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Soft-tissue abscess involving Actinomyces odontolyticus and two Prevotella species in an intravenous drug abuser
Comparative Immunology, Microbiology & Infectious Diseases 27 (2004) 75–79 www.elsevier.com/locate/cimid
Soft-tissue abscess involving Actinomyces odontolyticus and two Prevotella species in an intravenous drug abuser D. Sofianoua, E. Avgoustinakisb, A. Dilopouloua, S. Pournarasa, G. Tsirakidisa, A. Tsakrisc,* a
Department of Clinical Microbiology, Hippokration General Hospital, Thessaloniki 54 642, Greece b Department of Fifth Surgery, Hippokration General Hospital, Thessaloniki 54 642, Greece c Department of Microbiology, Faculty of Nursing, School of Health Sciences, University of Athens, 123 Papadiamantopoulou Street, Athens 115 27, Greece Accepted 30 June 2003
Abstract Skin and soft-tissue infections in intravenous users comprise a variety of microorganisms and anaerobic bacteria are frequently involved in these suppurative infections. A case of subcutaneous abscess into anterior femoral muscles involving Actinomyces odontolyticus and two Prevotella species (Prevotella buccae and Prevotella melaninogenica) in an intravenous drug abuser is presented. This combination of microorganisms has not previously been described in soft-tissue infections. The patient volunteering that he licked his hypodermic needle prior to cocaine injection supports that the implicating bacteria originated from the oral cavity. Eventually, the patient recovered and at a 6-month follow-up a gradual improvement of his subcutaneous infection was noticed. q 2003 Elsevier Ltd. All rights reserved. Keywords: Subcutaneous abscess; Drug abuser; Actinomyces odontolyticus; Prevotella species
Re´sume´ Les infections de la peau et des tissus-souples des fersournis qui font usage de drogues en utilisant des injections intraveineuses, comfortent une varie´te´ de micro-organismes et de bacte´ries anae´robies. Ces micro-organismes et bacte´ries anae´robies sont souvent implique´s dausdes infections suppuratives. On pre´sente ici une etude sur le cas d’un patient qui faisait abus de cocaine en utilisant des injections intraveineuses. Ce patient-a souffert d’ abce`s sous-cutane´s aux muscles fe´moraux ante´rieurs impliquant Actinomyces odontolyticus et deux espe`ces de Prevotella (Prevotella buccae et Prevotella melaninogenica). C’est la premiere fois semble-til que cette * Corresponding author. Fax: þ 30-210-7461489. E-mail address: [email protected] (A. Tsakris). 0147-9571/$ - see front matter q 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0147-9571(03)00052-3
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D. Sofianou et al. / Comp. Immun. Microbiol. Infect. Dis. 27 (2004) 75–79
combinaison de micro-organismes est de´crite dans les infections de tissus-souples. Le patient ca avoue´ avoir le´che´ l’aiguille hypodermique avant l’injection de cocaine, e´v qui e´vopue le fait que les bacte´ries implique´es proviennent de la cavite´ orale. Six mois plus tard on a note´ que l’ abce`s souscutane´ a cede´ graduellement. q 2003 Elsevier Ltd. All rights reserved. Mots-cle´: Abce`s sous-cutane´; usage abusif des drogues; Actinomyces odontolyticus; Prevotella
1. Introduction Abscess formation at the site of drug injection is a common complication of parenteral drug abuse. Skin and soft-tissue infections in intravenous users comprise a variety of microorganisms and anaerobic bacteria are frequently involved in these suppurative infections [1 – 3]. We describe a case of soft-tissue abscess caused by Actinomyces odontolyticus, an inhabitant of the normal mouth and gums, in mixed culture with Prevotella buccae and Prevotella melaninogenica in a parenteral drug abuser.
2. Case report A 32 year-old man was admitted to the hospital with pain, swelling and erythema of the right femoral area. The patient was an intravenous heroin addict from 17 years of age. He reported repeated soft-tissue abscesses and treatment for pulmonary tuberculosis in the past. On physical examination, he had fever (38.8 8C) and the skin of the femur was hot, red and tensely swollen (Table 1). The dimension of the swollen area was 5 £ 7 cm2. Crepitation was not detected. Laboratory findings were hemoglobin 10.3 g/dl, hematocrit 31%, leukocyte count 15,400 cells/mm3 (87% neutrophils), erythrocyte sedimentation rate 92 mm/h, CPK 502 IU/l and iron 20 mg/dl. He was positive for hepatitis B surface antigen and anti-HCV. Empirical treatment was started with amoxicillin/clavulanate intravenously (1.2 g every 8 h, i.v.) that was continued with oral administration (625 mg every 6 h) one day later. Two blood cultures were drawn before antibiotics were initiated that yielded no growth. A Doppler examination of the blood vessels showed a thrombosis of the superficial femoral vein and oedema of inguinal lymph nodes. The patient’s condition worsened. Leukocyte count increased (17,000 cells/mm3 with 90% neutrophils) and the treatment was changed to oral ciprofloxacin (500 mg every 12 h). On day 8 of hospitalization, a computerized tomography scan was performed that revealed a large abscess into anterior femoral muscles and gas. Ciprofloxacin was discontinued and replaced by oral administration of metronidazole (500 mg every 8 h) and cefuroxime (250 mg every 12 h). However, the suppurative lesion increased in size and spread to the knee. Therefore, the patient was transferred to the surgical department for incision and drainage of the abscess. Two redons with negative pressure were placed at the poles of the lesion that yielded approximately 150 –250 ml of purulent fluid. Aspirated pus sample was taken with strict antiseptic techniques and cultured aerobically and
D. Sofianou et al. / Comp. Immun. Microbiol. Infect. Dis. 27 (2004) 75–79
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Table 1 Timeline specifying the clinical course, drug treatment and isolates recovered from the soft-tissue abscess Day of hospitalization
Clinical course
Drug treatment
Bacteria isolated
Day 1
Fever (38.8 8C); hot, red and tensely swollen skin of the femur The patient’s condition worsened Large abscess into anterior femoral muscles and gas
Amoxicillin/clavulanate (1.2 g every 8 h, i.v.)
No growth (from blood cultures)
Ciprofloxacin (500 mg every 12 h, orally) Metronidazole (500 mg every 8 h, orally) and cefuroxime (250 mg every 12 h, orally) Same antimicrobial treatment; drainage of the abscess Addition of clindamycin (150 mg every 8 h, orally) Same antimicrobial treatment
Not taken
Day 4 Day 8
Day 9
Day 11 Day 13
Day 18 Day 23
Spread of the suppurative lesion to the knee Slight improvement Temperature 36.8 8C, subsidence of the suppurative lesion Temperature 38.0 8C, the abscess worsened Temperature 36.5 8C, subsidence of the abscess
Piperacillin/tazobactam (2.25 g every 12 h, i.v.) Metronidazole (500 mg every 8 h, orally) and ampicillin/sulbactam (750 mg every 12 h, orally)
Not taken
A. odontolyticus, P. buccae, P. melaninogenica Not taken No growth
Acinetobacter baumannii No growth
anaerobically. Aerobic culture was negative. However, anaerobic culture, using anaerobe blood agar, anaerobe kanamycin – vancomycin blood agar and enriched thioglycolate medium (Oxoid Ltd, Basingstoke, UK), yielded three different species after incubation at 37 8C for four days. On the basis of morphological, cultural and biochemical characteristics with API A system (bioMe´rieux, La Balme Les Grottes, France) the isolates were identified as A. odontolyticus, P. buccae and P. melaninogenica. bLactamase was produces by the P. buccae. Identification was confirmed by testing for various properties using key tests prepared in-house [4]. All isolates were susceptible to amoxicillin/clavulanate, cefoxitin, clindamycin, metronidazole but resistant to ciprofloxacin. Per os clindamycin (150 mg every 8 h) was added to the treatment with subsequent clinical improvement of the patient’s condition. The temperature returned to normal level and the suppurative lesion subsided. Laboratory findings showed a decrease of leukocytes (6000 cells/mm3 with 75% neutrophils). A second aspirated pus sample taken two days later was sterile. On day 18 of admission the patient’s temperature rose to 38 8C again. A third pus sample yielded, according to the identification of the Vitek system and the API 20NE system (bioMe´rieux), a moderate growth of Acinetobacter baumannii that was susceptible only to ampicillin/sulbactam, piperaciilin/tazobactam and imipenem. On
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D. Sofianou et al. / Comp. Immun. Microbiol. Infect. Dis. 27 (2004) 75–79
the basis of susceptibility testing the therapy was changed to piperacillin/tazobactam (2.25 g every 12 h, i.v.). On day 23, a small amount of purulent fluid was discharged that was sterile and the patient was further treated by oral administration of metronidazole (500 mg every 8 h) and ampicillin/sulbactam (750 mg every 12 h) (Table 1). In addition to his antibiotic treatment, the patient also received methadone (100 mg/d) because of his drug abuse. Eventually, the patient recovered and at a 6-month follow-up by our outpatient clinics a gradual improvement of his subcutaneous infection was noticed.
3. Discussion Skin and soft-tissue abscesses are a frequent and serious complication of parenteral drug addiction [5,6]. Although there are only few studies about the bacteriology of these infections, the implication of anaerobic bacteria alone or in combination with aerobes, particularly Staphylococcus aureus and Streptococcus milleri, appears to be common [3,7, 8]. In most studies Bacteroides species are the commonest anaerobes isolated from softtissue infections in individuals with history of intravenous drug use [1,2,5]. Pigmented Prevotella species as well as A. odontolyticus have also been recovered from such abscesses in a report studying the bacteriology of cutaneous and subcutaneous abscesses among intravenous drug users [8]. However, the present report is the first where Prevotella species along with A. odontolyticus were involved in an abscess of a parenteral drug abuser. The implication of the isolated bacteria cannot be contradicted as they were recovered from aspirated pus samples using strict aseptic techniques. Isolates recognized as important potential pathogens in this type of abscesses are frequently resident in the mouth suggesting the oral origin of the infection [5,8]. In the present study, the patient volunteering that he licked his hypodermic needle prior to cocaine injection supports that the implicating bacteria originated from the oral cavity. Other factors predisposing to an anaerobic local infection is the decreased oxygen tension caused by the presence of underlying peripheral thrombosis, a condition that favors the growth of strict and facultative anaerobes. Therefore, empirical therapy should include coverage for mixed aerobic and anaerobic infection. The present report refreshes the anaerobe awareness in abscesses from intravenous drug abusers. Samples from such infections should be cultured for a prolonged period to ensure recovery of fastidious organisms, which may have implications for antibiotic therapy. However, the failure of the initial treatment with antimicrobials such as amoxicillin/clavulanate and metronidazole, indicates that antimicrobial treatment might be insufficient alone and surgical drainage of the abscess should be considered as a complementary treatment.
References [1] Bergstein JM, Baker 4th EJ, Aprahamian C, Schein M, Wittmann DH. Soft tissue abscesses associated with parenteral drug abuse: presentation, microbiology, and treatment. Am Surg 1995;61:1105–8. [2] Brook I, Frazier EH. Aerobic and anaerobic bacteriology of wounds and cutaneous abscesses. Arch Surg 1990;125:1445–51.
D. Sofianou et al. / Comp. Immun. Microbiol. Infect. Dis. 27 (2004) 75–79
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[3] George WL. Other infections of skin, soft tissue, and muscle. In: Finegold SM, George WL, editors. Anaerobic infections in humans. New York: Academic Press; 1989. p. 485 –506. [4] Murray PR, Jo Baron E, Pfaller MA, Tenover FC, Yolken RH. Manual of clinical microbiology, 7th ed. Washington, DC: American Society for Microbiology; 1999. [5] Henriksen BM, Albrektsen SB, Simper LB, Gutschik E. Soft tissue infections from drug abuse. A clinical and microbiological review of 145 cases. Acta Orthop Scand 1994;65:625–8. [6] Vollum DI. Skin lesions in drug addicts. Br Med J 1970;2:647–50. [7] Muller F, von Graevenitz A, Ferber T. Streptococcus milleri subcutaneous abscesses in drug addicts. Infection 1987;15:201. [8] Summanen PH, Talan DA, Strong C, McTeague M, Bennion R, Thompson Jr. JE, Vaisanen ML, Moran G, Winer M, Finegold SM. Bacteriology of skin and soft tissue infections: comparison of infections in intravenous drug users and individuals with no history of intravenous drug use. Clin Infect Dis 1995;20(Suppl 2):S279–82.
Soft-tissue abscess involving Actinomyces odontolyticus and two Prevotella species in an intravenous drug abuser D. Sofianoua, E. Avgoustinakisb, A. Dilopouloua, S. Pournarasa, G. Tsirakidisa, A. Tsakrisc,* a
Department of Clinical Microbiology, Hippokration General Hospital, Thessaloniki 54 642, Greece b Department of Fifth Surgery, Hippokration General Hospital, Thessaloniki 54 642, Greece c Department of Microbiology, Faculty of Nursing, School of Health Sciences, University of Athens, 123 Papadiamantopoulou Street, Athens 115 27, Greece Accepted 30 June 2003
Abstract Skin and soft-tissue infections in intravenous users comprise a variety of microorganisms and anaerobic bacteria are frequently involved in these suppurative infections. A case of subcutaneous abscess into anterior femoral muscles involving Actinomyces odontolyticus and two Prevotella species (Prevotella buccae and Prevotella melaninogenica) in an intravenous drug abuser is presented. This combination of microorganisms has not previously been described in soft-tissue infections. The patient volunteering that he licked his hypodermic needle prior to cocaine injection supports that the implicating bacteria originated from the oral cavity. Eventually, the patient recovered and at a 6-month follow-up a gradual improvement of his subcutaneous infection was noticed. q 2003 Elsevier Ltd. All rights reserved. Keywords: Subcutaneous abscess; Drug abuser; Actinomyces odontolyticus; Prevotella species
Re´sume´ Les infections de la peau et des tissus-souples des fersournis qui font usage de drogues en utilisant des injections intraveineuses, comfortent une varie´te´ de micro-organismes et de bacte´ries anae´robies. Ces micro-organismes et bacte´ries anae´robies sont souvent implique´s dausdes infections suppuratives. On pre´sente ici une etude sur le cas d’un patient qui faisait abus de cocaine en utilisant des injections intraveineuses. Ce patient-a souffert d’ abce`s sous-cutane´s aux muscles fe´moraux ante´rieurs impliquant Actinomyces odontolyticus et deux espe`ces de Prevotella (Prevotella buccae et Prevotella melaninogenica). C’est la premiere fois semble-til que cette * Corresponding author. Fax: þ 30-210-7461489. E-mail address: [email protected] (A. Tsakris). 0147-9571/$ - see front matter q 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0147-9571(03)00052-3
76
D. Sofianou et al. / Comp. Immun. Microbiol. Infect. Dis. 27 (2004) 75–79
combinaison de micro-organismes est de´crite dans les infections de tissus-souples. Le patient ca avoue´ avoir le´che´ l’aiguille hypodermique avant l’injection de cocaine, e´v qui e´vopue le fait que les bacte´ries implique´es proviennent de la cavite´ orale. Six mois plus tard on a note´ que l’ abce`s souscutane´ a cede´ graduellement. q 2003 Elsevier Ltd. All rights reserved. Mots-cle´: Abce`s sous-cutane´; usage abusif des drogues; Actinomyces odontolyticus; Prevotella
1. Introduction Abscess formation at the site of drug injection is a common complication of parenteral drug abuse. Skin and soft-tissue infections in intravenous users comprise a variety of microorganisms and anaerobic bacteria are frequently involved in these suppurative infections [1 – 3]. We describe a case of soft-tissue abscess caused by Actinomyces odontolyticus, an inhabitant of the normal mouth and gums, in mixed culture with Prevotella buccae and Prevotella melaninogenica in a parenteral drug abuser.
2. Case report A 32 year-old man was admitted to the hospital with pain, swelling and erythema of the right femoral area. The patient was an intravenous heroin addict from 17 years of age. He reported repeated soft-tissue abscesses and treatment for pulmonary tuberculosis in the past. On physical examination, he had fever (38.8 8C) and the skin of the femur was hot, red and tensely swollen (Table 1). The dimension of the swollen area was 5 £ 7 cm2. Crepitation was not detected. Laboratory findings were hemoglobin 10.3 g/dl, hematocrit 31%, leukocyte count 15,400 cells/mm3 (87% neutrophils), erythrocyte sedimentation rate 92 mm/h, CPK 502 IU/l and iron 20 mg/dl. He was positive for hepatitis B surface antigen and anti-HCV. Empirical treatment was started with amoxicillin/clavulanate intravenously (1.2 g every 8 h, i.v.) that was continued with oral administration (625 mg every 6 h) one day later. Two blood cultures were drawn before antibiotics were initiated that yielded no growth. A Doppler examination of the blood vessels showed a thrombosis of the superficial femoral vein and oedema of inguinal lymph nodes. The patient’s condition worsened. Leukocyte count increased (17,000 cells/mm3 with 90% neutrophils) and the treatment was changed to oral ciprofloxacin (500 mg every 12 h). On day 8 of hospitalization, a computerized tomography scan was performed that revealed a large abscess into anterior femoral muscles and gas. Ciprofloxacin was discontinued and replaced by oral administration of metronidazole (500 mg every 8 h) and cefuroxime (250 mg every 12 h). However, the suppurative lesion increased in size and spread to the knee. Therefore, the patient was transferred to the surgical department for incision and drainage of the abscess. Two redons with negative pressure were placed at the poles of the lesion that yielded approximately 150 –250 ml of purulent fluid. Aspirated pus sample was taken with strict antiseptic techniques and cultured aerobically and
D. Sofianou et al. / Comp. Immun. Microbiol. Infect. Dis. 27 (2004) 75–79
77
Table 1 Timeline specifying the clinical course, drug treatment and isolates recovered from the soft-tissue abscess Day of hospitalization
Clinical course
Drug treatment
Bacteria isolated
Day 1
Fever (38.8 8C); hot, red and tensely swollen skin of the femur The patient’s condition worsened Large abscess into anterior femoral muscles and gas
Amoxicillin/clavulanate (1.2 g every 8 h, i.v.)
No growth (from blood cultures)
Ciprofloxacin (500 mg every 12 h, orally) Metronidazole (500 mg every 8 h, orally) and cefuroxime (250 mg every 12 h, orally) Same antimicrobial treatment; drainage of the abscess Addition of clindamycin (150 mg every 8 h, orally) Same antimicrobial treatment
Not taken
Day 4 Day 8
Day 9
Day 11 Day 13
Day 18 Day 23
Spread of the suppurative lesion to the knee Slight improvement Temperature 36.8 8C, subsidence of the suppurative lesion Temperature 38.0 8C, the abscess worsened Temperature 36.5 8C, subsidence of the abscess
Piperacillin/tazobactam (2.25 g every 12 h, i.v.) Metronidazole (500 mg every 8 h, orally) and ampicillin/sulbactam (750 mg every 12 h, orally)
Not taken
A. odontolyticus, P. buccae, P. melaninogenica Not taken No growth
Acinetobacter baumannii No growth
anaerobically. Aerobic culture was negative. However, anaerobic culture, using anaerobe blood agar, anaerobe kanamycin – vancomycin blood agar and enriched thioglycolate medium (Oxoid Ltd, Basingstoke, UK), yielded three different species after incubation at 37 8C for four days. On the basis of morphological, cultural and biochemical characteristics with API A system (bioMe´rieux, La Balme Les Grottes, France) the isolates were identified as A. odontolyticus, P. buccae and P. melaninogenica. bLactamase was produces by the P. buccae. Identification was confirmed by testing for various properties using key tests prepared in-house [4]. All isolates were susceptible to amoxicillin/clavulanate, cefoxitin, clindamycin, metronidazole but resistant to ciprofloxacin. Per os clindamycin (150 mg every 8 h) was added to the treatment with subsequent clinical improvement of the patient’s condition. The temperature returned to normal level and the suppurative lesion subsided. Laboratory findings showed a decrease of leukocytes (6000 cells/mm3 with 75% neutrophils). A second aspirated pus sample taken two days later was sterile. On day 18 of admission the patient’s temperature rose to 38 8C again. A third pus sample yielded, according to the identification of the Vitek system and the API 20NE system (bioMe´rieux), a moderate growth of Acinetobacter baumannii that was susceptible only to ampicillin/sulbactam, piperaciilin/tazobactam and imipenem. On
78
D. Sofianou et al. / Comp. Immun. Microbiol. Infect. Dis. 27 (2004) 75–79
the basis of susceptibility testing the therapy was changed to piperacillin/tazobactam (2.25 g every 12 h, i.v.). On day 23, a small amount of purulent fluid was discharged that was sterile and the patient was further treated by oral administration of metronidazole (500 mg every 8 h) and ampicillin/sulbactam (750 mg every 12 h) (Table 1). In addition to his antibiotic treatment, the patient also received methadone (100 mg/d) because of his drug abuse. Eventually, the patient recovered and at a 6-month follow-up by our outpatient clinics a gradual improvement of his subcutaneous infection was noticed.
3. Discussion Skin and soft-tissue abscesses are a frequent and serious complication of parenteral drug addiction [5,6]. Although there are only few studies about the bacteriology of these infections, the implication of anaerobic bacteria alone or in combination with aerobes, particularly Staphylococcus aureus and Streptococcus milleri, appears to be common [3,7, 8]. In most studies Bacteroides species are the commonest anaerobes isolated from softtissue infections in individuals with history of intravenous drug use [1,2,5]. Pigmented Prevotella species as well as A. odontolyticus have also been recovered from such abscesses in a report studying the bacteriology of cutaneous and subcutaneous abscesses among intravenous drug users [8]. However, the present report is the first where Prevotella species along with A. odontolyticus were involved in an abscess of a parenteral drug abuser. The implication of the isolated bacteria cannot be contradicted as they were recovered from aspirated pus samples using strict aseptic techniques. Isolates recognized as important potential pathogens in this type of abscesses are frequently resident in the mouth suggesting the oral origin of the infection [5,8]. In the present study, the patient volunteering that he licked his hypodermic needle prior to cocaine injection supports that the implicating bacteria originated from the oral cavity. Other factors predisposing to an anaerobic local infection is the decreased oxygen tension caused by the presence of underlying peripheral thrombosis, a condition that favors the growth of strict and facultative anaerobes. Therefore, empirical therapy should include coverage for mixed aerobic and anaerobic infection. The present report refreshes the anaerobe awareness in abscesses from intravenous drug abusers. Samples from such infections should be cultured for a prolonged period to ensure recovery of fastidious organisms, which may have implications for antibiotic therapy. However, the failure of the initial treatment with antimicrobials such as amoxicillin/clavulanate and metronidazole, indicates that antimicrobial treatment might be insufficient alone and surgical drainage of the abscess should be considered as a complementary treatment.
References [1] Bergstein JM, Baker 4th EJ, Aprahamian C, Schein M, Wittmann DH. Soft tissue abscesses associated with parenteral drug abuse: presentation, microbiology, and treatment. Am Surg 1995;61:1105–8. [2] Brook I, Frazier EH. Aerobic and anaerobic bacteriology of wounds and cutaneous abscesses. Arch Surg 1990;125:1445–51.
D. Sofianou et al. / Comp. Immun. Microbiol. Infect. Dis. 27 (2004) 75–79
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[3] George WL. Other infections of skin, soft tissue, and muscle. In: Finegold SM, George WL, editors. Anaerobic infections in humans. New York: Academic Press; 1989. p. 485 –506. [4] Murray PR, Jo Baron E, Pfaller MA, Tenover FC, Yolken RH. Manual of clinical microbiology, 7th ed. Washington, DC: American Society for Microbiology; 1999. [5] Henriksen BM, Albrektsen SB, Simper LB, Gutschik E. Soft tissue infections from drug abuse. A clinical and microbiological review of 145 cases. Acta Orthop Scand 1994;65:625–8. [6] Vollum DI. Skin lesions in drug addicts. Br Med J 1970;2:647–50. [7] Muller F, von Graevenitz A, Ferber T. Streptococcus milleri subcutaneous abscesses in drug addicts. Infection 1987;15:201. [8] Summanen PH, Talan DA, Strong C, McTeague M, Bennion R, Thompson Jr. JE, Vaisanen ML, Moran G, Winer M, Finegold SM. Bacteriology of skin and soft tissue infections: comparison of infections in intravenous drug users and individuals with no history of intravenous drug use. Clin Infect Dis 1995;20(Suppl 2):S279–82.