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Kingella kingae bacteremia
spection and accreditation checklist, and enrollment in appropriate proficiency test programs. Other accreditation requirements are not relevant to this discussion. Struggling with the process of responding to the checklist items is sometimes puzzling, as some items are so specific while others are so general. It may be helpful to review part of the process by which these items are derived. The CAP laboratory accreditation process has been in existence for many years, even before the specific mandate of the Clinical Laboratory Improvement Act of 1967. Originally, the program was designed to bring uniformity to certain aspects of laboratory practice and to set goals to help the laboratory function at a high level of competence. At first, accreditation had an extremely useful educational function but, with the passage of specific federal and state legislation, the guidelines gradually took on a regulatory aspect that had not been envisioned. At present, the CAP Commission on Laboratory Accreditation works closely with federal agencies to ensure that the checklist items conform with regulatory expectations and that they are at least as stringent as the requirements in the regulations. Therefore, a number of constraints are placed on that Commission in terms of how far it can move without jeopardizing the accreditation process as viewed by federal agencies. Some states have their own accreditation process, which may be different from the CAP program. Generally, however, the inspection and accreditation checklist serves as a reasonable guide for a clinical laboratory standard of practice. The above comments notwith-
standing, a conscious effort has been made to prevent checklist items from becoming a specific standard of practice in all laboratory areas. The accreditation program involves thousands of laboratories of different sizes, geographic locations, and expertise. The checklist must remain sufficiently general so that some functions common to all laboratories can be considered, but at the same time ensure that practices appropriate for a large city hospital are not imposed on a small rural hospital. For these reasons, certain items of the checklist are very specific in areas that might be considered trivial or simply bookkeeping, but for procedures such as blood culture techniques, they are fairly general. An attempt is made not to favor one technique or manufacturer over another unless there is unequivocal agreement that a certain standardization is appropriate. For example, in the area of antimicrobial susceptibility testing, there is agreement that the standards promulgated by the National Committee for Clinical Laboratory Standards are appropriate for clinical practice; therefore, a number of questions relate to use of these standards. However, the checklist is not designed to evaluate every aspect of a standard method. General laboratory activities are evaluated, especially in regard to adequate documentation of laboratory functions, without being specific as to what those functions should be. Each individual has a preferred way of performing a particular diagnostic procedure, but all those varieties of artistry and creativity cannot be included in such a document. Reasonable questions can be raised, however, when a specific technique is
used and the accreditation guidelines appear to be biased against it. How should a laboratory director proceed under those circumstances? At least two options are available and both of them should be explored. The first is to document the performance of a specific method in the laboratory. For example, if laboratories are able to document that less frequent testing of quality-control specimens or less frequent testing of staining reagents is a good standard of practice in that laboratory, then the documentation can be forwarded to the original inspector when these deficiencies are noted for the laboratory. Another mechanism that should be considered is to communicate directly with the Commission on Laboratory Accreditation and request feedback from the appropriate CAP scientific resource committee as to the appropriateness of a procedure. Usually, questions in the area of microbiology are referred to the Microbiology Resource Committee, one of whose functions is to serve as a scientific adviser and reference for the inspection committee. The Microbiology Resource Committee may then make a recommendation to the Commission on Laboratory Accreditation that a specific checklist item be changed or modified. If such a modification can be shown to be scientifically sound and not in conflict with regulatory demands, then the change is usually made. Many thoughtful and co_n_st~ctive changes have been made to the checklist by individuals responding to the accreditation process in this way. The CAP welcomes this type of scientific input because, if it benefits one laboratory, it may benefit others as well.
A 43-year-old man on hemodialysis for chronic renal failure secondary to hypertension presented to the hospital with a 4-day history of fever, nausea, vomiting, and diarrhea. The patient was in mild distress, and physical examination revealed a pulse and blood pressure of 76 beats per minute and 165/90 mm Hg, respectively, a temper-
ature of 101.5°F, hyperactive bowel sounds, and poor dentition. Laboratory data revealed a white blood cell count of 9,400/mm 3 (63% polymorphonuclear leukocytes, 17% band cells, 8% lymphocytes, 8% monocytes, 1% eosinophils, and 3% atypical lymphocytes; occasional toxic granulations were noted), and metabolic findings were
Case Report
Kingella kingae Bacteremia Mary C. O'Connor, M.D. Robert E. Sperry, M.D. Cynthia A. Burdick, BSMT, ASCP Christopher J. Papasian, Ph.D. Veterans Administration Medical Center
Kansas City, MO 64128
142 IIIIIJIL
.........
0196-4399/89/$0.00 + 02.20
© 1989 Elsevier Science Publishing Co., Inc.
Clinical Microbiology Newsletter 11:18, 1989
consistent with chronic renal failure. The patient was believed to suffer from a viral enteritis and was not admitted for further evaluation, nor was specific therapy initiated; however, a blood specimen was collected and inoculated into one set (aerobic and anaerobic) of blood culture bottles (BACTEC; Becton Dickinson Diagnostic Instrument Systems, Towson, MD). By the time the patient presented for dialysis two days later, his clinical symptoms were much improved. However, a gramnegative coccobacillus had been recovered from the aerobic blood culture bottle; repeat blood cultures were not collected at this time because of the patient's improved clinical status. The organism, subsequently identified as Kingella kingae, was susceptible to ampicillin, cefazolin, gentamicin, and trimethoprim/sulfamethoxazole by the disk diffusion method. Although the patient was thought to have had a transient bacteremia and most likely would have continued to recover without antimicrobial therapy, he received gentamicin intravenously (120 mg loading dose followed by 80 mg every other day following dialysis). All symptoms resolved without complications. Gentamicin was administered because the patient was anephric and, therefore, the risk of neprotoxicity was absent. Although aminoglycosides are normally excreted by the kidneys, the antimicrobial agent was removed primarily by hemodialysis in this patient. Therefore, the serum half-life was prolonged, and he could be given this agent when he came every other day for his hemodialysis. K. kingae is a fastidious, gram-negative coccobacillus in the family Neisseriaceae. It is oxidase-positive, nonmotile, and an obligate aerobe, and it degrades glucose. First described by King in 1966 and classified as Moraxella New Species 1, it is an occasional inhabitant of the nasopharynx. The genus Kingella includes two additional species: Kingella denitrificans and Kingella indologenes. K. kingae produces beta hemolysis on sheep blood agar, and two colony morphotypes can be seen: one is pinpoint, smooth, and convex with a well-defined margin, and the other is a larger colony type that
Clinical Microbiology Newsletter 11:18, 1989
corrodes or pits the agar surface. Both morphotypes may be seen on the same plate. Key characteristics that differentiate K. kingae from phenotypically similar organisms are its beta hemolysis, negative urease, catalase and indole reactions, and its ability to degrade maltose (1, 2). The organism was initially described as a rare cause of osteomyelitis, arthritis, and endocarditis in children. However, as recognition of its pathogenicity emerged, an increasing number of infections in adults has been reported. Most adult patients have presented with endocarditis and have a history of an underlying disease. Commonly reported antecedent illnesses or physical findings include upper respiratory tract illnesses, stomatitis, recent dental work, or poor dentition. In view of our patient's preceding gastrointestinal complaints, it was interesting to note that only two other patients were reported to have had preceding gastrointestinal symptoms: a 62year-old female who developed endocarditis after presumed gastroenteritis secondary to food poisoning (2) and a 15-month-old male with vomiting and diarrhea associated with occult bacteremia (1). No studies were done to specifically identify K. kingae in either patient's stool specimens. Osteomyelitis involving K. kingae has been reported only in children and is described as insidious and indolent. Septic arthritis, on the other hand, has been reported in all age groups and appears to have a more acute course. Discitis is a frequent complication of Kingella infections in children (3). All bone and joint cases were successfully treated with medical management, including antibiotic therapy (1, 3-5). Endocarditis caused by this bacterium often produces a very stormy clinical course and occurs in patients over a wide distribution of ages. Approximately 60% of all patients had underlying congenital or valvular anomalies (1, 2, 6, 7). Severe complications include residual neurologic deficits secondary to embolization of vegetations, and/or death despite adequate antibiotic therapy. Including the currently presented case, seven episodes of bacteremia
© 1989 Elsevier Science Publishing Co., Inc.
have been reported without an associated focus of infection (1, 2). In four cases, patients improved clinically or were asymptomatic by the time treatment was initiated. Two patients never required therapy, and all cases had a favorable outcome. One case of meningitis was seen in a patient with sickle cell anemia (6). Antimicrobial susceptibility test of K. kingae strains recovered from clinical cases have shown the organism to be susceptible to a wide range of antibiotics. The standard recommended therapy includes either penicillin or ampicillin; however, the organism is usually susceptible to the cephalosporins, imipenem, the aminoglycosides, and trimethoprim/sulfamethoxazole. Studies have shown variable susceptibilities to clindamycin, erythromycin, and chloramphenicol (1-7). Infections with K. kingae have a wide range of clinical expression. The increasing number of reported cases suggests that it is a significant human pathogen in those with or without underlying disease.
References 1. Claesson, A., E. Falsen, and B. Kjellman. 1985. Kingella kingae infections: a review and a presentation of data from ten Swedish cases. Scand. J. Infect. Dis. 17:233-243. 2. Verbruggen, A. M. et al. 1986. Infections caused by Kingella kingae: report of four cases and review. J. Infect. 13:133-142. 3. Woolfrey, B. F., R. T. Lally, and R. J. Faville. 1986. Intervertebral discitis caused by Kingella kingae. Am. J. Clin. Pathol. 85:745-749. 4. Salminen, I. et al. 1984. A pitfall in purulent arthritis brought out in Kingella kingae infection of the knee. Ann. Rheum. Dis. 43:656-657. 5. Raymond, J. et al. 1986. Isolation of two strains of Kingella kingae associated with septic arthritis. J. Clin. Microbiol. 24: 1100-1101. 6. Toshniwal, R. et al. 1986. Manifestations of Kingella kingae infections in adults: resemblance to neisserial infections. Diagn. Microbiol. Infect. Dis. 5:81-85. 7. Khan, J. A. et al. 1986. Case report: Kingella denitrificans prosthetic endocarditis. Am. J. Med. Sci. 3:187-189.
0196-4399/89/$0.00 + 02.20
143
standing, a conscious effort has been made to prevent checklist items from becoming a specific standard of practice in all laboratory areas. The accreditation program involves thousands of laboratories of different sizes, geographic locations, and expertise. The checklist must remain sufficiently general so that some functions common to all laboratories can be considered, but at the same time ensure that practices appropriate for a large city hospital are not imposed on a small rural hospital. For these reasons, certain items of the checklist are very specific in areas that might be considered trivial or simply bookkeeping, but for procedures such as blood culture techniques, they are fairly general. An attempt is made not to favor one technique or manufacturer over another unless there is unequivocal agreement that a certain standardization is appropriate. For example, in the area of antimicrobial susceptibility testing, there is agreement that the standards promulgated by the National Committee for Clinical Laboratory Standards are appropriate for clinical practice; therefore, a number of questions relate to use of these standards. However, the checklist is not designed to evaluate every aspect of a standard method. General laboratory activities are evaluated, especially in regard to adequate documentation of laboratory functions, without being specific as to what those functions should be. Each individual has a preferred way of performing a particular diagnostic procedure, but all those varieties of artistry and creativity cannot be included in such a document. Reasonable questions can be raised, however, when a specific technique is
used and the accreditation guidelines appear to be biased against it. How should a laboratory director proceed under those circumstances? At least two options are available and both of them should be explored. The first is to document the performance of a specific method in the laboratory. For example, if laboratories are able to document that less frequent testing of quality-control specimens or less frequent testing of staining reagents is a good standard of practice in that laboratory, then the documentation can be forwarded to the original inspector when these deficiencies are noted for the laboratory. Another mechanism that should be considered is to communicate directly with the Commission on Laboratory Accreditation and request feedback from the appropriate CAP scientific resource committee as to the appropriateness of a procedure. Usually, questions in the area of microbiology are referred to the Microbiology Resource Committee, one of whose functions is to serve as a scientific adviser and reference for the inspection committee. The Microbiology Resource Committee may then make a recommendation to the Commission on Laboratory Accreditation that a specific checklist item be changed or modified. If such a modification can be shown to be scientifically sound and not in conflict with regulatory demands, then the change is usually made. Many thoughtful and co_n_st~ctive changes have been made to the checklist by individuals responding to the accreditation process in this way. The CAP welcomes this type of scientific input because, if it benefits one laboratory, it may benefit others as well.
A 43-year-old man on hemodialysis for chronic renal failure secondary to hypertension presented to the hospital with a 4-day history of fever, nausea, vomiting, and diarrhea. The patient was in mild distress, and physical examination revealed a pulse and blood pressure of 76 beats per minute and 165/90 mm Hg, respectively, a temper-
ature of 101.5°F, hyperactive bowel sounds, and poor dentition. Laboratory data revealed a white blood cell count of 9,400/mm 3 (63% polymorphonuclear leukocytes, 17% band cells, 8% lymphocytes, 8% monocytes, 1% eosinophils, and 3% atypical lymphocytes; occasional toxic granulations were noted), and metabolic findings were
Case Report
Kingella kingae Bacteremia Mary C. O'Connor, M.D. Robert E. Sperry, M.D. Cynthia A. Burdick, BSMT, ASCP Christopher J. Papasian, Ph.D. Veterans Administration Medical Center
Kansas City, MO 64128
142 IIIIIJIL
.........
0196-4399/89/$0.00 + 02.20
© 1989 Elsevier Science Publishing Co., Inc.
Clinical Microbiology Newsletter 11:18, 1989
consistent with chronic renal failure. The patient was believed to suffer from a viral enteritis and was not admitted for further evaluation, nor was specific therapy initiated; however, a blood specimen was collected and inoculated into one set (aerobic and anaerobic) of blood culture bottles (BACTEC; Becton Dickinson Diagnostic Instrument Systems, Towson, MD). By the time the patient presented for dialysis two days later, his clinical symptoms were much improved. However, a gramnegative coccobacillus had been recovered from the aerobic blood culture bottle; repeat blood cultures were not collected at this time because of the patient's improved clinical status. The organism, subsequently identified as Kingella kingae, was susceptible to ampicillin, cefazolin, gentamicin, and trimethoprim/sulfamethoxazole by the disk diffusion method. Although the patient was thought to have had a transient bacteremia and most likely would have continued to recover without antimicrobial therapy, he received gentamicin intravenously (120 mg loading dose followed by 80 mg every other day following dialysis). All symptoms resolved without complications. Gentamicin was administered because the patient was anephric and, therefore, the risk of neprotoxicity was absent. Although aminoglycosides are normally excreted by the kidneys, the antimicrobial agent was removed primarily by hemodialysis in this patient. Therefore, the serum half-life was prolonged, and he could be given this agent when he came every other day for his hemodialysis. K. kingae is a fastidious, gram-negative coccobacillus in the family Neisseriaceae. It is oxidase-positive, nonmotile, and an obligate aerobe, and it degrades glucose. First described by King in 1966 and classified as Moraxella New Species 1, it is an occasional inhabitant of the nasopharynx. The genus Kingella includes two additional species: Kingella denitrificans and Kingella indologenes. K. kingae produces beta hemolysis on sheep blood agar, and two colony morphotypes can be seen: one is pinpoint, smooth, and convex with a well-defined margin, and the other is a larger colony type that
Clinical Microbiology Newsletter 11:18, 1989
corrodes or pits the agar surface. Both morphotypes may be seen on the same plate. Key characteristics that differentiate K. kingae from phenotypically similar organisms are its beta hemolysis, negative urease, catalase and indole reactions, and its ability to degrade maltose (1, 2). The organism was initially described as a rare cause of osteomyelitis, arthritis, and endocarditis in children. However, as recognition of its pathogenicity emerged, an increasing number of infections in adults has been reported. Most adult patients have presented with endocarditis and have a history of an underlying disease. Commonly reported antecedent illnesses or physical findings include upper respiratory tract illnesses, stomatitis, recent dental work, or poor dentition. In view of our patient's preceding gastrointestinal complaints, it was interesting to note that only two other patients were reported to have had preceding gastrointestinal symptoms: a 62year-old female who developed endocarditis after presumed gastroenteritis secondary to food poisoning (2) and a 15-month-old male with vomiting and diarrhea associated with occult bacteremia (1). No studies were done to specifically identify K. kingae in either patient's stool specimens. Osteomyelitis involving K. kingae has been reported only in children and is described as insidious and indolent. Septic arthritis, on the other hand, has been reported in all age groups and appears to have a more acute course. Discitis is a frequent complication of Kingella infections in children (3). All bone and joint cases were successfully treated with medical management, including antibiotic therapy (1, 3-5). Endocarditis caused by this bacterium often produces a very stormy clinical course and occurs in patients over a wide distribution of ages. Approximately 60% of all patients had underlying congenital or valvular anomalies (1, 2, 6, 7). Severe complications include residual neurologic deficits secondary to embolization of vegetations, and/or death despite adequate antibiotic therapy. Including the currently presented case, seven episodes of bacteremia
© 1989 Elsevier Science Publishing Co., Inc.
have been reported without an associated focus of infection (1, 2). In four cases, patients improved clinically or were asymptomatic by the time treatment was initiated. Two patients never required therapy, and all cases had a favorable outcome. One case of meningitis was seen in a patient with sickle cell anemia (6). Antimicrobial susceptibility test of K. kingae strains recovered from clinical cases have shown the organism to be susceptible to a wide range of antibiotics. The standard recommended therapy includes either penicillin or ampicillin; however, the organism is usually susceptible to the cephalosporins, imipenem, the aminoglycosides, and trimethoprim/sulfamethoxazole. Studies have shown variable susceptibilities to clindamycin, erythromycin, and chloramphenicol (1-7). Infections with K. kingae have a wide range of clinical expression. The increasing number of reported cases suggests that it is a significant human pathogen in those with or without underlying disease.
References 1. Claesson, A., E. Falsen, and B. Kjellman. 1985. Kingella kingae infections: a review and a presentation of data from ten Swedish cases. Scand. J. Infect. Dis. 17:233-243. 2. Verbruggen, A. M. et al. 1986. Infections caused by Kingella kingae: report of four cases and review. J. Infect. 13:133-142. 3. Woolfrey, B. F., R. T. Lally, and R. J. Faville. 1986. Intervertebral discitis caused by Kingella kingae. Am. J. Clin. Pathol. 85:745-749. 4. Salminen, I. et al. 1984. A pitfall in purulent arthritis brought out in Kingella kingae infection of the knee. Ann. Rheum. Dis. 43:656-657. 5. Raymond, J. et al. 1986. Isolation of two strains of Kingella kingae associated with septic arthritis. J. Clin. Microbiol. 24: 1100-1101. 6. Toshniwal, R. et al. 1986. Manifestations of Kingella kingae infections in adults: resemblance to neisserial infections. Diagn. Microbiol. Infect. Dis. 5:81-85. 7. Khan, J. A. et al. 1986. Case report: Kingella denitrificans prosthetic endocarditis. Am. J. Med. Sci. 3:187-189.
0196-4399/89/$0.00 + 02.20
143