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Clinical Resistance to Amoxicillin of a Gravidic Urinary Tract Infection Caused by Neisseria mucosa
160
Letters to the Editor
American Indian male with primary actinomycosis of the greater omentum, as in our patient. Based upon our patient's history and especially upon our operative findings, we believe that inoculation of the organism in the omentum occurred by haematogenous spread. Such a spread, although unusual, is possible.7 Penicillin is the antibiotic of choice but other chemotherapeutic agents (tetracycline, erythromycin, clindamycin, imipenem etc.) are effective alternatives in patients who do not respond or are allergic to penicillin.2,5,7 Surgery, apart its valuable contribution to the diagnosis of the disease, remains an important therapeutic adjunct.7 Although nowadays surgery is usually limited to incision and drainage with curettage of large abscesses, radical surgical treatment can be applied in some cases.3 The combination of antibiotics with the appropriate surgical approach remains the mainstay of therapy for abdominal actinomycosis. A. J. Papachristodoulou1, D. C. Angouras1, V. G. Papavassiliou1,*, J. K. Delladetsima2, Ch. J. Markopoulos1, and J. G. Gogas 1 Second Department of Propedeutic Surgery, Athens University Medical School, Laiko Hospital and 2Department of Pathology, Laiko Hospital, Athens, Greece *Correspondence: Vassilios G Papavassiliou 2 Cedar Court Walnut Street Residences, Walnut Street, Leicester, LE2 7GJ, U.K. Fax: 0116-2523179
References 1 Bronner M, Bronner M. Actinomycosis. 2nd edn. Bristol: John Wright & Sons, Ltd., 1971. 2 Davies M, Keddie NC: Abdominal actinomycosis. Br J Surg 1973: 60: 18±22. 3 Miller BJ, Wrigth JL, Colquhoun BPD. Some etiologic concepts of actinomycosis of the greater omentum. Surg Gynecol Obstet 1978;146: 412±414. 4 Hylton RP, Samuels HS, Oates GW Jr. Actinomycosis ± is it really rare? Oral Surg 1970; 29: 138±147. 5 Deshmukh N, Heaney SJ. Actinomycosis at multiple colonic sites. Am J Gastroenterol 1986; S1: 1212±1214. 6 Weese WC, Smith IM. A study of 57 cases of actinomycosis over a 36year period. A diagnostic `failure' with good prognosis after treatment. Arch Intern Med 1975; 135: 1562±1568. 7 Spinola SM, Bell A, Henderson FW. Actinomycosis: A cause of pulmonary and mediastinal mass lesions in children. Am J Dis Child 1981; 135: 336±339. Accepted for publication 6 July 2001. doi:10.1053/jinf.2001.0895, available online at http://www.idealibrary.com on
Clinical Resistance to Amoxicillin of a Gravidic Urinary Tract Infection Caused by Neisseria mucosa Sir, Neisseria mucosa is usually found in the commensal flora of the oropharynx and considered non-pathogenic. There have been
numerous reports of its involvement in infective endocarditis,1 articular infections2 and meningitis.3 To our knowledge, commensal Neisseriae have been reported twice in urinary tract infections,4,5 and once as complicating pregnancy.6 We report the first case of gravidic urinary tract infection with N. mucosa. A 23-year-old pregnant woman from Zambia, with a previous medical history of heterozygous sickle-cell anaemia, was followed for her fourth pregnancy. Previous pregnancies were unremarkable except for the third which featured a Klebsiella pneumoniae urinary tract infection. At 19 weeks of amenorrhoea, the patient presented with a left pyelonephritis caused by an oxacillin-susceptible Staphylococcus aureus isolated from urine culture. Antibiotherapy originally aimed at Gram-negative rods was revised with in total 3 days of netilmicin 180 mg twice daily and cefotaxime 1 g thrice daily, and oxacillin 1 g thrice daily for 11 days (3 days IV, 8 days PO). The aetiologic work-up showed unimpaired renal function. The renal echogram was unremarkable considering the ongoing pregnancy and urodynamic investigations were normal. Regular urine cultures were performed every week and remained sterile until the 32nd week of amenorrhoea. A urinary tract infection was then diagnosed with 740/mm3 leukocytes and a pure culture of >106 colony forming units (CFU) of Gramnegative cocci identified as non beta-lactamase producing N. mucosa using the NEISSERIA 4H test (Biorad, Marnes la Coquette, France) confirmed by the Centre National de ReÂfeÂrence, Institut Pasteur, Paris, France. In the absence of clinical symptoms and aware of the non-pathogenic behaviour of this micro-organism, a urinary antiseptic (nitrofuratoin) was administered for 10 days. A control urine culture at 35 weeks of amenorrhoea revealed more than 1000/mm3 leukocytes with >106 CFU N. mucosa, still without any clinical complaints. Minimal inhibitory concentrations (MICs) of beta-lactam antibiotics against this N. mucosa strain were assayed with the E-Test method (AB Biodisk, Solna, Sweden). Benzylpenicillin, amoxicillin, and cefotaxime MICs were 1.0 mg/ml, 1.0 mg/ml, and 0.19 mg/ml respectively, indicating susceptibility according to published guidelines. Oral amoxicillin 1 g twice daily was administered for 15 days. At 38 weeks of amenorrhoea, control urine culture showed 110/mm3 leukocytes, and >106 CFU N. mucosa. Amoxicillin dosage was raised to 1 g thrice daily. Vaginal delivery occurred at 39 weeks of amenorrhoea under this treatment with no complications. A urine culture on the second day postpartum showed 170 leukocytes/mm3 and thepersistence of N. mucosa. The patient was discharged the next day and was lost to follow-up. The patient had recognized risk factors for gravidic bacteriuria: a history of gravidic urinary tract infections in the course of both this pregnancy and the previous one, and sickle-cell trait.7 Still, the persistent infection of the urinary tract with N. mucosa, a normally commensal micro-organism, in an immunocompetent patient is intriguing. Neisseria spp. are generally reported to be susceptible to betalactams, and the MICs we determined were in the range1 usually reported for N. mucosa. The infection resisted treatment despite repeated courses of amoxicillin. The ease of sampling in the case of urinary tract infection allowed confirmation of microbiological failure. The lack of correlation between in-vitro susceptibility and clinical outcome under theoretically adequate antibiotherapy should lead to caution. Specific susceptibility breakpoints are defined for amoxicillin against Neisseria meningitidis and Neisseria gonorrhoeae (0.25 mg/ml and 2 mg/ml)
Letters to the Editor in order to take into account the possibility of decreased susceptibility of these organisms to beta-lactams through the horizontal transfer of genetic material encoding penicillin binding proteins from commensal species.8 Since no provision is made for the commensal Neisseriae, the default breakpoints published for amoxicillin (4 mg/ml and 16 mg/ml) are usually applied. This case suggests that the breakpoints specifically defined for N. meningitidis and N. gonorrhoeae could be extended to the rest of the genus Neisseria. B. Hanau-BercËot1,*, M. Rottman1,3, L. Raskine1, D. Jacob2, G. Barnaud1, A. Gabarre1 and M.-J. Sanson Le Pors1 1 Laboratoire de BacteÂriologie-Virologie, 2 Service de GyneÂcologie-ObsteÂtrique, HoÃpital LariboisieÁre, 2 rue Ambroise PareÂ, 75475 Paris Cedex10, 3 Laboratoire de Microbiologie, HoÃpital Raymond PoincareÂ, 104 Bd Raymond PoincareÂ, 92380, Garches, France. *Corresponding author.
2 Van Linthoudt D, Modde H, Ott H. Neisseria mucosa septic arthritis. Br J Rheumatol 1987; 26: 314. 3 Stotka JL, Rupp ME, Meier FA, Markowitz SM. Meningitis due to Neisseria mucosa: case report and review. Rev Infect Dis 1991; 13: 837±841. 4 Garcia SD, Descole EM, Famiglietti AM, Lopez EG, Vag CA. Infection of the urinary tract caused by Neisseria cinerea. Enferm Infecc Microbiol Clin 1996; 14: 576. 5 Janda WM, Senseng C, Todd KM, Schreckenberger PC. Asymptomatic Neisseria subflava biovar perflava bacteriuria in a child with obstructive uropathy. Eur J Clin Microbiol Infect Dis 1993; 12: 540±542. 6 Deger R, Ludmir J. Neisseria sicca endocarditis complicating pregnancy, a case report. J Reprod Med 1992; 5: 473±475. 7 Pastore LM, Savitz DA, Thorp JM. Predictors of urinary tract infection at the first prenatal visit. Epidemiology 1999; 10: 282±287. 8 Bowler LD, Zhang QY, Riou JY, Spratt BG. Interspecies recombination between the penA genes of Neisseria meningitidis and commensal Neisseria species during the emergence of penicillin resistance in N. meningitidis: natural events and laboratory simulation. J Bacteriol 1994; 176: 333±337. Accepted for publication 24 July 2001
References 1 Ingram RJH, Cornere B, Ellis-Pegler RB. Endocarditis due to Neisseria mucosa: two case reports and review. Clin Infect Dis 1992; 15: 321±324.
161
Letters to the Editor
American Indian male with primary actinomycosis of the greater omentum, as in our patient. Based upon our patient's history and especially upon our operative findings, we believe that inoculation of the organism in the omentum occurred by haematogenous spread. Such a spread, although unusual, is possible.7 Penicillin is the antibiotic of choice but other chemotherapeutic agents (tetracycline, erythromycin, clindamycin, imipenem etc.) are effective alternatives in patients who do not respond or are allergic to penicillin.2,5,7 Surgery, apart its valuable contribution to the diagnosis of the disease, remains an important therapeutic adjunct.7 Although nowadays surgery is usually limited to incision and drainage with curettage of large abscesses, radical surgical treatment can be applied in some cases.3 The combination of antibiotics with the appropriate surgical approach remains the mainstay of therapy for abdominal actinomycosis. A. J. Papachristodoulou1, D. C. Angouras1, V. G. Papavassiliou1,*, J. K. Delladetsima2, Ch. J. Markopoulos1, and J. G. Gogas 1 Second Department of Propedeutic Surgery, Athens University Medical School, Laiko Hospital and 2Department of Pathology, Laiko Hospital, Athens, Greece *Correspondence: Vassilios G Papavassiliou 2 Cedar Court Walnut Street Residences, Walnut Street, Leicester, LE2 7GJ, U.K. Fax: 0116-2523179
References 1 Bronner M, Bronner M. Actinomycosis. 2nd edn. Bristol: John Wright & Sons, Ltd., 1971. 2 Davies M, Keddie NC: Abdominal actinomycosis. Br J Surg 1973: 60: 18±22. 3 Miller BJ, Wrigth JL, Colquhoun BPD. Some etiologic concepts of actinomycosis of the greater omentum. Surg Gynecol Obstet 1978;146: 412±414. 4 Hylton RP, Samuels HS, Oates GW Jr. Actinomycosis ± is it really rare? Oral Surg 1970; 29: 138±147. 5 Deshmukh N, Heaney SJ. Actinomycosis at multiple colonic sites. Am J Gastroenterol 1986; S1: 1212±1214. 6 Weese WC, Smith IM. A study of 57 cases of actinomycosis over a 36year period. A diagnostic `failure' with good prognosis after treatment. Arch Intern Med 1975; 135: 1562±1568. 7 Spinola SM, Bell A, Henderson FW. Actinomycosis: A cause of pulmonary and mediastinal mass lesions in children. Am J Dis Child 1981; 135: 336±339. Accepted for publication 6 July 2001. doi:10.1053/jinf.2001.0895, available online at http://www.idealibrary.com on
Clinical Resistance to Amoxicillin of a Gravidic Urinary Tract Infection Caused by Neisseria mucosa Sir, Neisseria mucosa is usually found in the commensal flora of the oropharynx and considered non-pathogenic. There have been
numerous reports of its involvement in infective endocarditis,1 articular infections2 and meningitis.3 To our knowledge, commensal Neisseriae have been reported twice in urinary tract infections,4,5 and once as complicating pregnancy.6 We report the first case of gravidic urinary tract infection with N. mucosa. A 23-year-old pregnant woman from Zambia, with a previous medical history of heterozygous sickle-cell anaemia, was followed for her fourth pregnancy. Previous pregnancies were unremarkable except for the third which featured a Klebsiella pneumoniae urinary tract infection. At 19 weeks of amenorrhoea, the patient presented with a left pyelonephritis caused by an oxacillin-susceptible Staphylococcus aureus isolated from urine culture. Antibiotherapy originally aimed at Gram-negative rods was revised with in total 3 days of netilmicin 180 mg twice daily and cefotaxime 1 g thrice daily, and oxacillin 1 g thrice daily for 11 days (3 days IV, 8 days PO). The aetiologic work-up showed unimpaired renal function. The renal echogram was unremarkable considering the ongoing pregnancy and urodynamic investigations were normal. Regular urine cultures were performed every week and remained sterile until the 32nd week of amenorrhoea. A urinary tract infection was then diagnosed with 740/mm3 leukocytes and a pure culture of >106 colony forming units (CFU) of Gramnegative cocci identified as non beta-lactamase producing N. mucosa using the NEISSERIA 4H test (Biorad, Marnes la Coquette, France) confirmed by the Centre National de ReÂfeÂrence, Institut Pasteur, Paris, France. In the absence of clinical symptoms and aware of the non-pathogenic behaviour of this micro-organism, a urinary antiseptic (nitrofuratoin) was administered for 10 days. A control urine culture at 35 weeks of amenorrhoea revealed more than 1000/mm3 leukocytes with >106 CFU N. mucosa, still without any clinical complaints. Minimal inhibitory concentrations (MICs) of beta-lactam antibiotics against this N. mucosa strain were assayed with the E-Test method (AB Biodisk, Solna, Sweden). Benzylpenicillin, amoxicillin, and cefotaxime MICs were 1.0 mg/ml, 1.0 mg/ml, and 0.19 mg/ml respectively, indicating susceptibility according to published guidelines. Oral amoxicillin 1 g twice daily was administered for 15 days. At 38 weeks of amenorrhoea, control urine culture showed 110/mm3 leukocytes, and >106 CFU N. mucosa. Amoxicillin dosage was raised to 1 g thrice daily. Vaginal delivery occurred at 39 weeks of amenorrhoea under this treatment with no complications. A urine culture on the second day postpartum showed 170 leukocytes/mm3 and thepersistence of N. mucosa. The patient was discharged the next day and was lost to follow-up. The patient had recognized risk factors for gravidic bacteriuria: a history of gravidic urinary tract infections in the course of both this pregnancy and the previous one, and sickle-cell trait.7 Still, the persistent infection of the urinary tract with N. mucosa, a normally commensal micro-organism, in an immunocompetent patient is intriguing. Neisseria spp. are generally reported to be susceptible to betalactams, and the MICs we determined were in the range1 usually reported for N. mucosa. The infection resisted treatment despite repeated courses of amoxicillin. The ease of sampling in the case of urinary tract infection allowed confirmation of microbiological failure. The lack of correlation between in-vitro susceptibility and clinical outcome under theoretically adequate antibiotherapy should lead to caution. Specific susceptibility breakpoints are defined for amoxicillin against Neisseria meningitidis and Neisseria gonorrhoeae (0.25 mg/ml and 2 mg/ml)
Letters to the Editor in order to take into account the possibility of decreased susceptibility of these organisms to beta-lactams through the horizontal transfer of genetic material encoding penicillin binding proteins from commensal species.8 Since no provision is made for the commensal Neisseriae, the default breakpoints published for amoxicillin (4 mg/ml and 16 mg/ml) are usually applied. This case suggests that the breakpoints specifically defined for N. meningitidis and N. gonorrhoeae could be extended to the rest of the genus Neisseria. B. Hanau-BercËot1,*, M. Rottman1,3, L. Raskine1, D. Jacob2, G. Barnaud1, A. Gabarre1 and M.-J. Sanson Le Pors1 1 Laboratoire de BacteÂriologie-Virologie, 2 Service de GyneÂcologie-ObsteÂtrique, HoÃpital LariboisieÁre, 2 rue Ambroise PareÂ, 75475 Paris Cedex10, 3 Laboratoire de Microbiologie, HoÃpital Raymond PoincareÂ, 104 Bd Raymond PoincareÂ, 92380, Garches, France. *Corresponding author.
2 Van Linthoudt D, Modde H, Ott H. Neisseria mucosa septic arthritis. Br J Rheumatol 1987; 26: 314. 3 Stotka JL, Rupp ME, Meier FA, Markowitz SM. Meningitis due to Neisseria mucosa: case report and review. Rev Infect Dis 1991; 13: 837±841. 4 Garcia SD, Descole EM, Famiglietti AM, Lopez EG, Vag CA. Infection of the urinary tract caused by Neisseria cinerea. Enferm Infecc Microbiol Clin 1996; 14: 576. 5 Janda WM, Senseng C, Todd KM, Schreckenberger PC. Asymptomatic Neisseria subflava biovar perflava bacteriuria in a child with obstructive uropathy. Eur J Clin Microbiol Infect Dis 1993; 12: 540±542. 6 Deger R, Ludmir J. Neisseria sicca endocarditis complicating pregnancy, a case report. J Reprod Med 1992; 5: 473±475. 7 Pastore LM, Savitz DA, Thorp JM. Predictors of urinary tract infection at the first prenatal visit. Epidemiology 1999; 10: 282±287. 8 Bowler LD, Zhang QY, Riou JY, Spratt BG. Interspecies recombination between the penA genes of Neisseria meningitidis and commensal Neisseria species during the emergence of penicillin resistance in N. meningitidis: natural events and laboratory simulation. J Bacteriol 1994; 176: 333±337. Accepted for publication 24 July 2001
References 1 Ingram RJH, Cornere B, Ellis-Pegler RB. Endocarditis due to Neisseria mucosa: two case reports and review. Clin Infect Dis 1992; 15: 321±324.
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