Case Report
Transient bacteraemia due to Chryseobacterium indologenes in an immunocompetent patient: a case report and literature review Silvano Esposito1, E. Russo2, G. De Simone2, R. Gioia2, S. Noviello2, M. Vitolo3, M. R. Rega3, A. Massari3, L. Posteraro3 1
Dipartimento di Malattie Infettive, Seconda Universita` di Napoli, Italy, 2Department of Infectious Diseases, University of Salerno, Italy, 3Department of Microbiology, Azienda Universitaria Ospedaliera, San Giovanni di Dio e Ruggi d’Aragona, Italy A 51-year-old woman was admitted to the emergency unit with diffuse headache, visus reduction, and paraesthesias of the trigeminal area and the left hand. Three days after admission she showed shaking chills, vomiting, and sudden onset of fever (39.4uC). Blood cultures were performed soon after fever onset. Fever persisted for the whole day, decreasing slowly after 12 hours. No empirical antibiotic treatment was started in order to better define the diagnosis. Fever completely disappeared the day after. Two blood cultures for aerobes were positive for Chryseobacterium indologenes. The patient was discharged with the diagnosis of transient bacteraemia and transferred to the neurology unit for further investigations. C. indologenes infections are described in 31 studies with a total of 171 cases (pneumonia and bacteraemia being the most frequent). Our case is the first report of transient bacteraemia caused by C. indologenes in an immunocompetent, non-elderly patient without needing medical devices.
Keywords: Chryseobacterium indologenes, Transient bacteraemia
Introduction Chryseobacteria are a group of non-motile, oxidasepositive, non-fermentative, or slowly fermentative Gram-negative bacilli. The genus Chryseobacterium includes several species that were formerly classified as Flavobacterium species.1 Among these bacteria, Chryseobacterium indologenes is the most common. C. indologenes colonies are smooth, convex, circular, mucous, 1–2 mm in diameter, and yellow pigmented. The yellow colour, due to the production of flexirubin, turns red after the culture is poured onto 10% KOH solution.2 C. indologenes is found in soil, foodstuffs, plants, salt water, fresh and drinking water (it is resistant to chlorination), but despite its extensive distribution in nature, it is not part of the normal human microflora.3 In the hospital environment, it is isolated from indwelling vascular catheters, vials, sink traps, feeding tubes and other fluidassociated equipment, and even disinfectants may become reservoirs for C. indologenes.3
Correspondence to: S. Esposito, Dipartimento di Malattie Infettive, Universita` di Salerno, Largo Ippocrate, Salerno, Italy. Email: silvanoesposito@fast webnet.it
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It is generally isolated in immunocompromised patients, affected by malignancies and diabetes mellitus and in those exposed to long-term treatment with broad-spectrum antibiotics. Although it forms a biofilm and produces a protease (metallo-beta-lactamase that provides resistance to carbapenems) that may be important in its virulence, it is not very pathogenic.4–34
Case Report A 51-year-old woman previously hospitalized in July 2013 for an asthmatic crisis with chronic obstructive pulmonary disease, drug allergies, arterial hypertension, bradycardia, ischaemic heart disease, and bilateral carotid atheromas, was admitted to the emergency unit of our hospital in October 2013 with diffuse headache, visus reduction, and paraesthesias of the left part of the face (trigeminal area) and the left hand. On admission, physical examination was normal showing blood pressure 130/100 mmHg, pulse 72 beats/min, and oral temperature 36.2uC. The patient complained of diffuse headache and paraesthesias. Blood tests were in the range of normality (haemoglobin 14.9; white blood cell count 6.726106/ml; C-reactive protein
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Journal of Chemotherapy
Acute meningitis (1) Ventilator-associated pneumonia (1)
Ventilator-associated pneumonia (1)
Peritonitis (1) Meningitis and sepsis (1) CVC related bacteraemia (1)
Meningitis (1) Bacteraemia (5)
Primary bacteraemia (1)
Subcutaneous port-related bacteraemia (1)
Ozcan N, 2013 (6) Yasmin S, 2013 (7)
Monteen MR, 2013 (8)
Afshar M, 2013 (9) Eshwara VK, 2013 (10) Kodama Y, 2013 (11)
Hendaus MA, 2013 (12) Gauna TT, 2013 (13)
Acosta-Ochoa MI, 2013 (14)
Shah S, 2012 (15)
UTI (1) Pneumonia (91) Bacteraemia (22)
CNS infection (1)
Olbrich P, 2014 (5)
Bhuyar G, 2012 (16) Chen FL, 2012 (17)
Catheter-related meningitis (1)
Clinical syndrome (no. of patients)
Wang X, 2014 (4)
Author, year (reference)
Pyelolithotomy (1) HCD (70) Diabetes mellitus (37) CKD (37) Malignancy (32) Stroke (31)
Insulin-dependent type 2 diabetes (1) CKD (1) Obesity (1) Respiratory infection (1) Decompensated heart failure (1) Liver transplant (1)
None End-stage renal disease (5)
End-stage renal disease (1) Small for gestational age (1) Acute myeloid leukaemia (1)
Trauma (1)
Respiratory failure (1)
Intracranial aneurysm clipping surgery (1) Holoprosencephaly (1) Obstructive hydrocephalus (1) Congenital hydrocephalus (1) Metastatic breast cancer (1)
Underlying conditions (no. of patients)
Hypothyroidism (1) Immunosuppression (1) Steatohepatitis (1) Malecot catheter (1) Mechanical ventilation (63) Tracheostomy (41) Corticosteroid therapy (46) Indwelling CVC (18) Concurrent candidaemia (1)
Mechanical ventilation (1) Peritoneal dialysis (1) … Cord blood stem cell transplantation (1) None Haemodialysis (5) CVC (5) Diabetic nephropathy and retinopathy (1) High blood pressure (1) Sacral oedema (1) Prolonged antibiotic use (1) E. coli infection (1) Cystic fibrosis (1)
Radiotherapy (1) Pericardial effusion (1) Cardiac arrest (1) Prolonged antibiotic use (1) Bilateral radiation-induced pleural effusion (1) Bilateral chest drains (1) Prolonged mechanical ventilation (1) Tracheostomy (1) Surgery (1)
Ventriculo-peritoneal shunt (1) E. coli meningitis (1) Ventriculo-peritoneal shunt (1) Mastectomy (1)
…
Other associated conditions (no. of patients)
Table 1 Clinical studies published in the period 2001–2014 concerning Chryseobacterium indologenes
Surgery (1) Infectious disease (1)
Internal medicine (1)
Nephrology (1)
Paediatrics (1)
Neonatology (1) Paediatrics (1)
ICU (1)
Paediatrics (1) Emergency department (1)
Urine (1) Sputum CVC tip
CSF (1) Catheter tips (5)
Peritoneal fluid (1) CSF (1)
BAL (1)
CSF (1) Tracheal aspirate sample (1)
CSF (1)
CSF (1)
Sites (other than blood) of C. indologenes isolation (no. of patients)
Paediatric infectious disease (1)
Neurosurgery (1)
Department (no. of patients)
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Bacteraemia (1)
Ventilator-associated pneumonia (1)
Primary bacteraemia (12) CVC-related bacteraemia (2) Peritonitis (1) UTI (1)
Caldero´n G, 2011 (22)
Lin YT, 2010 (23)
Meningitis and sepsis (1) Bacteraemia (10)
Peritonitis (1)
Clinical syndrome (no. of patients)
Sudharani V, 2011 (21)
Ceylan A., 2011 (19) Chou DW, 2011 (20)
Wang YC, 2011 (18)
Author, year (reference)
Table 1 Continued
Diabetes mellitus (8) Hypertension (8) Burkitt’s lymphoma (1) Lymphoma (1) CHF (5) CKD (6) COPD (2) Dementia (1) Breast cancer (1) Prostate cancer (1) Urothelial cell carcinoma of right kidney (1)
Congenital heart disease (1)
Stroke (2) Cirrhosis (2) Colon cancer (2) Gastric cancer (1) HCC (1) Head trauma (1) Preterm baby (1)
Hydrocephalus (1) Pneumonia (4) Septic shock (4) Diabetes mellitus (3)
Arrhythmia (19) Liver cirrhosis (4) Breast cancer, stage II (1)
CHF (21)
COPD (26)
Underlying conditions (no. of patients)
Mechanical ventilation (1) Meconium-stained liquor (1) Prolonged mechanical ventilation (1) Prolonged antibiotic use (1) Fever (1) Pulmonary infiltrate (1) Undergone surgery (1) Mechanical ventilation (3) Prolonged antibiotic use (6) CVC (8) UIC (7) Immunosuppression (5) Neutropenia (3) ICU admission (2) Recent surgery (2) Left PCN (1) Digiunostomy (1)
Malignant ascites (1) Mastectomy (1) Chemotherapy (1) Indwelling intraperitoneal catheter (1) CSF shunt (1) Mechanical ventilation (10) CVC (8) Prolonged broad spectrum antibiotic use (8) UC (5) SBP (2)
Concurrent Pseudomonas bacteraemia (1) Concurrent E. faecalis bacteraemia (3)
Other associated conditions (no. of patients)
Oncology (5) Urology (1) Nephrology (2) ICU (2) Chest unit (1) Infection disease unit (1) Allergy–immunology– rheumatology (1) Cardiology (1) General rehabilitation (1) Respiratory ICU (1)
Neonatology (1)
Neonatal ICU (1)
Paediatrics (1) ICU (10)
Infectious disease (1)
Department (no. of patients)
Urine (1) CVC tip (1) Peritoneal fluid (1)
BAL (1)
CSF (1) Pleural effusion (1) CVC tip (1)
Ascitic fluid (1)
Sites (other than blood) of C. indologenes isolation (no. of patients)
Esposito et al. Transient bacteraemia due to Chryseobacterium indologenes
Primary bacteraemia (1)
Primary bacteraemia (1)
Severe pneumonia (1) Lumboperitonial shunt infection (1) CVC-related bacteraemia (1)
Primary bacteraemia (1)
Bayraktar MR, 2007 (25)
Sibellas F, 2007 (26)
Reynaud I, 2007 (27) Al-Tatari H, 2007 (28)
Christakis GB, 2005 (30)
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Bacteraemia (1)
Cellulitis and bacteraemia (1) Recurrent bacteraemia (1)
Lin JT, 2003 (32)
Green BT, 2001 (33) Nulens E, 2001 (34)
Chronic myelocytic leukaemia (1) Bone marrow transplant (1) Chronic graft-versus-host disease (1) Squamous cell carcinoma (1) Immunosuppression (1)
Type I diabetes mellitus (1) Coma due to inappropriate treatment for ketoacidosis (1)
Squamous carcinoma of the right nasal tube with multiple metastases in regional cervical lymphnodes (1)
Myelodysplastic syndrome (1)
None Congenital hydrocephalus (1)
Down syndrome (1) Atrial septal defect (1) Myelodysplastic syndrome (1) Rheumatoid arthritis (1) Spondylodiskitis with E. coli and S. aureus abscess (1)
Neuroendocrine tumour in liver (1) Compression fracture of L spine (1) Right knee MFH (1) CVA (2) Motoneuron disease (1) Greenish rhinorrhea (1)
Underlying conditions (no. of patients)
Antibiotic therapy (1) Cerebral oedema (1) Chemotherapy (1) Immunosuppression (1) Pancytopenia (1) … CVC (1)
Severe mass haemorrhage (1) PVC (1) Corticosteroid therapy (1)
Pancytopenia (1) Bone marrow transplant (1) Prolonged antibiotic use(1) Bone marrow aspiration (1) CVC (1) Gastrostomy (1)
CVC (1) None
Mechanical ventilation (1) Prolonged antibiotic use (1) Prolonged corticosteroid therapy (1) Mechanical ventilation (1) Prolonged antibiotic use (1)
Fever (1)
Other associated conditions (no. of patients)
…
Oncology (1)
Paediatrics (1)
Oncology (1)
ICU (1) Paediatric infectious disease (1) Oncology (1)
ICU (1)
Paediatric infectious diseases (1) Paediatric surgery (1)
Department (no. of patients)
Wound exudate (1)
Bronchial sample (1) CSF (1)
Naso-gastric tube (1)
Sites (other than blood) of C. indologenes isolation (no. of patients)
Note: BAL5bronchoalveolar lavage; CHF5congestive heart failure; CKD5chronic kidney disease; COPD5chronic obstructive pulmonary disease; CSF5cerebrospinal fluid; CVA5cerebrovascular accident; CVC5central venous catheter; HCC5hepatocellular carcinoma; HCD5hypertensive cardiovascular disease; ICU5intensive care unit; MFH5malignant fibrous histiocytoma; PCN5percutaneous nephrostomy; PVC5peripheral venous catheter; SBP5spontaneous bacterial peritonitis; UC5urinary catheter; UIC5urinary indwelling catheter; UTI5urinary tract infection; VAP5ventilator-associated pneumonia.
Primary bacteraemia (1)
Cascio A, 2005 (31)
Akay M, 2006 (29)
Primary bacteraemia (1)
Clinical syndrome (no. of patients)
Dovoyiannis M, 2010 (24)
Author, year (reference)
Table 1 Continued
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,0.35), but the erythrocyte sedimentation rate was 23 (normal until 14). The following investigations were performed: electrocardiogram, electroencephalography, chest X-ray, brain nuclear magnetic resonance, carotid Doppler, and immunological and rheumatological screening. Three days after admission the patient showed shaking chills with vomiting and sudden onset of fever (oral temperature: 39.4uC). Her neurological symptoms (paraesthesias, visus reduction, and above all, headache), continued. Four different blood cultures (for aerobes and anaerobes) were performed soon after fever onset and 2 hours later. Fever persisted for the whole day, decreasing slowly after about 12 hours. No empirical antibiotic treatment was started as the patients did not show any other clinical or laboratory sign of bacterial infection and in order to better define the diagnosis with possible further bacterial cultures. Fever completely disappeared the day after. Both blood cultures for aerobes were positive and four days later C. indologenes was identified with the following susceptibility pattern determined using the Vitek System (bioMe´rieux): resistant to amikacin, amoxicillin/clavulanic acid, cefepime, cefotaxime, ceftazidime, ertapenem, gentamicin, imipenem, meropenem, piperacillin/tazobactam, tigecycline, and susceptible to ciprofloxacin and trimethoprim/sulfamethoxazole (TMP–SMX). The patient was discharged with the diagnosis of transient bacteraemia and transferred to the neurology unit for further investigations.
In addition, much information could be obtained from the analysis of these studies, especially about the antimicrobial susceptibility of this microorganism. C. indologenes is intrinsically resistant to aminoglycosides, most beta-lactams, chloramphenicol, linezolid, and glycopeptides, and susceptible to levofloxacin, TMP–SMX, and piperacillin/tazobactam (.90% susceptibility).4–34 According to the literature, antimicrobial susceptibility varies greatly from case to case, suggesting that in vitro testing should always be performed. Chen et al.17 reported the in vitro antimicrobial susceptibility of the greatest collection of clinical isolates and concluded that TMP–SMX is the most active agent, followed by cefoperazonesulbactam and tigecycline. According to the clinical and epidemiological features of these infections, the authors have noted a great increase, since 2006, of the numbers of patients with isolated C. indologenes infections related to the increased consumption of colistin and tigecycline. Our patient shows, instead, an atypical antimicrobial susceptibility pattern showing a multidrug resistance to all the antimicrobials tested with the exception of ciprofloxacin and TMP–SMX. Furthermore, to the best of our knowledge, our case is the first report of transient bacteraemia caused by C. indologenes in an immunocompetent, nonelderly patient without needing medical devices. It can be interpreted as the first documented case of C. indologenes transient bacteraemia.
Disclaimer Statements Discussion Based on a research performed by means of PUBMED utilizing as keywords ‘Chryseobacterium indologenes infections’, we identified 31 studies, summarized in Table 1, which were published in the period 2001–2014. Most of these studies report single clinical cases (27 articles), whereas four studies describe a higher number of cases. The total number of C. indologenes-related infections was 171, with pneumonia (95 cases) and bacteraemia (66 cases) being the most frequently observed, followed by meningitis (6), peritonitis (3), urinary tract infection (2), shunt infections (2), and cellulitis (1). Analysis of the scientific literature suggests that the highest frequency of Chryseobacterium species infections occurs among the elderly (.65 years old) and the lowest frequency among children ,5 years of age. Approximately half of C. indologenes infections are associated with indwelling devices that include intravascular catheters, surgical drainage, feeding tubes, endotracheal tubes, and Foley catheters; most of the patients are immunocompromised (cancer, transplantation, diabetes, peritoneal dialysis, corticosteroid therapy, chemotherapy).4–34
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Contributors All authors gave equal contribution to the present report. Funding None. Conflicts of interest None. Ethics approval Not needed.
References 1 Fraser SL, Jorgensen JH. Reappraisal of the antimicrobial susceptibilities of Chryseobacterium and Flavobacterium species and methods for reliable susceptibility testing. Antimicrob Agents Chemother. 1997;41(12):2738–41. 2 Sakurada ZA. Chryseobacterium indologenes. Rev Chilena Infectol. 2008;25(6):446. 3 Hsueh PR, Hsiue TR, Wu JJ, Teng LJ, Ho SW, Hsieh WC, et al. Flavobacterium indologenes bacteremia: clinical and microbiological characteristics. Clin Infect Dis. 1996;23(3): 550–5. 4 Wang X, Hu Z, Fan Y, Wang H. Chryseobacterium indologenes catheter-related meningitis in an elderly patient after intracranial aneurysm clipping surgery. Neurol Sci. 2014;35(1):113–5. 5 Olbrich P, Rivero-Garvı´a M, Falco´n-Neyra MD, Lepe JA, Cisneros JM, Marquez-Rivas J, et al. Chryseobacterium indologenes central nervous system infection in infancy: an emergent pathogen? Infection. 2014;42(1):179–83. 6 Ozcan N, Dal T, Tekin A, Kelekci S, Can S, Ezin O, et al. Is Chryseobacterium indologenes a shunt lover bacterium? A case report and review of the literature. Infez Med. 2013;4(21):312–6.
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7 Yasmin S, Garcia G, Sylvester T, Sunenshine R. Chryseobacterium indologenes in a woman with metastatic breast cancer in the United States of America: a case report. J Med Case Rep. 2013;26(1):190. 8 Monteen MR, Ponnapula S, Wood GC, Croce MA, Swanson JM, Boucher BA, et al. Treatment of Chryseobacterium indologenes ventilator-associated pneumonia in a critically ill trauma patient. Ann Pharmacother. 2013;47(12):1736–9. 9 Afshar M, Nobakht E, Lew SQ. Chryseobacterium indologenes peritonitis in peritoneal dialysis. BMJ Case Rep. 2013 May 24 [Epub ahead of print] doi: 10.1136/bcr-2013-009410. 10 Eshwara VK, Sasi A, Munim F, Purkayastha J, Lewis LE, Mukhopadhyay C. Neonatal meningitis and sepsis by Chryseobacterium indologenes: a rare and resistant bacterium. Indian J Pediatr. 2014;81(6):611–3. 11 Kodama Y, Nishimura M, Nakashima K, Ito N, Fukano R, Okamura J, et al. Central intravenous catheter-related bacteremia due to Chryseobacterium indologenes after cord blood transplantation. Rinsho Ketsueki. 2013;54(3):305–10. Japanese. 12 Hendaus MA, Zahraldin K. Chryseobacterium indologenes. Meningitis in a healthy newborn: a case report. Oman Med J. 2013;28(2):133–4. 13 Gauna TT, Oshiro E, Luzio YC, Paniago AM, Pontes ER, Chang MR. Bloodstream infection in patients with end-stage renal disease in a teaching hospital in central–western Brazil. Rev Soc Bras Med Trop. 2013;46(4):426–32. 14 Acosta-Ochoa MI, Rodrigo-Parra A, Rodrı´guez-Martı´n F, Molina-Miguel A. Urinary infection due to Chryseobacterium indologenes. Nefrologia. 2013;33(4):620. 15 Shah S, Sarwar U, King EA, Lat A. Chryseobacterium indologenes subcutaneous port-related bacteremia in a liver transplant patient. Transpl Infect Dis. 2012;14(4):398–402. 16 Bhuyar G, Jain S, Shah H, Mehta VK. Urinary tract infection by Chryseobacterium indologenes. Indian J Med Microbiol. 2012;30(3):370–2. 17 Chen FL, Wang GC, Teng SO, Ou TY, Yu FL, Lee WS. Clinical and epidemiological features of Chryseobacterium indologenes infections: analysis of 215 cases. J Microbiol Immunol Infect. 2013;46(6):425–32. 18 Wang YC, Yeh KM, Chiu SK, Shang ST, Kan LP, Yu CM, et al. Chryseobacterium indologenes peritonitis in a patient with malignant ascites. Int Med Case Rep J. 2011;4:13–5. 19 Ceylan A, Gu¨du¨cu¨og˘lu H, Akbayram S, Bektas¸ A, Berktas¸ M. Sepsis caused by Chryseobacterium indologenes in a patient with hydrocephalus. Mikrobiyol Bul. 2011;45(4):735–40. Turkish. 20 Chou DW, Wu SL, Lee CT, Tai FT, Yu WL. Clinical characteristics, antimicrobial susceptibilities, and outcomes of
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patients with Chryseobacterium indologenes bacteremia in an intensive care unit. Jpn J Infect Dis. 2011;64(6):520–4. Sudharani V, Asiya, Saxena NK. Chryseobacterium indologenes bacteraemia in a preterm baby. Indian J Med Microbiol. 2011;29:196–8. Caldero´n G, Garcı´a E, Rojas P, Garcı´a E, Rosso M, Losada A. Chryseobacterium indologenes infection in a newborn: a case report. J Med Case Rep. 2011;5:10. Lin YT, Jeng YY, Lin ML, Yu JM, Wang FD, Liu CY. Clinical and microbiological characteristics of Chryseobacterium indologenes bacteremia. J Microbiol Immunol Infect. 2010;43(6): 498–505. Dovoyiannis M, Kalyoussef S, Philip G, Mayers MM. Chryseobacterium indologenes bacteremia in an infant. Int J Infect Dis. 2010;14(6):531–2. 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(3):368–9. Sibellas F, Mohammedi I, Illinger J, Lina G, Robert D. Bacte´rie´mie a` Chryseobacterium indologenes chez un patient traite´ par corticothe´rapie au long cours. Ann Fr Anesth Reanim. 2007;26(10):887–9. Reynaud I, Chanteperdrix V, Broux C, Pavese P, Croize´ J, Maurin M, et al. A severe form of Chryseobacterium indologenes pneumonia in an immunocompetent patient. Med Mal Infect. 2007;37(11):762–4. Al-Tatari H, Asmar BI, Ang JY. Lumboperitonial shunt infection due to Chryseobacterium indologenes. Pediatr Infect Dis J. 2007;26(7):657–9. Akay M, Gunduz E, Gulbas Z. Catheter related bacteremia due to Chryseobacterium indologenes in a bone marrow transplant recipient. Bone Marrow Transplant. 2006;37(4):435–6. Christakis GB, Perlorentzou SP, Chalkiopoulou I, Athanasiou A, Legakis NJ. Chryseobacterium indologenes non-catheterrelated bacteremia in a patient with a solid tumor. J Clin Microbiol. 2005;43(4):2021–3. Cascio A, Stassi G, Costa GB, Crisafulli G, Rulli I, Ruggeri C, et al. Chryseobacterium indologenes bacteraemia in a diabetic child. J Med Microbiol. 2005;54:677–80. Lin JT, Wang WS, Yen CC, Liu JH, Chiou TJ, Yang MH, et al. Chryseobacterium indologenes bacteremia in a bone marrow transplant recipient with chronic graft versus host disease. Scand J Infect Dis. 2003;35(11–12):882–3. Green BT, Nolan PE. Cellulitis and bacteremia due to Chryseobacterium indologenes. J Infect. 2001;42(3):219–20. Nulens E, Bussels B, Bols A, Gordst B, van Landuyt HW. Recurrent bacteremia by Chryseobacterium indologenes in an oncology patient with a totally implanted intravasacular device. Clin Microbiol Infect. 2001;7(7):391–3.
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Transient bacteraemia due to Chryseobacterium indologenes in an immunocompetent patient: a case report and literature review Silvano Esposito1, E. Russo2, G. De Simone2, R. Gioia2, S. Noviello2, M. Vitolo3, M. R. Rega3, A. Massari3, L. Posteraro3 1
Dipartimento di Malattie Infettive, Seconda Universita` di Napoli, Italy, 2Department of Infectious Diseases, University of Salerno, Italy, 3Department of Microbiology, Azienda Universitaria Ospedaliera, San Giovanni di Dio e Ruggi d’Aragona, Italy A 51-year-old woman was admitted to the emergency unit with diffuse headache, visus reduction, and paraesthesias of the trigeminal area and the left hand. Three days after admission she showed shaking chills, vomiting, and sudden onset of fever (39.4uC). Blood cultures were performed soon after fever onset. Fever persisted for the whole day, decreasing slowly after 12 hours. No empirical antibiotic treatment was started in order to better define the diagnosis. Fever completely disappeared the day after. Two blood cultures for aerobes were positive for Chryseobacterium indologenes. The patient was discharged with the diagnosis of transient bacteraemia and transferred to the neurology unit for further investigations. C. indologenes infections are described in 31 studies with a total of 171 cases (pneumonia and bacteraemia being the most frequent). Our case is the first report of transient bacteraemia caused by C. indologenes in an immunocompetent, non-elderly patient without needing medical devices.
Keywords: Chryseobacterium indologenes, Transient bacteraemia
Introduction Chryseobacteria are a group of non-motile, oxidasepositive, non-fermentative, or slowly fermentative Gram-negative bacilli. The genus Chryseobacterium includes several species that were formerly classified as Flavobacterium species.1 Among these bacteria, Chryseobacterium indologenes is the most common. C. indologenes colonies are smooth, convex, circular, mucous, 1–2 mm in diameter, and yellow pigmented. The yellow colour, due to the production of flexirubin, turns red after the culture is poured onto 10% KOH solution.2 C. indologenes is found in soil, foodstuffs, plants, salt water, fresh and drinking water (it is resistant to chlorination), but despite its extensive distribution in nature, it is not part of the normal human microflora.3 In the hospital environment, it is isolated from indwelling vascular catheters, vials, sink traps, feeding tubes and other fluidassociated equipment, and even disinfectants may become reservoirs for C. indologenes.3
Correspondence to: S. Esposito, Dipartimento di Malattie Infettive, Universita` di Salerno, Largo Ippocrate, Salerno, Italy. Email: silvanoesposito@fast webnet.it
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It is generally isolated in immunocompromised patients, affected by malignancies and diabetes mellitus and in those exposed to long-term treatment with broad-spectrum antibiotics. Although it forms a biofilm and produces a protease (metallo-beta-lactamase that provides resistance to carbapenems) that may be important in its virulence, it is not very pathogenic.4–34
Case Report A 51-year-old woman previously hospitalized in July 2013 for an asthmatic crisis with chronic obstructive pulmonary disease, drug allergies, arterial hypertension, bradycardia, ischaemic heart disease, and bilateral carotid atheromas, was admitted to the emergency unit of our hospital in October 2013 with diffuse headache, visus reduction, and paraesthesias of the left part of the face (trigeminal area) and the left hand. On admission, physical examination was normal showing blood pressure 130/100 mmHg, pulse 72 beats/min, and oral temperature 36.2uC. The patient complained of diffuse headache and paraesthesias. Blood tests were in the range of normality (haemoglobin 14.9; white blood cell count 6.726106/ml; C-reactive protein
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Journal of Chemotherapy
Acute meningitis (1) Ventilator-associated pneumonia (1)
Ventilator-associated pneumonia (1)
Peritonitis (1) Meningitis and sepsis (1) CVC related bacteraemia (1)
Meningitis (1) Bacteraemia (5)
Primary bacteraemia (1)
Subcutaneous port-related bacteraemia (1)
Ozcan N, 2013 (6) Yasmin S, 2013 (7)
Monteen MR, 2013 (8)
Afshar M, 2013 (9) Eshwara VK, 2013 (10) Kodama Y, 2013 (11)
Hendaus MA, 2013 (12) Gauna TT, 2013 (13)
Acosta-Ochoa MI, 2013 (14)
Shah S, 2012 (15)
UTI (1) Pneumonia (91) Bacteraemia (22)
CNS infection (1)
Olbrich P, 2014 (5)
Bhuyar G, 2012 (16) Chen FL, 2012 (17)
Catheter-related meningitis (1)
Clinical syndrome (no. of patients)
Wang X, 2014 (4)
Author, year (reference)
Pyelolithotomy (1) HCD (70) Diabetes mellitus (37) CKD (37) Malignancy (32) Stroke (31)
Insulin-dependent type 2 diabetes (1) CKD (1) Obesity (1) Respiratory infection (1) Decompensated heart failure (1) Liver transplant (1)
None End-stage renal disease (5)
End-stage renal disease (1) Small for gestational age (1) Acute myeloid leukaemia (1)
Trauma (1)
Respiratory failure (1)
Intracranial aneurysm clipping surgery (1) Holoprosencephaly (1) Obstructive hydrocephalus (1) Congenital hydrocephalus (1) Metastatic breast cancer (1)
Underlying conditions (no. of patients)
Hypothyroidism (1) Immunosuppression (1) Steatohepatitis (1) Malecot catheter (1) Mechanical ventilation (63) Tracheostomy (41) Corticosteroid therapy (46) Indwelling CVC (18) Concurrent candidaemia (1)
Mechanical ventilation (1) Peritoneal dialysis (1) … Cord blood stem cell transplantation (1) None Haemodialysis (5) CVC (5) Diabetic nephropathy and retinopathy (1) High blood pressure (1) Sacral oedema (1) Prolonged antibiotic use (1) E. coli infection (1) Cystic fibrosis (1)
Radiotherapy (1) Pericardial effusion (1) Cardiac arrest (1) Prolonged antibiotic use (1) Bilateral radiation-induced pleural effusion (1) Bilateral chest drains (1) Prolonged mechanical ventilation (1) Tracheostomy (1) Surgery (1)
Ventriculo-peritoneal shunt (1) E. coli meningitis (1) Ventriculo-peritoneal shunt (1) Mastectomy (1)
…
Other associated conditions (no. of patients)
Table 1 Clinical studies published in the period 2001–2014 concerning Chryseobacterium indologenes
Surgery (1) Infectious disease (1)
Internal medicine (1)
Nephrology (1)
Paediatrics (1)
Neonatology (1) Paediatrics (1)
ICU (1)
Paediatrics (1) Emergency department (1)
Urine (1) Sputum CVC tip
CSF (1) Catheter tips (5)
Peritoneal fluid (1) CSF (1)
BAL (1)
CSF (1) Tracheal aspirate sample (1)
CSF (1)
CSF (1)
Sites (other than blood) of C. indologenes isolation (no. of patients)
Paediatric infectious disease (1)
Neurosurgery (1)
Department (no. of patients)
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Bacteraemia (1)
Ventilator-associated pneumonia (1)
Primary bacteraemia (12) CVC-related bacteraemia (2) Peritonitis (1) UTI (1)
Caldero´n G, 2011 (22)
Lin YT, 2010 (23)
Meningitis and sepsis (1) Bacteraemia (10)
Peritonitis (1)
Clinical syndrome (no. of patients)
Sudharani V, 2011 (21)
Ceylan A., 2011 (19) Chou DW, 2011 (20)
Wang YC, 2011 (18)
Author, year (reference)
Table 1 Continued
Diabetes mellitus (8) Hypertension (8) Burkitt’s lymphoma (1) Lymphoma (1) CHF (5) CKD (6) COPD (2) Dementia (1) Breast cancer (1) Prostate cancer (1) Urothelial cell carcinoma of right kidney (1)
Congenital heart disease (1)
Stroke (2) Cirrhosis (2) Colon cancer (2) Gastric cancer (1) HCC (1) Head trauma (1) Preterm baby (1)
Hydrocephalus (1) Pneumonia (4) Septic shock (4) Diabetes mellitus (3)
Arrhythmia (19) Liver cirrhosis (4) Breast cancer, stage II (1)
CHF (21)
COPD (26)
Underlying conditions (no. of patients)
Mechanical ventilation (1) Meconium-stained liquor (1) Prolonged mechanical ventilation (1) Prolonged antibiotic use (1) Fever (1) Pulmonary infiltrate (1) Undergone surgery (1) Mechanical ventilation (3) Prolonged antibiotic use (6) CVC (8) UIC (7) Immunosuppression (5) Neutropenia (3) ICU admission (2) Recent surgery (2) Left PCN (1) Digiunostomy (1)
Malignant ascites (1) Mastectomy (1) Chemotherapy (1) Indwelling intraperitoneal catheter (1) CSF shunt (1) Mechanical ventilation (10) CVC (8) Prolonged broad spectrum antibiotic use (8) UC (5) SBP (2)
Concurrent Pseudomonas bacteraemia (1) Concurrent E. faecalis bacteraemia (3)
Other associated conditions (no. of patients)
Oncology (5) Urology (1) Nephrology (2) ICU (2) Chest unit (1) Infection disease unit (1) Allergy–immunology– rheumatology (1) Cardiology (1) General rehabilitation (1) Respiratory ICU (1)
Neonatology (1)
Neonatal ICU (1)
Paediatrics (1) ICU (10)
Infectious disease (1)
Department (no. of patients)
Urine (1) CVC tip (1) Peritoneal fluid (1)
BAL (1)
CSF (1) Pleural effusion (1) CVC tip (1)
Ascitic fluid (1)
Sites (other than blood) of C. indologenes isolation (no. of patients)
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Primary bacteraemia (1)
Primary bacteraemia (1)
Severe pneumonia (1) Lumboperitonial shunt infection (1) CVC-related bacteraemia (1)
Primary bacteraemia (1)
Bayraktar MR, 2007 (25)
Sibellas F, 2007 (26)
Reynaud I, 2007 (27) Al-Tatari H, 2007 (28)
Christakis GB, 2005 (30)
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Bacteraemia (1)
Cellulitis and bacteraemia (1) Recurrent bacteraemia (1)
Lin JT, 2003 (32)
Green BT, 2001 (33) Nulens E, 2001 (34)
Chronic myelocytic leukaemia (1) Bone marrow transplant (1) Chronic graft-versus-host disease (1) Squamous cell carcinoma (1) Immunosuppression (1)
Type I diabetes mellitus (1) Coma due to inappropriate treatment for ketoacidosis (1)
Squamous carcinoma of the right nasal tube with multiple metastases in regional cervical lymphnodes (1)
Myelodysplastic syndrome (1)
None Congenital hydrocephalus (1)
Down syndrome (1) Atrial septal defect (1) Myelodysplastic syndrome (1) Rheumatoid arthritis (1) Spondylodiskitis with E. coli and S. aureus abscess (1)
Neuroendocrine tumour in liver (1) Compression fracture of L spine (1) Right knee MFH (1) CVA (2) Motoneuron disease (1) Greenish rhinorrhea (1)
Underlying conditions (no. of patients)
Antibiotic therapy (1) Cerebral oedema (1) Chemotherapy (1) Immunosuppression (1) Pancytopenia (1) … CVC (1)
Severe mass haemorrhage (1) PVC (1) Corticosteroid therapy (1)
Pancytopenia (1) Bone marrow transplant (1) Prolonged antibiotic use(1) Bone marrow aspiration (1) CVC (1) Gastrostomy (1)
CVC (1) None
Mechanical ventilation (1) Prolonged antibiotic use (1) Prolonged corticosteroid therapy (1) Mechanical ventilation (1) Prolonged antibiotic use (1)
Fever (1)
Other associated conditions (no. of patients)
…
Oncology (1)
Paediatrics (1)
Oncology (1)
ICU (1) Paediatric infectious disease (1) Oncology (1)
ICU (1)
Paediatric infectious diseases (1) Paediatric surgery (1)
Department (no. of patients)
Wound exudate (1)
Bronchial sample (1) CSF (1)
Naso-gastric tube (1)
Sites (other than blood) of C. indologenes isolation (no. of patients)
Note: BAL5bronchoalveolar lavage; CHF5congestive heart failure; CKD5chronic kidney disease; COPD5chronic obstructive pulmonary disease; CSF5cerebrospinal fluid; CVA5cerebrovascular accident; CVC5central venous catheter; HCC5hepatocellular carcinoma; HCD5hypertensive cardiovascular disease; ICU5intensive care unit; MFH5malignant fibrous histiocytoma; PCN5percutaneous nephrostomy; PVC5peripheral venous catheter; SBP5spontaneous bacterial peritonitis; UC5urinary catheter; UIC5urinary indwelling catheter; UTI5urinary tract infection; VAP5ventilator-associated pneumonia.
Primary bacteraemia (1)
Cascio A, 2005 (31)
Akay M, 2006 (29)
Primary bacteraemia (1)
Clinical syndrome (no. of patients)
Dovoyiannis M, 2010 (24)
Author, year (reference)
Table 1 Continued
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,0.35), but the erythrocyte sedimentation rate was 23 (normal until 14). The following investigations were performed: electrocardiogram, electroencephalography, chest X-ray, brain nuclear magnetic resonance, carotid Doppler, and immunological and rheumatological screening. Three days after admission the patient showed shaking chills with vomiting and sudden onset of fever (oral temperature: 39.4uC). Her neurological symptoms (paraesthesias, visus reduction, and above all, headache), continued. Four different blood cultures (for aerobes and anaerobes) were performed soon after fever onset and 2 hours later. Fever persisted for the whole day, decreasing slowly after about 12 hours. No empirical antibiotic treatment was started as the patients did not show any other clinical or laboratory sign of bacterial infection and in order to better define the diagnosis with possible further bacterial cultures. Fever completely disappeared the day after. Both blood cultures for aerobes were positive and four days later C. indologenes was identified with the following susceptibility pattern determined using the Vitek System (bioMe´rieux): resistant to amikacin, amoxicillin/clavulanic acid, cefepime, cefotaxime, ceftazidime, ertapenem, gentamicin, imipenem, meropenem, piperacillin/tazobactam, tigecycline, and susceptible to ciprofloxacin and trimethoprim/sulfamethoxazole (TMP–SMX). The patient was discharged with the diagnosis of transient bacteraemia and transferred to the neurology unit for further investigations.
In addition, much information could be obtained from the analysis of these studies, especially about the antimicrobial susceptibility of this microorganism. C. indologenes is intrinsically resistant to aminoglycosides, most beta-lactams, chloramphenicol, linezolid, and glycopeptides, and susceptible to levofloxacin, TMP–SMX, and piperacillin/tazobactam (.90% susceptibility).4–34 According to the literature, antimicrobial susceptibility varies greatly from case to case, suggesting that in vitro testing should always be performed. Chen et al.17 reported the in vitro antimicrobial susceptibility of the greatest collection of clinical isolates and concluded that TMP–SMX is the most active agent, followed by cefoperazonesulbactam and tigecycline. According to the clinical and epidemiological features of these infections, the authors have noted a great increase, since 2006, of the numbers of patients with isolated C. indologenes infections related to the increased consumption of colistin and tigecycline. Our patient shows, instead, an atypical antimicrobial susceptibility pattern showing a multidrug resistance to all the antimicrobials tested with the exception of ciprofloxacin and TMP–SMX. Furthermore, to the best of our knowledge, our case is the first report of transient bacteraemia caused by C. indologenes in an immunocompetent, nonelderly patient without needing medical devices. It can be interpreted as the first documented case of C. indologenes transient bacteraemia.
Disclaimer Statements Discussion Based on a research performed by means of PUBMED utilizing as keywords ‘Chryseobacterium indologenes infections’, we identified 31 studies, summarized in Table 1, which were published in the period 2001–2014. Most of these studies report single clinical cases (27 articles), whereas four studies describe a higher number of cases. The total number of C. indologenes-related infections was 171, with pneumonia (95 cases) and bacteraemia (66 cases) being the most frequently observed, followed by meningitis (6), peritonitis (3), urinary tract infection (2), shunt infections (2), and cellulitis (1). Analysis of the scientific literature suggests that the highest frequency of Chryseobacterium species infections occurs among the elderly (.65 years old) and the lowest frequency among children ,5 years of age. Approximately half of C. indologenes infections are associated with indwelling devices that include intravascular catheters, surgical drainage, feeding tubes, endotracheal tubes, and Foley catheters; most of the patients are immunocompromised (cancer, transplantation, diabetes, peritoneal dialysis, corticosteroid therapy, chemotherapy).4–34
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Contributors All authors gave equal contribution to the present report. Funding None. Conflicts of interest None. Ethics approval Not needed.
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