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Staphylococcus warneri and Staphylococcus lugdunensis bacteriemia after handling intrauterine device
Med Clin (Barc). 2016;147(4):e21
www.elsevier.es/medicinaclinica
Letter to the Editor Staphylococcus warneri and Staphylococcus lugdunensis bacteriemia after handling intrauterine device夽 Bacteriemia por Staphylococcus warneri y Staphylococcus lugdunensis tras manipulación de dispositivo intrauterino Dear Editor, The most common infection caused by insertion or manipulation of an intrauterine device (IUD) is pelvic inflammatory disease, and the microorganisms most frequently involved are Chlamydia trachomatis, Neisseria gonorrhoeae or Escherichia coli, among others. The incidence of infection is low. Revisions have been carried out about antibiotic prophylaxis prior to IUD insertion without conclusive data being obtained. We report a case of bacteraemia 24 h after gynaecological manipulation. A 56-year-old obese female with hypertension, diabetes mellitus, anxiety-depressive syndrome and fibromyalgia. Hormonal IUD carrier. She went to the emergency room for severe asthenia, headache, decreased urine output and syncope without loss of consciousness at home. Twenty-four hours earlier she had a IUD gynaecological examination, subsequently presenting severe headache and hypertensive crisis treated in her health centre. Upon arrival to the emergency room the patient was conscious, alert, eupnoeic at rest, no tachycardia or tachypnea, hypotensive (BP 87/59 mmHg), with HR 90 bpm and SatO2 98% without input. Lab results showed levels of haemoglobin at 9.3 g/dl, leukopenia with left shift (3.12 mill/mm3 ) and thrombocytopenia (25,000/mm3 ). Biochemistry showed hyperglycaemia at 170 mg/dl, urea at 95 mg/dL, creatinine at 2.27 mg/dl and CRP at 314.9 mg/l. Proteins, erythrocytes and leukocytes appeared in urine, with negative nitrites. Urine and blood cultures were requested, empirical antibiotic treatment was started with ceftriaxone 2 g iv/24 h and the patient was admitted to Internal Medicine. Blood culture, with 3 samples taken, was positive to methicillinresistant Staphylococcus warneri and Staphylococcus lugdunensis in the 3 instances, both sensitive to aminoglycosides and resistant to quinolones and penicillins. Following the results of blood cultures, the patient underwent transthoracic and transesophageal echocardiography so as to rule out endocarditis, without visualizing warts or lesions compatible with the said infectious condition. The antibiotic was changed to vancomycin 1 g/12 h and gentamicin 120 mg/8 h during 15 days of admission, performing a control blood culture after 10 days of treatment, which was negative and a transthoracic echocardiography, which was also negative for
夽 Please cite this article as: Prado Mel E, Gil López M, Rojas Ramírez AB. Bacteriemia por Staphylococcus warneri y Staphylococcus lugdunensis tras manipulación de dispositivo intrauterino. Med Clin (Barc). 2016;147:e21. ˜ S.L.U. All rights reserved. 2387-0206/© 2016 Elsevier Espana,
endocarditis. The patient was discharged after 25 days of hospital admission. S. warneri and S. lugdenensis are coagulase-negative staphylococci (CNS). S. lugdenensis presents major differences with other microorganisms in their group. Currently it is closer to Staphylococcus aureus than to the CNS, being highly virulent and causing infectious processes, sepsis and/or endocarditis.1 A case of isolated brain abscess2 was recently published without coexistence of bacteraemia and/or endocarditis, which points to the bacterium’s migration and virulence ability. Several studies establish S. lugdenensis as part of the normal microbial flora,3 being especially located in the lower abdominal area, perineum and lower extremities. In the case of S. warneri, however, the incidence and virulence of the microorganism are lower4 compared to S. lugdenensis and it is usually associated with the implantation of prosthetic and/or medical devices. In our case, the patient had bacteraemia caused by both microorganisms, without genital involvement; IUD implantation is associated with the occurrence of infections localized in the upper genital tract, with or without bacteraemia and by different microorganisms. One case of septicaemia caused by S. aureus after implantation of an IUD5 is found in the literature; however, the patient in addition to septicaemia, had focality in the upper genital tract; there are no reported cases of bacteraemia due to gynaecological IUD manipulation without coexistence of pelvic inflammatory disease. Our case is atypical both in terms of the type of microorganisms that cause infection as well as the manner of presentation, therefore, it should be considered in women that, without pelvic infectious foci, develop an infectious condition after IUD manipulation. References 1. Duhon B, Dallas S, Velasquez ST, Hand E. Staphylococcus lugdunensis bacteremia and endocarditis treated with cefazolin and rifampicin. Am J Health Syst Pharm. 2015;72:1114–8. 2. Matas A, Velga A, Gabriel JP. Brain abscess due to Staphylococcus lugdunensis in the absence of endocarditis o bacteremia. Case Rep Neurol. 2015;7:1–5. 3. Bieber L, Kahlmeter G. Staphylococcus lugdunensis in several niches of the normal skin flora. Clin Microbiol Infect. 2010;16:385–8. 4. Stöllberger C, Wechsler-Fördös A, Geppert F, Gulz W, Brownstone E, Nicolakis M, et al. Staphylococcus warneri endocarditis after implantation of a lumbar disc prosthesis in an immunocompetent patient. J Infect. 2006;52:e15–8. 5. Geddes AM. Staphylococcal septicaemia after insertion of an intrauterine contraceptive device. Br Med J. 1980;281:1639.
Elena Prado Mel a,∗ , María Gil López b , Antonio Bernabé Rojas Ramírez b a
Servicio de Farmacia, Hospital La Inmaculada, Servicio Andaluz de Salud, Huércal-Overa, Almería, Spain b Servicio de Urgencias, Hospital Comarcal La Merced, Servicio Andaluz de Salud, Osuna, Sevilla, Spain ∗ Corresponding author. E-mail address: [email protected] (E. Prado Mel).
www.elsevier.es/medicinaclinica
Letter to the Editor Staphylococcus warneri and Staphylococcus lugdunensis bacteriemia after handling intrauterine device夽 Bacteriemia por Staphylococcus warneri y Staphylococcus lugdunensis tras manipulación de dispositivo intrauterino Dear Editor, The most common infection caused by insertion or manipulation of an intrauterine device (IUD) is pelvic inflammatory disease, and the microorganisms most frequently involved are Chlamydia trachomatis, Neisseria gonorrhoeae or Escherichia coli, among others. The incidence of infection is low. Revisions have been carried out about antibiotic prophylaxis prior to IUD insertion without conclusive data being obtained. We report a case of bacteraemia 24 h after gynaecological manipulation. A 56-year-old obese female with hypertension, diabetes mellitus, anxiety-depressive syndrome and fibromyalgia. Hormonal IUD carrier. She went to the emergency room for severe asthenia, headache, decreased urine output and syncope without loss of consciousness at home. Twenty-four hours earlier she had a IUD gynaecological examination, subsequently presenting severe headache and hypertensive crisis treated in her health centre. Upon arrival to the emergency room the patient was conscious, alert, eupnoeic at rest, no tachycardia or tachypnea, hypotensive (BP 87/59 mmHg), with HR 90 bpm and SatO2 98% without input. Lab results showed levels of haemoglobin at 9.3 g/dl, leukopenia with left shift (3.12 mill/mm3 ) and thrombocytopenia (25,000/mm3 ). Biochemistry showed hyperglycaemia at 170 mg/dl, urea at 95 mg/dL, creatinine at 2.27 mg/dl and CRP at 314.9 mg/l. Proteins, erythrocytes and leukocytes appeared in urine, with negative nitrites. Urine and blood cultures were requested, empirical antibiotic treatment was started with ceftriaxone 2 g iv/24 h and the patient was admitted to Internal Medicine. Blood culture, with 3 samples taken, was positive to methicillinresistant Staphylococcus warneri and Staphylococcus lugdunensis in the 3 instances, both sensitive to aminoglycosides and resistant to quinolones and penicillins. Following the results of blood cultures, the patient underwent transthoracic and transesophageal echocardiography so as to rule out endocarditis, without visualizing warts or lesions compatible with the said infectious condition. The antibiotic was changed to vancomycin 1 g/12 h and gentamicin 120 mg/8 h during 15 days of admission, performing a control blood culture after 10 days of treatment, which was negative and a transthoracic echocardiography, which was also negative for
夽 Please cite this article as: Prado Mel E, Gil López M, Rojas Ramírez AB. Bacteriemia por Staphylococcus warneri y Staphylococcus lugdunensis tras manipulación de dispositivo intrauterino. Med Clin (Barc). 2016;147:e21. ˜ S.L.U. All rights reserved. 2387-0206/© 2016 Elsevier Espana,
endocarditis. The patient was discharged after 25 days of hospital admission. S. warneri and S. lugdenensis are coagulase-negative staphylococci (CNS). S. lugdenensis presents major differences with other microorganisms in their group. Currently it is closer to Staphylococcus aureus than to the CNS, being highly virulent and causing infectious processes, sepsis and/or endocarditis.1 A case of isolated brain abscess2 was recently published without coexistence of bacteraemia and/or endocarditis, which points to the bacterium’s migration and virulence ability. Several studies establish S. lugdenensis as part of the normal microbial flora,3 being especially located in the lower abdominal area, perineum and lower extremities. In the case of S. warneri, however, the incidence and virulence of the microorganism are lower4 compared to S. lugdenensis and it is usually associated with the implantation of prosthetic and/or medical devices. In our case, the patient had bacteraemia caused by both microorganisms, without genital involvement; IUD implantation is associated with the occurrence of infections localized in the upper genital tract, with or without bacteraemia and by different microorganisms. One case of septicaemia caused by S. aureus after implantation of an IUD5 is found in the literature; however, the patient in addition to septicaemia, had focality in the upper genital tract; there are no reported cases of bacteraemia due to gynaecological IUD manipulation without coexistence of pelvic inflammatory disease. Our case is atypical both in terms of the type of microorganisms that cause infection as well as the manner of presentation, therefore, it should be considered in women that, without pelvic infectious foci, develop an infectious condition after IUD manipulation. References 1. Duhon B, Dallas S, Velasquez ST, Hand E. Staphylococcus lugdunensis bacteremia and endocarditis treated with cefazolin and rifampicin. Am J Health Syst Pharm. 2015;72:1114–8. 2. Matas A, Velga A, Gabriel JP. Brain abscess due to Staphylococcus lugdunensis in the absence of endocarditis o bacteremia. Case Rep Neurol. 2015;7:1–5. 3. Bieber L, Kahlmeter G. Staphylococcus lugdunensis in several niches of the normal skin flora. Clin Microbiol Infect. 2010;16:385–8. 4. Stöllberger C, Wechsler-Fördös A, Geppert F, Gulz W, Brownstone E, Nicolakis M, et al. Staphylococcus warneri endocarditis after implantation of a lumbar disc prosthesis in an immunocompetent patient. J Infect. 2006;52:e15–8. 5. Geddes AM. Staphylococcal septicaemia after insertion of an intrauterine contraceptive device. Br Med J. 1980;281:1639.
Elena Prado Mel a,∗ , María Gil López b , Antonio Bernabé Rojas Ramírez b a
Servicio de Farmacia, Hospital La Inmaculada, Servicio Andaluz de Salud, Huércal-Overa, Almería, Spain b Servicio de Urgencias, Hospital Comarcal La Merced, Servicio Andaluz de Salud, Osuna, Sevilla, Spain ∗ Corresponding author. E-mail address: [email protected] (E. Prado Mel).