Jun 27, 1995 - administered via the PAC for 1 week. Forty-six weeks after the implantation of the PAC, a second F. oryzihabitans bacteremia following the ...
JOURNAL OF CLINICAL MICROBIOLOGY, Nov. 1995, p. 3047–3048 0095-1137/95/$04.0010 Copyright q 1995, American Society for Microbiology
Vol. 33, No. 11
Case of Recurrent Flavimonas oryzihabitans Bacteremia Associated with an Implanted Central Venous Catheter (Port-A-Cath): Assessment of Clonality by Arbitrarily Primed PCR BRUNO VERHASSELT,1 GEERT CLAEYS,1 ABDESLAM ELAICHOUNI,1 GERDA VERSCHRAEGEN,1 ` VE LAUREYS,2 AND MARIO VANEECHOUTTE1* GENEVIE Department of Clinical Chemistry, Microbiology and Immunology1 and Department of Pediatrics,2 University Hospital Ghent, Ghent, Belgium Received 21 April 1995/Returned for modification 27 June 1995/Accepted 14 August 1995
Flavimonas oryzihabitans bacteremias, which occurred immediately after the flushing or use of an implanted central venous catheter (Port-A-Cath) in two patients at the same pediatric ward, were studied by arbitrarily primed PCR. We conclude that the colonization of the Port-A-Cath with F. oryzihabitans described here lasted for several months.
was documented. The blood culture also yielded S. epidermidis. Treatment with ceftriaxone (100 mg/kg) and teicoplanin (10 mg/kg) in a single daily dose was given at home via the PAC for 4 days, during which time the patient remained afebrile. Sixtyone weeks after implantation, a third F. oryzihabitans bacteremia, again concomitant with S. epidermidis, following the infusion of platelets via the PAC was observed. In contrast to the previous febrile episodes, the patient was now neutropenic (619 3 106 neutrophils per liter). Netilmicin (7.5 mg/kg) and piperacillin (200 mg/kg) were administered for 3 days via the PAC, and this was followed by home treatment with teicoplanin (10 mg/kg) and ceftriaxone (100 mg/kg) for 9 days. Because of the lack of response to chemotherapy and a worsening prognosis, chemotherapy was ceased some weeks later. The PAC was left in place unused, and no further febrile episodes were observed. Because of tumor progression, the patient died 80 weeks after the implantation of the PAC. Patient 2 was a boy who was admitted to our hospital at the age of 2 years and 8 months and who was suffering from severe anemia due to acute lymphoblastic leukemia, pre-pre-B (FAB L1). A PAC was inserted in a cephalic vein. Twelve weeks after the insertion, a short febrile episode following vincristine sulfate therapy was observed. A blood culture grew F. oryzihabitans. However, no antibiotic therapy was started, and the fever disappeared within a few hours. This F. oryzihabitans bacteremia occurred within 1 week after the second F. oryzihabitans bacteremia of patient 1. No further bacteremia was demonstrated in this patient until the removal of the PAC. The PAC had to be removed 24 weeks after insertion because of a Staphylococcus aureus infection of the site of entry. In all four episodes, fever was observed within 1 h after the infusion of various products via the PAC, but it always resolved in less than 12 h without apparent infectious complications. Blood samples were immediately taken via the PAC and cultured in a BacT/Alert hemoculture system (Organon Teknika, Turnhout, Belgium). In patient 1, antibiotic therapy was started shortly after blood sampling. The four gram-negative nonfermenting isolates were identified as F. oryzihabitans with a commercial kit (API20NE; BioMe´rieux, Marcy-l’Etoile, France). Also, the type strains (LMG Culture Collection, Ghent, Belgium) of Chryseomonas luteola (ATCC 43273), which is a closely related species (3, 4), and of F. oryzihabitans
Catheters for long-term vascular access are implanted by surgery and can be left in place for several years (6). Port-ACath (Low Profile; Pharmacia Deltec) (PAC) devices are indwelling catheters connected to a subdermal port, allowing frequent puncturing through intact skin. Catheter-related infection, the most frequent complication, is defined as bacteremia and/or exit-site infection and/or tunnel infection (6). Infections occur at a rate of 0.04 (2) to 0.002 (11) per 100 days of catheterization. Most frequently, gram-positive cocci, especially Staphylococcus epidermidis, are isolated (2). It is generally accepted that the catheter has to be replaced if clinical symptoms of catheter infection do not resolve after antibiotic therapy (2, 11). However, catheter-related infections with Flavimonas oryzihabitans do not usually require removal of the catheter (5). F. oryzihabitans, a gram-negative, nonfermenting bacillus, has until the present been reported to have caused infections in humans in about 60 cases (8, 9). Infections with this organism are typically related to the presence of an intravascular catheter in immunocompromised hosts (5). Here, we present a total of four episodes of PAC-related F. oryzihabitans bacteremia which occurred in two patients who were treated by the same team on the same ward. The clonal relationship of the four isolates was investigated. Patient 1 was a severely ill boy who was admitted to our hospital at the age of 3 and who had a painful abdomen. A stage IV neuroblastoma was diagnosed. As an access for intravenous chemotherapy, a PAC was inserted in a cephalic vein. An episode of fever and chills was observed after the catheter was flushed with a sterile 0.85% (wt/vol) NaCl solution 15 weeks after the implantation of the catheter. A blood culture demonstrated the presence of F. oryzihabitans. Netilmicin (7.5 mg/kg of body weight daily) and piperacillin (200 mg/kg) were administered via the PAC for 1 week. Forty-six weeks after the implantation of the PAC, a second F. oryzihabitans bacteremia following the infusion of packed erythrocytes through the PAC * Corresponding author. Mailing address: Department of Clinical Chemistry, Microbiology and Immunology, Blok A, University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium. Phone: 32 9 240 36 92. Fax: 32 9 240 36 59. Electronic mail address: Mario.Vaneechoutte @rug.ac.be. 3047
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colonization of the PAC of patient 1 with F. oryzihabitans was due to the persistent presence of a single clone and not to reinfection and that the F. oryzihabitans isolate from patient 2 was acquired independently of that from patient 1. As for the cases described here, the source of the F. oryzihabitans bacteremia is in both cases obscure. Patient 1 represents, to our knowledge, the first patient with a recurrent infection documented to be caused by a single F. oryzihabitans clone. Persistent colonization of the PAC despite adequate antimicrobial therapy through the PAC is the probable source. Especially for an immunocompromised host, catheter-related F. oryzihabitans infection should alert the physician to the possibility of catheter colonization. FIG. 1. Arbitrarily primed PCR fingerprints obtained by independent use of three primers for different F. oryzihabitans isolates. Lanes: M, marker (marker VI; Boehringer, Mannheim, Germany); T, F. oryzihabitans type strain ATCC 43272; 1a, 1b, and 1c, subsequent F. oryzihabitans isolates from patient 1; 2, F. oryzihabitans isolate from patient 2. Molecular sizes are indicated in base pairs.
We thank Ann De Rouck for excellent technical assistance, Christiaan De Boever for photographs, and Dominique Bullens for the supply of clinical data. REFERENCES
(ATCC 43272) were included as a control for the reliability of the identification kit. Antimicrobial susceptibility testing was carried out according to National Committee for Clinical Laboratory Standards criteria (7) on Mueller-Hinton II agar (Becton Dickinson Europe, Meylan, France) with disks (Oxoid, Basingstoke, United Kingdom) of ampicillin, sulfamethoxazoletrimethoprim, cefuroxime, gentamicin, colistin sulfate, temocillin, ofloxacin, amikacin, piperacillin, cefotaxime, ceftazidime, aztreonam, and imipenem. Clonal identity was assessed by arbitrarily primed PCR (10, 12) with three different primers, as described previously (1). The primer sequences were CTC CCACCXCCXAGA (M13c), GTTGGTGGCT (OPM1), and TCACGATGCA (PH1). The arbitrarily primed PCR patterns of the F. oryzihabitans type strain were compared with those obtained for the four clinical isolates. In both patients, the fever and bacteremia followed the flushing or use of the PAC, strongly suggesting that catheter colonization was implicated in the observed symptoms. Direct evidence could not be obtained, since the PAC devices were not available for culture. Since the disk diffusion antimicrobial susceptibility tests showed various susceptibilities of the different F. oryzihabitans isolates to ampicillin, sulfamethoxazole-trimethoprim, and cefuroxime, no clonal relationship between the isolates was evident. All the isolates were susceptible to all the other antibiotics tested, except for temocillin. Arbitrarily primed PCR revealed that the three isolates from patient 1 (Fig. 1, lanes 1a, 1b, and 1c) had highly identical fingerprints which could be differentiated easily from those of the type strain (Fig. 1, lanes T) and those of the isolate of patient 2 (Fig. 1, lanes 2). This leads to the conclusion that the
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