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Pneumococcal Bacteremia Associated With an Infected Central Venous Catheter
Pneumococcal Bacteremia Associated With an Infected Central Venous Catheter* Samjot Singh Dhillon, MD; and Chatrchai Watanakunakorn, MD, FCCP
Pneumococcus (Streptococcus pneumoniae) bacteremia is a serious infection. Pneumococcus has never been implicated as a cause of a central venous catheter-related bacteremia. It has been isolated from the catheter tip only twice before, and in one case caused the infection of an infusion port device. We report case of a 41-year-old woman who developed pneumococcal bacteremia after 6 days of an indwelling central venous catheter. The catheter tip grew > 300 cfu of S pneumoniae by the roll-plate method described by Maki and colleagues. No other focus of infection could be found in this patient. To the best of our knowledge, this is the first reported case of pneumococcal bacteremia associated with an infected central venous catheter. (CHEST 2000; 117:1515–1516) Key words: infected central venous catheter; pneumococcal bacteremia; Streptococcus pneumoniae
(Streptococcus pneumoniae) is among P neumococcus the most pathogenic bacteria and is known to cause
various infections such as pneumonia, meningitis, endocarditis, septic arthritis, osteomyelitis, brain abscess, pyomyositis, and peritonitis, among others.1 Pneumococcal bacteremia is associated with a very high mortality rate, varying from 14 to 42% in adults, depending on the age.2 The commonly associated infections with pneumococcal bacteremia are pneumonia, meningitis, and upper respiratory tract infections.2 In approximately 14% of cases, the source cannot be determined.2 Streptococcus species have rarely been described as a cause of central venous catheter-related bacteremia. To the best of our knowledge, S pneumoniae has never been implicated as a cause of catheter-related bacteremia. We report a case of pneumococcal bacteremia associated with an infected central venous catheter.
Case Report A 41-year-old woman was admitted from a group home for mentally challenged persons because of abdominal pain and vomiting. It was not known whether the patient had been immunized with pneumococcal vaccine. She had schizophrenia and seizure disorder and was discharged from the hospital 3 days prior to admission after radioactive iodine treatment for Graves’ disease. She was taking lithium, benztropine mesylate, thiothix*From the Department of Internal Medicine, St. Elizabeth Health Center, Youngstown; and The Northeastern Ohio Universities College of Medicine, Rootstown, OH. Manuscript received July 2, 1999; revision accepted October 20, 1999. Correspondence to: Chatrchai Watanakunakorn, MD, FCCP, St. Elizabeth Health Center, 1044 Belmont Ave, Youngstown, OH 44501-1790
ene, and risperidone. She was afebrile on admission. Physical examination was unremarkable, except for a systolic ejection murmur over the left sternal border and mild tenderness diffusely over the lower part of the abdomen. Her WBC count was 4,600 cells/L; hemoglobin, 11.5 g/dL; thyroid-stimulating hormone, ⬍ 0.1 U/mL (normal range, 0.4 to 4.6 U/mL); and thyroxine, 13.1 g/dL (normal range, 5.5 to 11.5 g/dL). A chest roentgenogram and an erect roentgenogram of the abdomen were unremarkable. The lithium level was 3.3 mmol/L (therapeutic level, 0.5 to 1.5 mmol/L). Amylase, lipase, and liver function tests were within normal limits. Over the next 5 days, her lithium level decreased to 0.9 mmol/L but her vomiting continued. Lithium therapy was resumed. Upper GI endoscopy was normal, and a right femoral triple-lumen catheter was inserted on day 7 to start total parenteral nutrition. The patient started improving clinically, and her oral intake was slowly increased over the next few days. Total parenteral nutrition was discontinued after 6 days and was replaced with dextrose solution. That evening, the patient developed a temperature of 40.1°C (104.2°F). Physical examination revealed normal ear, nose, and throat and clear chest. The patient had no sputum production. No vaginal culture was done. Two sets of blood cultures were obtained, and the right femoral triple-lumen catheter was removed and its tip was sent for culture. Urinalysis and chest roentgenogram were normal. Both sets of blood culture grew ␣-hemolytic streptococci, and the patient was given ampicillin and gentamicin. Gentamicin was discontinued after the organism was identified as S pneumoniae by standard technique using optochin disk.3 The tip of the triple-lumen catheter grew ⬎ 300 cfu of S pneumoniae by the roll-plate technique.4 The S pneumoniae was susceptible to penicillin and ampicillin. The patient was afebrile within the next 48 h, and repeat blood cultures had no growth. Transesophageal echocardiography was attempted but could not be done because the patient was extremely agitated. A two-dimensional echocardiogram did not reveal any evidence of valvular vegetation. The patient was found to have diabetes insipidus due to lithium, and hence the lithium was discontinued, resulting in significant clinical improvement. Ampicillin was given for 10 days, and the patient was discharged in a stable condition. She had no recurrence of pneumococcal bacteremia during the 15-month follow-up period.
Discussion This patient developed pneumococcal bacteremia due to an infected central venous catheter. Pneumococcal bacteremia is associated with a high mortality rate of about 25%, and this rate does not seem to have decreased since the 1950s, despite many advances in the field of medicine.2 In approximately 14% of the cases, the source of bacteremia is undetermined.2 Many of these patients had central venous catheters that may be the source of bacteremia. If the tip of the catheter is not cultured, the real source of bacteremia may not be known. Multiple studies have been conducted to identify the pathogens involved in vascular catheter colonization and bacteremia. A review of many of these studies showed no cases of infected central venous catheters causing pneumococcal bacteremia.5–9 Brun-Buisson and colleagues10 reported a case of S pneumoniae contamination/colonization of a central venous catheter in their study using the broth dilution quantitative tip culture, but there was no evidence of sepsis and blood cultures had no growth. Aufwerber and colleagues11 cultured S pneumoniae from CHEST / 117 / 5 / MAY, 2000
1515
the tip of one central venous catheter, but this was not associated with bacteremia. The colony count for pneumococcus was also not specified. Groeger and colleagues12 described the port pocket infection of an implanted infusion port device by S pneumoniae, but there was no associated bacteremia. Thus, it seems that pneumococcus can colonize and infect various forms of IV catheters and devices. However, after an extensive literature search through MEDLINE, to the best of our knowledge, an IV catheter has never been implicated as a source of pneumococcal bacteremia. Our patient received total parenteral nutrition through this central venous catheter for 6 days. Many of the central venous catheters mentioned in previous studies were used for parenteral nutrition. Even in studies of catheters used for total parenteral nutrition only, there were no cases of catheter-tip infection or bacteremia due to S pneumoniae.13–17 The roll-plate method is a semiquantitative technique first described by Maki and colleagues in 1977.4 It has been extensively used since that time. A colony count ⬎ 15 on blood agar plate is considered significant and indicates that the catheter is the source of bacteremia. In this case, there were ⬎ 300 cfu on the tip of triple-lumen catheter. This would argue against secondary colonization of the catheter tip from primary bacteremia. Most of the catheter-related bacteremia involves organisms normally found on the skin surface, Staphylococcus aureus being the most serious pathogen.18 Maximum barrier precautions were used at the time of catheter insertion. It was unlikely that the catheter was contaminated by the operator’s nasopharyngeal flora. Pneumococcus is a part of the nasopharyngeal flora. However, it has been suggested that pneumococcus can become a part of the vaginal flora transiently when the organisms are transferred from the upper respiratory tract because of inadequate hygiene. This can cause peritonitis as a result of ascending infection through the female genital tract.19 –20 Bartholin gland infection with S pneumoniae has been reported.19 It is possible that the patient’s right femoral region was colonized with pneumococcus from either the upper respiratory tract or the genital tract. Although uncommon, S pneumoniae can colonize a central venous catheter and can result in bacteremia.
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9 10 11 12 13
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single-lumen central venous catheters: a prospective study in a critically ill population. Arch Intern Med 1989; 149:1139 – 1143 Benezra D, Kiehn TE, Gold JW, et al. Prospective study of infections in indwelling central venous catheters using quantitative blood cultures. Am J Med 1988; 85:495– 498 Richet H, Hubert B, Nitemberg G, et al. Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central- catheter cultures in intensive care unit patients. J Clin Microbiol 1990; 28:2520 –2525 Tacconelli E, Tumbarello M, Pittiruti M, et al. Central venous catheter-related sepsis in a cohort of 366 hospitalized patients. Eur J Clin Microbiol Infect Dis 1997; 16:203–209 Brun-Buisson C, Abrouk F, Legrand P, et al. Diagnosis of central venous catheter-related sepsis: critical level of quantitative tip cultures. Arch Intern Med 1987; 147:873– 877 Aufwerber E, Ringertz S, Ransjo¨ U. Routine semiquantitative cultures and central venous catheter-related bacteremia. APMIS 1991; 99:627– 630 Groeger JS, Lucas AB, Thaler HT, et al. Infectious morbidity associated with long-term use of venous access devices in patients with cancer. Ann Intern Med 1993; 119:1168 –1174 Armstrong CW, Mayhall CG, Miller KB, et al. Prospective study of catheter replacement and other risk factors for infection of hyperalimentation catheters. J Infect Dis 1986; 154:808 – 816 Pettigrew RA, Lang SD, Haydock DA, et al. Catheter-related sepsis in patients on intravenous nutrition: a prospective study of quantitative catheter cultures and guidewire changes for suspected sepsis. Br J Surg 1985; 72:52–55 Hansell DT, Park R, Jensen R, et al. Clinical significance and etiology of infected catheters used for total parenteral nutrition. Surg Gynecol Obstet 1986; 163:469 – 474 Pemberton LB, Lyman B, Lander V, et al. Sepsis from triplevs single-lumen catheters during total parenteral nutrition in surgical or critically ill patients. Arch Surg 1986; 121:591–594 Ryan JA Jr, Abel RM, Abbott WM, et al. Catheter complications in total parenteral nutrition: a prospective study of 200 consecutive patients N Engl J Med 1974; 290:757–761 Watanakunakorn C, Baird IM. Staphylococcus aureus bacteremia and endocarditis associated with a removable intravenous device. Am J Med 1977; 63:253–256 Westh H, Skibsted L, Korner B. Streptococcus pneumoniae infections of the female genital tract and in the newborn child. Rev Infect Dis 1990; 12:416 – 422 Sirotnak AP, Eppes SC, Klein JD. Tuboovarian abscess and peritonitis caused by Streptococcus pneumoniae serotype 1 in young girls. Clin Infect Dis 1996; 22:993–996
References 1 Musher DM. Infections caused by Streptococcus pneumoniae: clinical spectrum, pathogenesis, immunity, and treatment. Clin Infect Dis 1992; 14:801– 807 2 Watanakunakorn C, Greifenstein A, Stroh K, et al. Pneumococcal bacteremia in three community teaching hospitals from 1980 to 1989. Chest 1993; 103:1152–1156 3 Ruoff KL. Streptococcus. In: Murray PR, Baron MJ, Pfaller MA, et al, eds. Manual of clinical microbiology. 6th ed. Washington, DC: American Society of Microbiology, 1995; 299 –307 4 Maki DG, Weise CE, Sarafin HW. A semiquantitative culture method for identifying intravenous-catheter-related infection. N Engl J Med 1977; 296:1305–1309 5 Fry DE, Fry RV, Borzotta AP. Nosocomial blood-borne infection secondary to intravascular devices. Am J Surg 1994; 167:268 –272 6 Gil RT, Kruse JA, Thill-Baharozian MC, et al. Triple- vs 1516
Yellow Nail Syndrome* Resolution of Yellow Nails After Successful Treatment of Breast Cancer Mobeen Iqbal, MD; Leonard J. Rossoff, MD; Kamel A. Marzouk MD; and Harry N. Steinberg, MD
Yellow nail syndrome (YNS) is a rare entity of unknown cause in which congenitally hypoplastic lymphatics play a major role in the clinical manifestations of the disease. YNS has been associated with Selected Reports
Pneumococcus (Streptococcus pneumoniae) bacteremia is a serious infection. Pneumococcus has never been implicated as a cause of a central venous catheter-related bacteremia. It has been isolated from the catheter tip only twice before, and in one case caused the infection of an infusion port device. We report case of a 41-year-old woman who developed pneumococcal bacteremia after 6 days of an indwelling central venous catheter. The catheter tip grew > 300 cfu of S pneumoniae by the roll-plate method described by Maki and colleagues. No other focus of infection could be found in this patient. To the best of our knowledge, this is the first reported case of pneumococcal bacteremia associated with an infected central venous catheter. (CHEST 2000; 117:1515–1516) Key words: infected central venous catheter; pneumococcal bacteremia; Streptococcus pneumoniae
(Streptococcus pneumoniae) is among P neumococcus the most pathogenic bacteria and is known to cause
various infections such as pneumonia, meningitis, endocarditis, septic arthritis, osteomyelitis, brain abscess, pyomyositis, and peritonitis, among others.1 Pneumococcal bacteremia is associated with a very high mortality rate, varying from 14 to 42% in adults, depending on the age.2 The commonly associated infections with pneumococcal bacteremia are pneumonia, meningitis, and upper respiratory tract infections.2 In approximately 14% of cases, the source cannot be determined.2 Streptococcus species have rarely been described as a cause of central venous catheter-related bacteremia. To the best of our knowledge, S pneumoniae has never been implicated as a cause of catheter-related bacteremia. We report a case of pneumococcal bacteremia associated with an infected central venous catheter.
Case Report A 41-year-old woman was admitted from a group home for mentally challenged persons because of abdominal pain and vomiting. It was not known whether the patient had been immunized with pneumococcal vaccine. She had schizophrenia and seizure disorder and was discharged from the hospital 3 days prior to admission after radioactive iodine treatment for Graves’ disease. She was taking lithium, benztropine mesylate, thiothix*From the Department of Internal Medicine, St. Elizabeth Health Center, Youngstown; and The Northeastern Ohio Universities College of Medicine, Rootstown, OH. Manuscript received July 2, 1999; revision accepted October 20, 1999. Correspondence to: Chatrchai Watanakunakorn, MD, FCCP, St. Elizabeth Health Center, 1044 Belmont Ave, Youngstown, OH 44501-1790
ene, and risperidone. She was afebrile on admission. Physical examination was unremarkable, except for a systolic ejection murmur over the left sternal border and mild tenderness diffusely over the lower part of the abdomen. Her WBC count was 4,600 cells/L; hemoglobin, 11.5 g/dL; thyroid-stimulating hormone, ⬍ 0.1 U/mL (normal range, 0.4 to 4.6 U/mL); and thyroxine, 13.1 g/dL (normal range, 5.5 to 11.5 g/dL). A chest roentgenogram and an erect roentgenogram of the abdomen were unremarkable. The lithium level was 3.3 mmol/L (therapeutic level, 0.5 to 1.5 mmol/L). Amylase, lipase, and liver function tests were within normal limits. Over the next 5 days, her lithium level decreased to 0.9 mmol/L but her vomiting continued. Lithium therapy was resumed. Upper GI endoscopy was normal, and a right femoral triple-lumen catheter was inserted on day 7 to start total parenteral nutrition. The patient started improving clinically, and her oral intake was slowly increased over the next few days. Total parenteral nutrition was discontinued after 6 days and was replaced with dextrose solution. That evening, the patient developed a temperature of 40.1°C (104.2°F). Physical examination revealed normal ear, nose, and throat and clear chest. The patient had no sputum production. No vaginal culture was done. Two sets of blood cultures were obtained, and the right femoral triple-lumen catheter was removed and its tip was sent for culture. Urinalysis and chest roentgenogram were normal. Both sets of blood culture grew ␣-hemolytic streptococci, and the patient was given ampicillin and gentamicin. Gentamicin was discontinued after the organism was identified as S pneumoniae by standard technique using optochin disk.3 The tip of the triple-lumen catheter grew ⬎ 300 cfu of S pneumoniae by the roll-plate technique.4 The S pneumoniae was susceptible to penicillin and ampicillin. The patient was afebrile within the next 48 h, and repeat blood cultures had no growth. Transesophageal echocardiography was attempted but could not be done because the patient was extremely agitated. A two-dimensional echocardiogram did not reveal any evidence of valvular vegetation. The patient was found to have diabetes insipidus due to lithium, and hence the lithium was discontinued, resulting in significant clinical improvement. Ampicillin was given for 10 days, and the patient was discharged in a stable condition. She had no recurrence of pneumococcal bacteremia during the 15-month follow-up period.
Discussion This patient developed pneumococcal bacteremia due to an infected central venous catheter. Pneumococcal bacteremia is associated with a high mortality rate of about 25%, and this rate does not seem to have decreased since the 1950s, despite many advances in the field of medicine.2 In approximately 14% of the cases, the source of bacteremia is undetermined.2 Many of these patients had central venous catheters that may be the source of bacteremia. If the tip of the catheter is not cultured, the real source of bacteremia may not be known. Multiple studies have been conducted to identify the pathogens involved in vascular catheter colonization and bacteremia. A review of many of these studies showed no cases of infected central venous catheters causing pneumococcal bacteremia.5–9 Brun-Buisson and colleagues10 reported a case of S pneumoniae contamination/colonization of a central venous catheter in their study using the broth dilution quantitative tip culture, but there was no evidence of sepsis and blood cultures had no growth. Aufwerber and colleagues11 cultured S pneumoniae from CHEST / 117 / 5 / MAY, 2000
1515
the tip of one central venous catheter, but this was not associated with bacteremia. The colony count for pneumococcus was also not specified. Groeger and colleagues12 described the port pocket infection of an implanted infusion port device by S pneumoniae, but there was no associated bacteremia. Thus, it seems that pneumococcus can colonize and infect various forms of IV catheters and devices. However, after an extensive literature search through MEDLINE, to the best of our knowledge, an IV catheter has never been implicated as a source of pneumococcal bacteremia. Our patient received total parenteral nutrition through this central venous catheter for 6 days. Many of the central venous catheters mentioned in previous studies were used for parenteral nutrition. Even in studies of catheters used for total parenteral nutrition only, there were no cases of catheter-tip infection or bacteremia due to S pneumoniae.13–17 The roll-plate method is a semiquantitative technique first described by Maki and colleagues in 1977.4 It has been extensively used since that time. A colony count ⬎ 15 on blood agar plate is considered significant and indicates that the catheter is the source of bacteremia. In this case, there were ⬎ 300 cfu on the tip of triple-lumen catheter. This would argue against secondary colonization of the catheter tip from primary bacteremia. Most of the catheter-related bacteremia involves organisms normally found on the skin surface, Staphylococcus aureus being the most serious pathogen.18 Maximum barrier precautions were used at the time of catheter insertion. It was unlikely that the catheter was contaminated by the operator’s nasopharyngeal flora. Pneumococcus is a part of the nasopharyngeal flora. However, it has been suggested that pneumococcus can become a part of the vaginal flora transiently when the organisms are transferred from the upper respiratory tract because of inadequate hygiene. This can cause peritonitis as a result of ascending infection through the female genital tract.19 –20 Bartholin gland infection with S pneumoniae has been reported.19 It is possible that the patient’s right femoral region was colonized with pneumococcus from either the upper respiratory tract or the genital tract. Although uncommon, S pneumoniae can colonize a central venous catheter and can result in bacteremia.
7 8
9 10 11 12 13
14
15 16 17 18 19 20
single-lumen central venous catheters: a prospective study in a critically ill population. Arch Intern Med 1989; 149:1139 – 1143 Benezra D, Kiehn TE, Gold JW, et al. Prospective study of infections in indwelling central venous catheters using quantitative blood cultures. Am J Med 1988; 85:495– 498 Richet H, Hubert B, Nitemberg G, et al. Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central- catheter cultures in intensive care unit patients. J Clin Microbiol 1990; 28:2520 –2525 Tacconelli E, Tumbarello M, Pittiruti M, et al. Central venous catheter-related sepsis in a cohort of 366 hospitalized patients. Eur J Clin Microbiol Infect Dis 1997; 16:203–209 Brun-Buisson C, Abrouk F, Legrand P, et al. Diagnosis of central venous catheter-related sepsis: critical level of quantitative tip cultures. Arch Intern Med 1987; 147:873– 877 Aufwerber E, Ringertz S, Ransjo¨ U. Routine semiquantitative cultures and central venous catheter-related bacteremia. APMIS 1991; 99:627– 630 Groeger JS, Lucas AB, Thaler HT, et al. Infectious morbidity associated with long-term use of venous access devices in patients with cancer. Ann Intern Med 1993; 119:1168 –1174 Armstrong CW, Mayhall CG, Miller KB, et al. Prospective study of catheter replacement and other risk factors for infection of hyperalimentation catheters. J Infect Dis 1986; 154:808 – 816 Pettigrew RA, Lang SD, Haydock DA, et al. Catheter-related sepsis in patients on intravenous nutrition: a prospective study of quantitative catheter cultures and guidewire changes for suspected sepsis. Br J Surg 1985; 72:52–55 Hansell DT, Park R, Jensen R, et al. Clinical significance and etiology of infected catheters used for total parenteral nutrition. Surg Gynecol Obstet 1986; 163:469 – 474 Pemberton LB, Lyman B, Lander V, et al. Sepsis from triplevs single-lumen catheters during total parenteral nutrition in surgical or critically ill patients. Arch Surg 1986; 121:591–594 Ryan JA Jr, Abel RM, Abbott WM, et al. Catheter complications in total parenteral nutrition: a prospective study of 200 consecutive patients N Engl J Med 1974; 290:757–761 Watanakunakorn C, Baird IM. Staphylococcus aureus bacteremia and endocarditis associated with a removable intravenous device. Am J Med 1977; 63:253–256 Westh H, Skibsted L, Korner B. Streptococcus pneumoniae infections of the female genital tract and in the newborn child. Rev Infect Dis 1990; 12:416 – 422 Sirotnak AP, Eppes SC, Klein JD. Tuboovarian abscess and peritonitis caused by Streptococcus pneumoniae serotype 1 in young girls. Clin Infect Dis 1996; 22:993–996
References 1 Musher DM. Infections caused by Streptococcus pneumoniae: clinical spectrum, pathogenesis, immunity, and treatment. Clin Infect Dis 1992; 14:801– 807 2 Watanakunakorn C, Greifenstein A, Stroh K, et al. Pneumococcal bacteremia in three community teaching hospitals from 1980 to 1989. Chest 1993; 103:1152–1156 3 Ruoff KL. Streptococcus. In: Murray PR, Baron MJ, Pfaller MA, et al, eds. Manual of clinical microbiology. 6th ed. Washington, DC: American Society of Microbiology, 1995; 299 –307 4 Maki DG, Weise CE, Sarafin HW. A semiquantitative culture method for identifying intravenous-catheter-related infection. N Engl J Med 1977; 296:1305–1309 5 Fry DE, Fry RV, Borzotta AP. Nosocomial blood-borne infection secondary to intravascular devices. Am J Surg 1994; 167:268 –272 6 Gil RT, Kruse JA, Thill-Baharozian MC, et al. Triple- vs 1516
Yellow Nail Syndrome* Resolution of Yellow Nails After Successful Treatment of Breast Cancer Mobeen Iqbal, MD; Leonard J. Rossoff, MD; Kamel A. Marzouk MD; and Harry N. Steinberg, MD
Yellow nail syndrome (YNS) is a rare entity of unknown cause in which congenitally hypoplastic lymphatics play a major role in the clinical manifestations of the disease. YNS has been associated with Selected Reports