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Ochrobactrum anthropi bacteremia in a preterm infant with meconium peritonitis
International Journal of Infectious Diseases (2009) 13, e61—e63
http://intl.elsevierhealth.com/journals/ijid
CASE REPORT
Ochrobactrum anthropi bacteremia in a preterm infant with meconium peritonitis ¨ mit N. Bas¸aran b ¨ lfet Vatansever a, Betu Rıdvan Duran a,*, U ¨l Acunas¸ a, U a b
Trakya University Faculty of Medicine, Department of Pediatrics, Edirne, Turkey Trakya University Faculty of Medicine, Department of Pediatric Surgery, Edirne, Turkey
Received 19 February 2008; received in revised form 11 June 2008; accepted 28 June 2008 Corresponding Editor: William Cameron, Ottawa, Canada
KEYWORDS Ochrobactrum anthropi; Preterm infant; Peritoneal lavage catheter; Meconium peritonitis
Summary Ochrobactrum anthropi is a non-fermenting Gram-negative rod that was identified as a pathogenic microorganism during the past decade. O. anthropi is extensively distributed in the environment, and has been found in hospital and environmental water sources. O. anthropi infection is rare in childhood. We report a case of O. anthropi bacteremia in a preterm infant with a peritoneal lavage catheter and meconium peritonitis. # 2008 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Introduction
Case report
Ochrobactrum anthropi is an aerobic, motile, oxidase-positive bacterium that belongs to the group of non-Enterobacteriaceae, non-fermentative aerobic Gram-negative bacilli.1,2 O. anthropi is extensively distributed in the environment, and has been found in hospital and environmental water sources. It has been isolated from different specimens and might be part of the normal flora of the large intestine. The organism is presently considered to be an opportunistic pathogen. O. anthropi infection is rare in childhood and is usually associated with immunocompromised patients with indwelling catheters.1—3 To the best of our knowledge, there is one report in the literature of O. anthropi meningitis in a preterm infant.1 Here, we describe a case of O. anthropi bacteremia in a preterm infant with a peritoneal lavage catheter and meconium peritonitis.
A male preterm infant was born vaginally at 29 weeks of gestation to a 35-year-old gravida 1 mother who developed vaginal hemorrhage at 28 weeks of gestation. Apgar scores were 5 at 1 minute and 7 at 5 minutes. His birth weight was 1090 g (10—50th percentile); height 37.5 cm (10—50th percentile) and head circumference 27 cm (10—50th percentile). On admission to the Neonatal Unit, the infant was tachypneic and had severe retractions, nasal flaring and grunting. Chest radiography showed opaque lungs; therefore, one dose of surfactant was administered, and ampicillin and amikacin were commenced. Full blood count and biochemistry were normal. While he was receiving mechanical ventilation support, a blue-purple discoloration developed on the skin of his abdomen on day 2 postnatally. Pediatric surgeons carried out paracentesis and meconium was obtained as paracentesis material. Thus, he was diagnosed with necrotizing enterocolitis (NEC) stage III B and received metronidazole therapy additionally. Because of his clinical instability, a peritoneal lavage catheter was inserted and peritoneal irrigation was performed every four hours. O. anthropi was isolated from
¨ niversitesi Tıp Faku * Corresponding author. Trakya U ¨ltesi, C ¸ocuk ˘lıg ˘ı ve Hastalıkları Anabilim Dalı, 22030 Edirne, Tu Sag ¨rkiye. Tel.: +90 284 235 76 41x4917; fax: +90 284 235 23 38. E-mail address: [email protected] (R. Duran).
1201-9712/$36.00 # 2008 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2008.06.027
e62
Figure 1
R. Duran et al.
Abdominal radiograph showing intestinal perforation.
blood cultures obtained from two different peripheral veins on postnatal day 7 and culture from the peritoneal lavage catheter on postnatal day 11. O. anthropi was resistant to ampicillinsulbactam, cefepime, ceftriaxone, tobramycin, amikacin, aztreonam and trimethoprim-sulfamethoxazole, and was susceptible to ciprofloxacin, gentamicin and imipenem. Therefore, his antibiotic regime was changed to ciprofloxacin and gentamicin. On postnatal day 9, the blue-purple color of the skin on his abdomen increased. Abdominal X-ray examination revealed intestinal perforation (Figure 1). A new peritoneal lavage catheter was inserted and peritoneal irrigation was carried out. After one week of antimicrobial therapy, blood culture results were reported as sterile, so antibiotic treatment was continued for 14 days and then stopped. Following extubation on postnatal day 18, he developed abdominal distention and bilious vomiting. During surgery performed on postnatal day 19, a perforation in the ileal region and meconium particles in the abdominal cavity were noted. A 5 cm ileac segment was resected and a double-barrel ileostomy was performed. However, while on postoperative mechanical ventilation support, our patient died on postnatal day 26.
Discussion We describe a case of O. anthropi bacteremia in a preterm infant associated with a peritoneal lavage catheter, meconium ileus and meconium peritonitis. O. anthropi is a non-fermenting Gram-negative rod that was identified as a pathogenic microorganism during the past decade. Previously known as CDC group Vd, in 1988 it was classified as an independent group. Its differentiation from
other Gram-negative rods is difficult.2 O. anthropi resembles Pseudomonas aeruginosa, because it is water borne and might cause nosocomial infection. In addition, both species are Gram-negative, non-lactose-fermenting bacilli, and both grow well on McConkey agar. O. anthropi differs from Pseudomonas species in that it lacks pigment production and has peritrichous flagella.2 O. anthropi has been isolated from different specimens, such as blood, urine, stool, throat and wounds, and might be part of the normal flora of the large intestine. O. anthropi is an opportunist of low pathogenicity and generally affects immunocompromised patients with clinical devices. In more than half of the cases described in children, the patients were immunocompromised.1—3 The first case described in pediatrics was a 14-year-old boy with osteochondritis in 1987.4 The most common clinical manifestation of O. anthropi appears to be vascular catheter-related bacteremia; the first case of catheter-related bacteremia was reported in 1992 by Cieslak et al.5 Pyogenic infections have been related to foreign bodies, including meningitis and bone flap osteomyelitis after the implantation of contaminated allograft tissue, and endophthalmitis after vitreous surgery.5—7 Other reported infections include bacteremia in pediatric oncology patients and community-acquired infections in immunocompromised patients.3,8 Infections in normal hosts have been reported, including intravenous catheter infection, endocarditis and osteomyelitis.9,10 To date, there is only one report of a preterm infant with O. anthropi meningitis.1 Our case, however, concerned a preterm infant with O. anthropi bacteremia in association with a peritoneal lavage catheter and meconium peritonitis. There is no consensus about the best treatment for O. anthropi bacteremia. Monotherapy with an aminoglycoside or appropriate antibiotic has yielded good clinical response.3,8 Strains of O. anthropi are susceptible to trimethoprim-sulfamethoxazole, tetracycline, aminoglycosides and fluoroquinolones. Resistance to b-lactam antibiotics is common, although isolates susceptible to ceftriaxone, cefotaxime, cefoperazone and imipenem have occasionally been reported.3,8 However, treatment failure with imipenem has been reported, despite the in vitro susceptibility of the strains.11 Therefore, our patient was treated with ciprofloxacin and gentamicin in accordance with the antibiogram. In conclusion, we present the first case of O. anthropi bacteremia occurring in a preterm infant with a peritoneal lavage catheter, who had undergone intestinal surgery and suffered meconium peritonitis. Conflict of interest: No conflict of interest to declare. No fund used for our writing. No conflict of interest exists for our writing. No ethical approval needed for our writing.
References 1. Hay AJ, Lo TY. Ochrobactrum anthropi meningitis in a preterm neonate. J Infect 1999;38:134—5. 2. Saavedra J, Garrido C, Folgueira D, Torres MJ, Ramos JT. Ochrobactrum anthropi bacteremia associated with a catheter in an immunocompromised child and review of the pediatric literature. Pediatr Infect Dis J 1999;18:658—60. 3. Stiakaki E, Galanakis E, Samonis G, Christidou A, Maraka S, Tselentis Y, Kalmanti M. Ochrobactrum anthropi bacteremia in
Ochrobactrum anthropi bacteremia in a preterm infant
4.
5.
6.
7.
pediatric oncology patients. Pediatr Infect Dis J 2002;21: 72—4. Barson WJ, Cromer BA, Marcon MJ. Puncture wound osteochondritis of the foot caused by CDC group Vd. J Clin Microbiol 1987;25:2014—6. Cieslak TJ, Robb ML, Drabick CJ, Fischer GW. Catheter-associated sepsis caused by Ochrobactrum anthropi: report of a case and review of related nonfermentative bacteria. Clin Infect Dis 1992;14:902—7. Chang HJ, Christenson JC, Pavia AT, Bobrin BD, Bland LA, Carson LA, et al. Ochrobactrum anthropi meningitis in paediatric pericardial allograft transplant recipients. J Infect Dis 1996;173:656—60. Inoue K, Numaga J, Nagata Y, Sakurai M, Aso N, Fujino Y. Ochrobactrum anthropi endophthalmitis after vitreous surgery. Br J Ophthalmol 1999;83:502.
e63 8. Yu WL, Lin CW, Wang DY. Clinical and microbiologic characteristics of Ochrobactrum anthropi bacteremia. J Formos Med Assoc 1998;97:106—12. 9. Gill MV, Ly H, Mueenuddin M, Schoch PE, Cunha BA. Intravenous line infection due to Ochrobactrum anthropi (CDC group Vd) in a normal host. Heart Lung 1997;26: 335—6. 10. Mahmood MS, Sarwari AR, Khan MA, Sophie Z, Khan E, Sami S. Infective endocarditis and septic embolization with Ochrobactrum anthropi: case report and review of literature. J Infect 2000;40:287—90. 11. Kern WV, Oethinger M, Kaufhold A, Rozdzinski E, Marre R. Ochrobactrum anthropi bacteremia: report of four cases and short review. Infection 1993;21:306—10.
http://intl.elsevierhealth.com/journals/ijid
CASE REPORT
Ochrobactrum anthropi bacteremia in a preterm infant with meconium peritonitis ¨ mit N. Bas¸aran b ¨ lfet Vatansever a, Betu Rıdvan Duran a,*, U ¨l Acunas¸ a, U a b
Trakya University Faculty of Medicine, Department of Pediatrics, Edirne, Turkey Trakya University Faculty of Medicine, Department of Pediatric Surgery, Edirne, Turkey
Received 19 February 2008; received in revised form 11 June 2008; accepted 28 June 2008 Corresponding Editor: William Cameron, Ottawa, Canada
KEYWORDS Ochrobactrum anthropi; Preterm infant; Peritoneal lavage catheter; Meconium peritonitis
Summary Ochrobactrum anthropi is a non-fermenting Gram-negative rod that was identified as a pathogenic microorganism during the past decade. O. anthropi is extensively distributed in the environment, and has been found in hospital and environmental water sources. O. anthropi infection is rare in childhood. We report a case of O. anthropi bacteremia in a preterm infant with a peritoneal lavage catheter and meconium peritonitis. # 2008 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Introduction
Case report
Ochrobactrum anthropi is an aerobic, motile, oxidase-positive bacterium that belongs to the group of non-Enterobacteriaceae, non-fermentative aerobic Gram-negative bacilli.1,2 O. anthropi is extensively distributed in the environment, and has been found in hospital and environmental water sources. It has been isolated from different specimens and might be part of the normal flora of the large intestine. The organism is presently considered to be an opportunistic pathogen. O. anthropi infection is rare in childhood and is usually associated with immunocompromised patients with indwelling catheters.1—3 To the best of our knowledge, there is one report in the literature of O. anthropi meningitis in a preterm infant.1 Here, we describe a case of O. anthropi bacteremia in a preterm infant with a peritoneal lavage catheter and meconium peritonitis.
A male preterm infant was born vaginally at 29 weeks of gestation to a 35-year-old gravida 1 mother who developed vaginal hemorrhage at 28 weeks of gestation. Apgar scores were 5 at 1 minute and 7 at 5 minutes. His birth weight was 1090 g (10—50th percentile); height 37.5 cm (10—50th percentile) and head circumference 27 cm (10—50th percentile). On admission to the Neonatal Unit, the infant was tachypneic and had severe retractions, nasal flaring and grunting. Chest radiography showed opaque lungs; therefore, one dose of surfactant was administered, and ampicillin and amikacin were commenced. Full blood count and biochemistry were normal. While he was receiving mechanical ventilation support, a blue-purple discoloration developed on the skin of his abdomen on day 2 postnatally. Pediatric surgeons carried out paracentesis and meconium was obtained as paracentesis material. Thus, he was diagnosed with necrotizing enterocolitis (NEC) stage III B and received metronidazole therapy additionally. Because of his clinical instability, a peritoneal lavage catheter was inserted and peritoneal irrigation was performed every four hours. O. anthropi was isolated from
¨ niversitesi Tıp Faku * Corresponding author. Trakya U ¨ltesi, C ¸ocuk ˘lıg ˘ı ve Hastalıkları Anabilim Dalı, 22030 Edirne, Tu Sag ¨rkiye. Tel.: +90 284 235 76 41x4917; fax: +90 284 235 23 38. E-mail address: [email protected] (R. Duran).
1201-9712/$36.00 # 2008 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2008.06.027
e62
Figure 1
R. Duran et al.
Abdominal radiograph showing intestinal perforation.
blood cultures obtained from two different peripheral veins on postnatal day 7 and culture from the peritoneal lavage catheter on postnatal day 11. O. anthropi was resistant to ampicillinsulbactam, cefepime, ceftriaxone, tobramycin, amikacin, aztreonam and trimethoprim-sulfamethoxazole, and was susceptible to ciprofloxacin, gentamicin and imipenem. Therefore, his antibiotic regime was changed to ciprofloxacin and gentamicin. On postnatal day 9, the blue-purple color of the skin on his abdomen increased. Abdominal X-ray examination revealed intestinal perforation (Figure 1). A new peritoneal lavage catheter was inserted and peritoneal irrigation was carried out. After one week of antimicrobial therapy, blood culture results were reported as sterile, so antibiotic treatment was continued for 14 days and then stopped. Following extubation on postnatal day 18, he developed abdominal distention and bilious vomiting. During surgery performed on postnatal day 19, a perforation in the ileal region and meconium particles in the abdominal cavity were noted. A 5 cm ileac segment was resected and a double-barrel ileostomy was performed. However, while on postoperative mechanical ventilation support, our patient died on postnatal day 26.
Discussion We describe a case of O. anthropi bacteremia in a preterm infant associated with a peritoneal lavage catheter, meconium ileus and meconium peritonitis. O. anthropi is a non-fermenting Gram-negative rod that was identified as a pathogenic microorganism during the past decade. Previously known as CDC group Vd, in 1988 it was classified as an independent group. Its differentiation from
other Gram-negative rods is difficult.2 O. anthropi resembles Pseudomonas aeruginosa, because it is water borne and might cause nosocomial infection. In addition, both species are Gram-negative, non-lactose-fermenting bacilli, and both grow well on McConkey agar. O. anthropi differs from Pseudomonas species in that it lacks pigment production and has peritrichous flagella.2 O. anthropi has been isolated from different specimens, such as blood, urine, stool, throat and wounds, and might be part of the normal flora of the large intestine. O. anthropi is an opportunist of low pathogenicity and generally affects immunocompromised patients with clinical devices. In more than half of the cases described in children, the patients were immunocompromised.1—3 The first case described in pediatrics was a 14-year-old boy with osteochondritis in 1987.4 The most common clinical manifestation of O. anthropi appears to be vascular catheter-related bacteremia; the first case of catheter-related bacteremia was reported in 1992 by Cieslak et al.5 Pyogenic infections have been related to foreign bodies, including meningitis and bone flap osteomyelitis after the implantation of contaminated allograft tissue, and endophthalmitis after vitreous surgery.5—7 Other reported infections include bacteremia in pediatric oncology patients and community-acquired infections in immunocompromised patients.3,8 Infections in normal hosts have been reported, including intravenous catheter infection, endocarditis and osteomyelitis.9,10 To date, there is only one report of a preterm infant with O. anthropi meningitis.1 Our case, however, concerned a preterm infant with O. anthropi bacteremia in association with a peritoneal lavage catheter and meconium peritonitis. There is no consensus about the best treatment for O. anthropi bacteremia. Monotherapy with an aminoglycoside or appropriate antibiotic has yielded good clinical response.3,8 Strains of O. anthropi are susceptible to trimethoprim-sulfamethoxazole, tetracycline, aminoglycosides and fluoroquinolones. Resistance to b-lactam antibiotics is common, although isolates susceptible to ceftriaxone, cefotaxime, cefoperazone and imipenem have occasionally been reported.3,8 However, treatment failure with imipenem has been reported, despite the in vitro susceptibility of the strains.11 Therefore, our patient was treated with ciprofloxacin and gentamicin in accordance with the antibiogram. In conclusion, we present the first case of O. anthropi bacteremia occurring in a preterm infant with a peritoneal lavage catheter, who had undergone intestinal surgery and suffered meconium peritonitis. Conflict of interest: No conflict of interest to declare. No fund used for our writing. No conflict of interest exists for our writing. No ethical approval needed for our writing.
References 1. Hay AJ, Lo TY. Ochrobactrum anthropi meningitis in a preterm neonate. J Infect 1999;38:134—5. 2. Saavedra J, Garrido C, Folgueira D, Torres MJ, Ramos JT. Ochrobactrum anthropi bacteremia associated with a catheter in an immunocompromised child and review of the pediatric literature. Pediatr Infect Dis J 1999;18:658—60. 3. Stiakaki E, Galanakis E, Samonis G, Christidou A, Maraka S, Tselentis Y, Kalmanti M. Ochrobactrum anthropi bacteremia in
Ochrobactrum anthropi bacteremia in a preterm infant
4.
5.
6.
7.
pediatric oncology patients. Pediatr Infect Dis J 2002;21: 72—4. Barson WJ, Cromer BA, Marcon MJ. Puncture wound osteochondritis of the foot caused by CDC group Vd. J Clin Microbiol 1987;25:2014—6. Cieslak TJ, Robb ML, Drabick CJ, Fischer GW. Catheter-associated sepsis caused by Ochrobactrum anthropi: report of a case and review of related nonfermentative bacteria. Clin Infect Dis 1992;14:902—7. Chang HJ, Christenson JC, Pavia AT, Bobrin BD, Bland LA, Carson LA, et al. Ochrobactrum anthropi meningitis in paediatric pericardial allograft transplant recipients. J Infect Dis 1996;173:656—60. Inoue K, Numaga J, Nagata Y, Sakurai M, Aso N, Fujino Y. Ochrobactrum anthropi endophthalmitis after vitreous surgery. Br J Ophthalmol 1999;83:502.
e63 8. Yu WL, Lin CW, Wang DY. Clinical and microbiologic characteristics of Ochrobactrum anthropi bacteremia. J Formos Med Assoc 1998;97:106—12. 9. Gill MV, Ly H, Mueenuddin M, Schoch PE, Cunha BA. Intravenous line infection due to Ochrobactrum anthropi (CDC group Vd) in a normal host. Heart Lung 1997;26: 335—6. 10. Mahmood MS, Sarwari AR, Khan MA, Sophie Z, Khan E, Sami S. Infective endocarditis and septic embolization with Ochrobactrum anthropi: case report and review of literature. J Infect 2000;40:287—90. 11. Kern WV, Oethinger M, Kaufhold A, Rozdzinski E, Marre R. Ochrobactrum anthropi bacteremia: report of four cases and short review. Infection 1993;21:306—10.