Actinomyces neuii: a case series and review of a rarely ...
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Actinomyces neuii: a case series and review of a rarely encountered pathogen Nathan Zelyas 1 , Susan Gee 1 , Barb Nilsson 2 , Tracy Bennett 3 , Robert Rennie 1 1 Provincial Laboratory for Public Health, Edmonton, Alberta, Canada; 2 Queen Elizabeth Hospital, Grande Prairie, Alberta, Canada; 3 Red Deer Regional Hospital, Red Deer, Alberta, Canada Introduction and Purpose Methods Results Acknowledgements The use of newer identification methods in clinical microbiology laboratories, such as matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF), have improved the ability to detect uncommon microbes. It has therefore become more important to understand the clinical significance and therapeutic options when identifying these less common organisms. One such rarely-encountered pathogen, Actinomyces neuii, is a Gram- positive coryneform rod which is catalase positive. While there are published case reports and series describing infections caused by this unusual pathogen, it is likely under- recognized due to its “coryneform” appearance and biochemical properties. The purpose of this study was : • To describe cases of A. neuii infections in Alberta, Canada • To review the literature concerning the pathogenicity of A. neuii • Clinical specimens were submitted to respective local microbiology laboratories during 2013 and 2014 in Alberta, Canada • Specimens were cultured aerobically and anaerobically on commonly-used bacterial culture media including sheep blood agar (SBA), brain heart infusion agar, (BHI) and phenylethyl alcohol agar • Isolates were tested with the Gram stain, the catalase test, and gas-liquid chromatography • One isolate was initially identified using the API-CORYNE® (bioMérieux) test strip • All isolates were subjected to MALDI-TOF (Vitek-MS, bioMérieux) • Four of seven isolates were subjected to 16S rRNA gene sequencing • Susceptibility testing was carried out at 48 hours with growth on laked sheep blood agar in anaerobic conditions Figure 2. Gram stain of A. neuii after 24 hours’ growth in O 2 on SBA. Figure 1. Growth of A. neuii after 48 hours on SBA in (A) CO 2 , (B) O 2 , and (C) anaerobically; (D) growth on BHI anaerobically. A D C B References Conclusions • Seven A. neuii isolates were identified (clinical and microbiologic characteristics of six are noted in Table 1) • Each grew as a Gram-positive non-filamentous, non-branching bacillus, and was catalase positive Age, sex Comorbidities Infection Gram stain Co-isolates Susceptibility of A. neuii isolates Treatment 30, M Previous head injury, right ACL repair Left thigh abscess 4+WBC 4+GPC 4+GPB Prevotella bivia Anaerobic GPC Penicillin S Amox/clav S Imipenem S Vancomycin S Clindamycin R Incision and drainage Cephalexin 7d 45, M TIIDM, dyslipidemia Left inguinal abscess 3+WBC 2+GPC 2+GNB 1+GPB Staphylococcus lugdunensis Anaerobic GPC Penicillin S Amox/clav S Imipenem S Vancomycin S Clindamycin S Incision and drainage Cephalexin 7d 46, M Paraplegia, renal calculi, atrial fibrillation, previous endocarditis, sacral ulcer Right axillary abscess 3+WBC 3+GPB 2+GPC None Penicillin S Amox/clav S Imipenem S Vancomycin S Clindamycin S Incision and drainage Cephalexin 48, M Hypertension, TIIDM, obesity, previous Fournier’s gangrene, diabetic foot infections Right groin abscess 3+WBC 3+GPB 3+GNB 2+GPC Proteus mirabilis Staphylococcus lugdunensis Actinomyces sp. Mixed anaerobes Penicillin S Amox/clav S Imipenem S Vancomycin S Clindamycin S Incision and drainage Ceftriaxone 3d Ertapenem 5d Amox/clav 10d 68, M Bilateral spermatoceles with spermatocelectomies Post- operative right scrotum abscess 2+WBC 3+GPC 2+GPB 2+GNB Coagulase negative Staphylococci Coryneforms Propionibacterium sp. Penicillin S Amox/clav S Imipenem S Vancomycin S Clindamycin S Ciprofloxacin 28d 85, F Hypertension, hypothyroidism, celiac disease Post-biopsy left ankle ulcer 3+GNB 2+GPC Acinetobacter baumannii/ calcoaceticus complex Streptococcus agalactiae Penicillin S Amox/clav S Imipenem S Vancomycin S Clindamycin S Wound care Clindamycin 10d Cephalexin 7d Total number of cases in the literature 90 Mean age (years) 49.6 Age range (years) 0-94 Males/females 1 44/41 Susceptible β-lactams 2 , vancomycin, clindamycin, erythromycin Resistant or variable susceptibility Fluoroquinolones, TMP-SMX, tetracycline, aminoglycosides Treatment regimen Source control with β-lactam therapy Abscess/infected atheroma (1-5) Cutaneous infection (5) Bacteremia (5,6) Genitourinary infection (5,6) Prosthetic material infection (7-11) Endophthalmitis (12-16) 1.1% Osteomyelitis (17) 1.1% Endocarditis (18) 1.1% Pericarditis (19) 59% 10% 8.9% 6.7% 6.7% 5.6% Figure 4. Distribution of A. neuii infections. Table 2. Patient characteristics, susceptibility profiles, and treatment of A. neuii infections from previous reports. 1 85/90 cases reported age and sex 2 β-lactams tested include penicillin, ampicillin, cefazolin, cefuroxime, ceftriaxone, and imipenem Table 1. Clinical and microbiological characteristics of patients with A. neuii infections. 1. Clarridge JE, Zhang Q. 2002. JCM 40:3442-3448. 2. Funke G, von Graevenitz A. 1995. Infection 23:73-75. 3. Gomez-Garces JL, Saez-Nieto JA. 2010. JCM 48:1508-1509. 4. Lacoste C, Escande M-C, Jammet P. 2009. Diagn Cytopath 37:311-312. 5. Roustan A, Al Nakib M, Boubli L. 2009. J Gynecol Obstet Biol Reprod (Paris) 39:64-67. 6. Mann C, Dertinger S, Hartmann G, Schurz R, Simma B. 2002. Infection 30:178-180. 7. Brunner S, Graf S, Riegel P, Altwegg M. 2000. Int J Med Microbiol 290:285-287. 8. Grundmann S, Huebner J, Stuplich J, Koch A, Wu K, Geibel-Zehender A, Bode C, Brunner M. 2010. JCM 48:1008-11. 9. Hsi RS, Hotaling JM, Spencer ES, Bollyky PL, Walsh TJ. 2011. J Sex Med 8:923-926. 10. Rieber H, Schwarz R, Kramer O, Cordier W, Frommelt L. 2009. JCM 47:4183-4184. 11. Watkins RR, Anthony K, Schroder S, Hall GS. 2008. JCM 46: 1888-1889. 12. Coudron PE, Harris RC, Vaughan MG, Dalton HP. 1985. JCM 22:475-477. 13. Garelick JM, Khodabakhsh AJ, Josephberg RG. 2002. Am J Ophthamol 133:145-147. 14. Graffi S, Peretz A, Naftali M. 2012. Eur J Ophthalmol 22:834-835. 15. Perez-Santonja JJ, Campos-Mollo E, Fuentes-Campos E, Samper-Gimenez J, Alio JL. 2007. Eur J Ophthalmol 17:445-447. 16. Raman VS, Evans N, Shreshta B, Cunningham R. 2004. J Cataract Refract Surg 30:2641-2643. 17. Van Bosterhaut B, Boucquey P, Janssens M, Wauters G, Delmee M. 2002. Eur J Clin Microbiol Infect Dis 21: 486-487. 18. Cohen E, Bishara J, Medalion B, Sagie A, Garty M. 2006. Scand J Infect Dis 39:180-183. 19. Levy P-Y, Fournier P-E, Charrel R, Metras D, Habib G, Raoult D. 2006. Eur Heart J 27:1942-1946. • A. neuii is an atypical pathogen which will likely be detected with greater frequency with increased use of advanced identification systems (such as MALDI-TOF) • Understanding that this organism predominantly participates in abscesses and soft tissue infections and is usually susceptible to β-lactams will aid in clinical decision- making when it is isolated from patients • These findings also highlight the pathogenic potential of coryneform bacteria which resemble skin flora We would like to thank Drs. Alain Brassard, Karen Doucette, Barry Norris, Adam Hrdlicka, and Juan San Vicente for providing patients’ clinical details.
Transcript of Actinomyces neuii: a case series and review of a rarely ...
Actinomyces neuii: a case series and review of a rarely encountered pathogen Nathan Zelyas1, Susan Gee1, Barb Nilsson2, Tracy Bennett3, Robert Rennie1
1Provincial Laboratory for Public Health, Edmonton, Alberta, Canada; 2Queen Elizabeth Hospital, Grande Prairie, Alberta, Canada; 3Red Deer Regional Hospital, Red Deer, Alberta, Canada
Introduction and Purpose
Methods
Results
Acknowledgements
The use of newer identification methods in clinical microbiology laboratories, such as matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF), have improved the ability to detect uncommon microbes. It has therefore become more important to understand the clinical significance and therapeutic options when identifying these less common organisms. One such rarely-encountered pathogen, Actinomyces neuii, is a Gram-positive coryneform rod which is catalase positive. While there are published case reports and series describing infections caused by this unusual pathogen, it is likely under-recognized due to its “coryneform” appearance and biochemical properties. The purpose of this study was : • To describe cases of A. neuii infections in Alberta, Canada • To review the literature concerning the pathogenicity of A. neuii
• Clinical specimens were submitted to respective local microbiology laboratories during 2013 and 2014 in Alberta, Canada
• Specimens were cultured aerobically and anaerobically on commonly-used bacterial culture media including sheep blood agar (SBA), brain heart infusion agar, (BHI) and phenylethyl alcohol agar
• Isolates were tested with the Gram stain, the catalase test, and gas-liquid chromatography
• One isolate was initially identified using the API-CORYNE® (bioMérieux) test strip
• All isolates were subjected to MALDI-TOF (Vitek-MS, bioMérieux) • Four of seven isolates were subjected to 16S rRNA gene sequencing • Susceptibility testing was carried out at 48 hours with growth on laked sheep blood
agar in anaerobic conditions
Figure 2. Gram stain of A. neuii after 24 hours’ growth in O2 on SBA.
Figure 1. Growth of A. neuii after 48 hours on SBA in (A) CO2, (B) O2, and (C) anaerobically; (D) growth on BHI anaerobically.
A
D
C
B
References Conclusions
• Seven A. neuii isolates were identified (clinical and microbiologic characteristics of six are noted in Table 1) • Each grew as a Gram-positive non-filamentous, non-branching bacillus, and was catalase positive
Age, sex Comorbidities Infection Gram stain
Co-isolates Susceptibility of A. neuii isolates
Treatment
30, M Previous head injury, right ACL repair
Left thigh abscess
4+WBC 4+GPC 4+GPB
Prevotella bivia Anaerobic GPC
Penicillin S Amox/clav S Imipenem S
Vancomycin S Clindamycin R
Incision and drainage Cephalexin 7d
45, M TIIDM, dyslipidemia Left inguinal abscess
3+WBC 2+GPC 2+GNB 1+GPB
Staphylococcus lugdunensis Anaerobic GPC
Penicillin S Amox/clav S Imipenem S
Vancomycin S Clindamycin S
Incision and drainage Cephalexin 7d
46, M Paraplegia, renal calculi, atrial fibrillation, previous endocarditis, sacral ulcer
Right axillary abscess
3+WBC 3+GPB 2+GPC
None
Penicillin S Amox/clav S Imipenem S
Vancomycin S Clindamycin S
Incision and drainage Cephalexin
48, M Hypertension, TIIDM, obesity, previous Fournier’s
gangrene, diabetic foot infections
Right groin abscess
3+WBC 3+GPB 3+GNB 2+GPC
Proteus mirabilis Staphylococcus lugdunensis
Actinomyces sp. Mixed anaerobes
Penicillin S Amox/clav S Imipenem S
Vancomycin S Clindamycin S
Incision and drainage Ceftriaxone 3d Ertapenem 5d Amox/clav 10d
68, M Bilateral spermatoceles with spermatocelectomies
Post-operative
right scrotum abscess
2+WBC 3+GPC 2+GPB 2+GNB
Coagulase negative Staphylococci Coryneforms
Propionibacterium sp.
Penicillin S Amox/clav S Imipenem S
Vancomycin S Clindamycin S
Ciprofloxacin 28d
85, F Hypertension, hypothyroidism, celiac
disease
Post-biopsy left ankle
ulcer
3+GNB 2+GPC
Acinetobacter baumannii/ calcoaceticus complex
Streptococcus agalactiae
Penicillin S Amox/clav S Imipenem S
Vancomycin S Clindamycin S
Wound care Clindamycin 10d
Cephalexin 7d
Total number of cases in the literature 90
Mean age (years) 49.6
Age range (years) 0-94
Males/females1 44/41
Susceptible β-lactams2, vancomycin, clindamycin, erythromycin
Resistant or variable susceptibility Fluoroquinolones, TMP-SMX, tetracycline, aminoglycosides
Treatment regimen Source control with β-lactam therapy
Abscess/infected atheroma (1-5)
Cutaneous infection (5)
Bacteremia (5,6)
Genitourinary infection (5,6)
Prosthetic material infection (7-11)
Endophthalmitis (12-16)
1.1% Osteomyelitis (17)
1.1% Endocarditis (18)
1.1% Pericarditis (19)
59%
10% 8.9%
6.7%
6.7%
5.6%
Figure 4. Distribution of A. neuii infections.
Table 2. Patient characteristics, susceptibility profiles, and treatment of A. neuii infections from previous reports. 1 85/90 cases reported age and sex 2 β-lactams tested include penicillin, ampicillin, cefazolin, cefuroxime, ceftriaxone, and imipenem
Table 1. Clinical and microbiological characteristics of patients with A. neuii infections.
1. Clarridge JE, Zhang Q. 2002. JCM 40:3442-3448. 2. Funke G, von Graevenitz A. 1995. Infection 23:73-75. 3. Gomez-Garces JL, Saez-Nieto JA. 2010. JCM 48:1508-1509. 4. Lacoste C, Escande M-C, Jammet P. 2009. Diagn Cytopath 37:311-312. 5. Roustan A, Al Nakib M, Boubli L. 2009. J Gynecol Obstet Biol Reprod (Paris) 39:64-67. 6. Mann C, Dertinger S, Hartmann G, Schurz R, Simma B. 2002. Infection 30:178-180. 7. Brunner S, Graf S, Riegel P, Altwegg M. 2000. Int J Med Microbiol 290:285-287. 8. Grundmann S, Huebner J, Stuplich J, Koch A, Wu K, Geibel-Zehender A, Bode C, Brunner M. 2010. JCM 48:1008-11. 9. Hsi RS, Hotaling JM, Spencer ES, Bollyky PL, Walsh TJ. 2011. J Sex Med 8:923-926. 10. Rieber H, Schwarz R, Kramer O, Cordier W, Frommelt L. 2009. JCM 47:4183-4184. 11. Watkins RR, Anthony K, Schroder S, Hall GS. 2008. JCM 46: 1888-1889. 12. Coudron PE, Harris RC, Vaughan MG, Dalton HP. 1985. JCM 22:475-477. 13. Garelick JM, Khodabakhsh AJ, Josephberg RG. 2002. Am J Ophthamol 133:145-147. 14. Graffi S, Peretz A, Naftali M. 2012. Eur J Ophthalmol 22:834-835. 15. Perez-Santonja JJ, Campos-Mollo E, Fuentes-Campos E, Samper-Gimenez J, Alio JL. 2007. Eur J Ophthalmol 17:445-447. 16. Raman VS, Evans N, Shreshta B, Cunningham R. 2004. J Cataract Refract Surg 30:2641-2643. 17. Van Bosterhaut B, Boucquey P, Janssens M, Wauters G, Delmee M. 2002. Eur J Clin Microbiol Infect Dis 21: 486-487. 18. Cohen E, Bishara J, Medalion B, Sagie A, Garty M. 2006. Scand J Infect Dis 39:180-183. 19. Levy P-Y, Fournier P-E, Charrel R, Metras D, Habib G, Raoult D. 2006. Eur Heart J 27:1942-1946.
• A. neuii is an atypical pathogen which will likely be detected with greater frequency with increased use of advanced identification systems (such as MALDI-TOF)
• Understanding that this organism predominantly participates in abscesses and soft tissue infections and is usually susceptible to β-lactams will aid in clinical decision-making when it is isolated from patients
• These findings also highlight the pathogenic potential of coryneform bacteria which resemble skin flora
We would like to thank Drs. Alain Brassard, Karen Doucette, Barry Norris, Adam Hrdlicka, and Juan San Vicente for providing patients’ clinical details.
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