotics against C indologenes. In the same study, they also evaluated the sensitivity to vancomycin and did not recommend its use for treatment [2]. With regard to this report, we performed an antibiogram and also evaluated vancomycin sensitivity. Although the isolate was sensitive to vancomycin, we did not use it and treated our patient with ceftazidime and ciprofloxacin. Because it is a low-virulence bacterium, there is limited information about infections due to C. .indologenes, which generally develop in immunocompromised patients with neoplasm, diabetes or heart conditions [9]. Lin et al. [10] recently reported 16 bacteremia episodes due to C indologenes, and all of the patients had underlying conditions including mechanical ventilation, neoplasm, chemotherapy, chronic heart and lung diseases, chronic bed-ridden status and indwelling catheters. Hsueh et al. [3] also found that most cases involved nosocomial pneumonia and catheter-related bacteremia [3]. Catheter-related infections most likely develop due to the production of biofilms on foreign materials and the protease activity of C. indoiogenes. Although Hsueh et al. did not recommend the removal of all indwelling catheters, Lin et al. [10] suggested that catheters be removed when a catheter-related infection occurs due to C indologenes. Our patient also had a neoplasm and an indwelling catheter (i.e., a port). In the English [1966-2011] literature, there is only one reported port-related infection, and our case is the second [11]. During the first bacteremia epi-

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sode, we also did not remove the port-a-catheter. However, despite appropriate antibiotic treatment, the patient,was readmitted 11 days later with a new bacteremia episode due to the same species. In conclusion, infections due to C indoiogenes are rare, and limited information is available. Further investigations must be performed to determine the MIC breakpoints of C indologenes. In the majority of cases, an immunosuppressive condition or an indwelling catheter is typically present. When an infection develops due to a port or a central catheter, we suggest its removal to obtain a rapid response. Conflict of interest statement: The authors declare that they have no conflict of interest to the publication of this article.

References 1.

Vandamme P, Segers P, Vancanneyt M, et al. Ornithobacterium rhinotracheale gen. nov., sp. nov., isolated from the avian respiratory tract. Int J Syst Bacteriol 1994; 44: 24-37. 2. Kirby JT, Sader HS, Walsh TR, Jones RN. Antimicrobial susceptibility and epidemiology of a worldwide collection of Chryseobacterium spp: report from the SENTRY Antimicrobial Surveillance Program (1997-2001). J Clin Microbiol 2004; 42: 445-8. 3. Hsueh PR, Hsiue TR, Wu JJ, et al. Flavobacterium indologenes bacteremia: clinical and microbiological characteristics. Clin Infect Dis 1996; 23: 550-5. 4. Hsueh PR, Teng U, Ho SW, Hsieh WC, Luh KT Clinical and microbiological characteristics of Flavobacterium indologenes infections associated with indwelling devices. J Clin Microbiol 1996; 34:1908-13. 5. Hsueh PR, Teng LJ, Yang PC, et al. Increasing incidence of nosocomial Chryseobacterium indologenes infections in Taiwan. Eur J Clin Microbiol Infect Dis 1997; 16: 568-74. 6. Green BT, Nolan PE. Cellulitis and bacteraemia due to Chryseobacterium indologenes. J Infect 2001; 42: 219-20. 7. Christakis GB, Perlorentzou SP, Chalkiopoulou I, Athanasiou A, Legakis NJ. Chryseobacterium indologenes non-catheter-related bacteremia in a patient with a solid tumor. J Clin Microbiol 2005; 43: 2021-3. 8. Bayraktar MR, Aktas E, Ersoy Y, Cicek A, Durmaz R. Postoperative Chryseobacterium indologenes bloodstream infection caused by contamination of distillate water. Infect Control Hosp Epidemiol 2007; 28: 368-9. 9. Douvoyiannis M, Kalyoussef S, Philip G, Mayers MM. Chryseobacterium indologenes bacteremia in an infant. Int J Infect Dis 2010; 14: 531-2. 10. Lin YT, Jeng YY, Lin ML, et al. Clinical and microbiological characteristics of Chryseobacterium indologenes bacteremia. J Microbiol Immunol Infect 2010; 43:498-505. 11. Nulens E, Bussels B, Bols A, Gordts B, Van Landuyt HW. Recurrent bacteremia by Chryseobacterium indologenes in an oncology patient with a totally implanted intravascular device. Clin Microbiol Infect 2001; 7:91-3.

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