Methicillin‐Resistant Staphylococcus intermedius Pneumonia Following...
2
7. Portolani M, Pietrosemoli P, Meacci M, et al. Detection of Epstein-Barr virus DNA in cerebrospinal fluid from immunocompetent individuals with brain disorders. Microbiologica 1998;21:77–9. 8. Studahl M, Bergstro ¨m T, Hagberg L. Acute viral encephalitis in adults— a prospective study. Scand J Infect Dis 1998;30:215–20. 9. Tang YW, Espy MJ, Persing DH, Smith TF. Molecular evidence and clinical significance of herpesvirus coinfection in the central nervous system. J Clin Microbiol 1997;35:2869 –72. Methicillin-Resistant Staphylococcus intermedius Pneumonia Following Coronary Artery Bypass Grafting All tube coagulase-positive staphylococci were identified as Staph- ylococcus aureus until Hajek [1] distinguished Staphylococcus inter- medius as a separate species. This organism is tube coagulase- positive, but the cell wall does not contain protein A. Clumping factor is present only in 14% of isolates [1]. Commercial latex agglutination tests that detect clumping factor or protein A often misidentify S. intermedius isolates as “coagulase-negative staphylococci.” We report a case of S. intermedius pneumonia in which sputum cultures reported positive for “staphylococcus not aureus” (SNA) were ini- tially dismissed as containing only nonpathogens. After the patient’s condition failed to improve with standard therapy and the organism was isolated repeatedly in pure cultures, clinical suspicion increased, and the organism was identified to the species level. A 73-year-old man with a history of type II diabetes mellitus underwent coronary artery bypass grafting. On postoperative day 5, the patient had fever (temperature to 38.8°C) and a large amount of pulmonary secretions that required nasotracheal suctioning four to five times a day. A chest radiograph showed a left lower lobe infiltrate, and ceftriaxone therapy was started. Fevers (temperatures as high as 39.2°C) continued, and on postoperative day 9, therapy was changed to ceftazidime and gentamicin. Gram staining of a sputum sample taken on that day revealed moderate polymorphonuclear leukocytes and moderate gram-positive cocci. Culture yielded moderate growth of a Staphylococcus strain that was negative for clumping factor and protein A by the Staphaureux test (Murex Biotech Limited, Dartford, UK). Our laboratory reported this strain as SNA. The patient required reintubation on the 11th postoperative day for respiratory failure. Therapy with ceftazidime and gentamicin was discontinued, and treatment with piperacillin/tazobactam was started. On the 14th postoperative day, flexible bronchos- copy showed marked bilateral thick mucoid lower lobe secre- tions causing obstruction. The patient no longer required ven- tilatory assistance on the 15th postoperative day but continued to require frequent suctioning via the tracheostomy tube to clear copious amounts of purulent secretions. By the 21st postoperative day, the patient remained febrile, and cultures of seven sputum specimens yielded pure growth of SNA. Further testing of the organism was requested. A tube coagulase test was positive. SNA isolates were identified as S. intermedius, and antimicrobial susceptibility testing was performed by using the Vitek System (bioMe ´rieux Vitek, Hazelwood, MO) and standard laboratory testing [2]. The isolates were susceptible to trimethoprim- sulfamethoxazole (0.25 mg/mL), gentamicin (0.5 mg/mL), and vancomycin (0.5 mg/mL) and resistant to penicillin (.4.0 mg/mL), oxacillin (.32.0 mg/mL), cefazolin (.64.0 mg/mL), cefotaxime (.64.0 mg/mL), clindamycin (.16.0 mg/mL), erythromycin (32.0 mg/mL), and ofloxacin (32.0 mg/mL). Therapy with vancomycin was started on the 21st postoperative day. After 24 hours of therapy, he was afebrile. A chest radiograph 1 month after discharge showed a small left pleural effusion with no infiltrates. S. intermedius is a common zoonotic organism found in dogs, pigeons, minks, cats, horses, foxes, raccoons, goats, and gray squirrels [3]. The organism is a well-described cause of human disease following canine-inflicted bite wounds [4]. Cellulitis and a malodorous discharge are common, while regional adenopathy, fever, and lymphangitis occur only in 20% of cases [4]. There have been few case reports describing invasive human disease. The organism was isolated as pure growth in cultures of specimens from three patients with non-canine-inflicted wounds [5]. A 17-year-old HIV-infected patient had S. intermedius tricus- pid valve endocarditis [6]. A third case report described a 63-year- old man; S. intermedius was isolated from three sets of blood cultures and from a culture of the tip of a permanent intravenous device that had been removed [3]. To our knowledge, this is the first reported case of S. interme- dius pneumonia and the first report of methicillin resistance in a human isolate. Several studies that tested S. intermedius isolates from different species reported susceptibility to oxacillin and, in some cases, penicillin [7]. The origin of the organism in our case is unknown. The patient had no exposure to dogs. It is unlikely that he was infected by colonized medical personnel since only 0.7% of veterinary staff with daily exposure to canines were found to have S. intermedius as part of their nasopharyngeal flora [8]. Pathogenicity is thought to correlate with the ability of both S. aureus and coagulase-positive SNA to produce coagulase [9]. Coagulase production may be missed in clinical laboratories where commercial latex agglutination tests have replaced the tube coag- ulase test. Although these tests have a sensitivity of 98.8%–99.3% and a specificity of 97.9%–100% for the identification of S. aureus [10], their ability to identify S. intermedius or other coagulase- positive SNA species is poor. We believe that staphylococci found to be negative by latex agglutination tests should be reported as “SNA” rather than “coagulase-negative staphylococci.” Kimberly Gerstadt, Jennifer S. Daly, Michael Mitchell, Mireya Wessolossky, and Sarah H. Cheeseman Departments of Medicine and Pathology, UMass Memorial Health Care and University of Massachusetts Medical School, Worcester, Massachusetts References 1. Hajek V. Staphylococcus intermedius, a new species isolated from ani- mals. Int J Syst Bacteriol 1976;26:401– 8. Reprints or correspondence: Dr. Jennifer S. Daly, Infectious Diseases, UMass Memorial Health Care, 55 Lake Avenue North, Worcester, Massachusetts 01655 ([email protected]). Clinical Infectious Diseases 1999;29:218 –9 © 1999 by the Infectious Diseases Society of America. All rights reserved. 1058 – 4838/99/2901– 0044$03.00 218 Brief Reports CID 1999;29 (July) at Northeastern University Libraries on October 2, 2014 http://cid.oxfordjournals.org/ Downloaded from
Transcript of Methicillin‐Resistant Staphylococcus intermedius Pneumonia Following...
7. Portolani M, Pietrosemoli P, Meacci M, et al. Detection of Epstein-Barrvirus DNA in cerebrospinal fluid from immunocompetent individualswith brain disorders. Microbiologica 1998;21:77–9.
8. Studahl M, Bergstrom T, Hagberg L. Acute viral encephalitis in adults—
a prospective study. Scand J Infect Dis 1998;30:215–20.9. Tang YW, Espy MJ, Persing DH, Smith TF. Molecular evidence and
clinical significance of herpesvirus coinfection in the central nervoussystem. J Clin Microbiol 1997;35:2869–72.
Methicillin-Resistant Staphylococcus intermediusPneumonia Following Coronary Artery Bypass Grafting
All tube coagulase-positive staphylococci were identified as Staph-ylococcus aureus until Hajek [1] distinguished Staphylococcus inter-medius as a separate species. This organism is tube coagulase-positive, but the cell wall does not contain protein A. Clumping factoris present only in 14% of isolates [1]. Commercial latex agglutinationtests that detect clumping factor or protein A often misidentifyS. intermedius isolates as “coagulase-negative staphylococci.” Wereport a case of S. intermedius pneumonia in which sputum culturesreported positive for “staphylococcus not aureus” (SNA) were ini-tially dismissed as containing only nonpathogens. After the patient’scondition failed to improve with standard therapy and the organismwas isolated repeatedly in pure cultures, clinical suspicion increased,and the organism was identified to the species level.
A 73-year-old man with a history of type II diabetes mellitusunderwent coronary artery bypass grafting. On postoperative day5, the patient had fever (temperature to 38.8°C) and a large amountof pulmonary secretions that required nasotracheal suctioning fourto five times a day. A chest radiograph showed a left lower lobeinfiltrate, and ceftriaxone therapy was started.
Fevers (temperatures as high as 39.2°C) continued, and onpostoperative day 9, therapy was changed to ceftazidime andgentamicin. Gram staining of a sputum sample taken on that dayrevealed moderate polymorphonuclear leukocytes and moderategram-positive cocci. Culture yielded moderate growth of aStaphylococcus strain that was negative for clumping factorand protein A by the Staphaureux test (Murex Biotech Limited,Dartford, UK). Our laboratory reported this strain as SNA. Thepatient required reintubation on the 11th postoperative day forrespiratory failure. Therapy with ceftazidime and gentamicinwas discontinued, and treatment with piperacillin/tazobactamwas started. On the 14th postoperative day, flexible bronchos-copy showed marked bilateral thick mucoid lower lobe secre-tions causing obstruction. The patient no longer required ven-tilatory assistance on the 15th postoperative day but continuedto require frequent suctioning via the tracheostomy tube to clearcopious amounts of purulent secretions.
By the 21st postoperative day, the patient remained febrile, andcultures of seven sputum specimens yielded pure growth of SNA.Further testing of the organism was requested. A tube coagulase testwas positive. SNA isolates were identified as S. intermedius, andantimicrobial susceptibility testing was performed by using the VitekSystem (bioMerieux Vitek, Hazelwood, MO) and standard laboratorytesting [2]. The isolates were susceptible to trimethoprim-
sulfamethoxazole (0.25 mg/mL), gentamicin (0.5 mg/mL), andvancomycin (0.5 mg/mL) and resistant to penicillin (.4.0 mg/mL),oxacillin (.32.0 mg/mL), cefazolin (.64.0 mg/mL), cefotaxime(.64.0 mg/mL), clindamycin (.16.0 mg/mL), erythromycin (32.0mg/mL), and ofloxacin (32.0 mg/mL).
Therapy with vancomycin was started on the 21st postoperativeday. After 24 hours of therapy, he was afebrile. A chest radiograph1 month after discharge showed a small left pleural effusion withno infiltrates.
S. intermedius is a common zoonotic organism found in dogs,pigeons, minks, cats, horses, foxes, raccoons, goats, and graysquirrels [3]. The organism is a well-described cause of humandisease following canine-inflicted bite wounds [4]. Cellulitis and amalodorous discharge are common, while regional adenopathy,fever, and lymphangitis occur only in 20% of cases [4].
There have been few case reports describing invasive humandisease. The organism was isolated as pure growth in cultures ofspecimens from three patients with non-canine-inflicted wounds[5]. A 17-year-old HIV-infected patient had S. intermedius tricus-pid valve endocarditis [6]. A third case report described a 63-year-old man; S. intermedius was isolated from three sets of bloodcultures and from a culture of the tip of a permanent intravenousdevice that had been removed [3].
To our knowledge, this is the first reported case of S. interme-dius pneumonia and the first report of methicillin resistance in ahuman isolate. Several studies that tested S. intermedius isolatesfrom different species reported susceptibility to oxacillin and, insome cases, penicillin [7]. The origin of the organism in our caseis unknown. The patient had no exposure to dogs. It is unlikely thathe was infected by colonized medical personnel since only 0.7% ofveterinary staff with daily exposure to canines were found to haveS. intermedius as part of their nasopharyngeal flora [8].
Pathogenicity is thought to correlate with the ability of bothS. aureus and coagulase-positive SNA to produce coagulase [9].Coagulase production may be missed in clinical laboratories wherecommercial latex agglutination tests have replaced the tube coag-ulase test. Although these tests have a sensitivity of 98.8%–99.3%and a specificity of 97.9%–100% for the identification of S. aureus[10], their ability to identify S. intermedius or other coagulase-positive SNA species is poor. We believe that staphylococci foundto be negative by latex agglutination tests should be reported as“SNA” rather than “coagulase-negative staphylococci.”
Kimberly Gerstadt, Jennifer S. Daly, Michael Mitchell,Mireya Wessolossky, and Sarah H. Cheeseman
Departments of Medicine and Pathology, UMass Memorial Health Careand University of Massachusetts Medical School, Worcester,
Massachusetts
References
1. Hajek V. Staphylococcus intermedius, a new species isolated from ani-mals. Int J Syst Bacteriol 1976;26:401–8.
Reprints or correspondence: Dr. Jennifer S. Daly, Infectious Diseases, UMassMemorial Health Care, 55 Lake Avenue North, Worcester, Massachusetts01655 ([email protected]).
Clinical Infectious Diseases 1999;29:218–9© 1999 by the Infectious Diseases Society of America. All rights reserved.1058–4838/99/2901–0044$03.00
218 Brief Reports CID 1999;29 (July)
at Northeastern U
niversity Libraries on O
ctober 2, 2014http://cid.oxfordjournals.org/
Dow
nloaded from
2. Ferraro MJ, Jorgensen JH. Instrument-based antibacterial susceptibilitytesting. In: Murray PR, Baron EJ, Pfaller MA, Tenover FC, Yolken RH,eds. Manual of clinical microbiology. 6th ed. Washington, DC: ASMPress, 1995:1379–83.
3. Vandenesch F, Celard M, Arpin D, Bes M, Greenland T, Etienne J.Catheter-related bacteremia associated with coagulase-positive Staphy-lococcus intermedius. J Clin Microbiol 1995;33:2508–10.
4. Goldstein EJC. Bite wound and infection. Clin Infect Dis 1992;14:633–40.5. Lee J. Staphylococcus intermedius isolated from dog-bite wounds. J Infect
1994;29:105.6. Llorca I, Gago S, Sanmartin J, Sanchez R. Endocarditis infecciosa por
Staphylococcus intermedius en paciente infectado por VIH. EnfermInfecc Microbiol Clin 1992;10:317–8.
7. Biberstein EL, Jang SS, Hirsh DC. Species distribution of coagulase-positive staphylococci in animals. J Clin Microbiol 1984;19:610 –5.
8. Talan DA, Staatz D, Staatz A, Overturf GD. Frequency of Staphylococcusintermedius as human nasopharyngeal flora. J Clin Microbiol 1989;27:2393.
9. Novick RP. Staphylococci. In: Davis BD, Dulbecco R, Eisen HN, Gins-berg HS, eds. Microbiology. 4th ed. Philadelphia: JB Lippincott Com-pany, 1990:539–50.
10. Summers WC, Brookings ES, Waites KB. Identification of oxacillin-susceptible and oxacillin-resistant Staphylococcus aureus using com-mercial latex agglutination tests. Diagn Microbiol Infect Dis1998;30:131–4.
Case of Pleuropericardial Disease Caused by Actinomycesodontolyticus That Resulted in Cardiac Tamponade
To our knowledge, pleuropericardial infection due to Actinomy-ces odontolyticus has not previously been reported. We describe a
patient with this infection who did not have the usual risk factorsfor actinomycosis. We hypothesize that infection developed fol-lowing previous gastric surgery. The patient was successfullytreated with ceftriaxone.
A previously healthy 68-year-old man was admitted to thehospital with fever, chills, fatigue, and dyspnea. Six months beforeadmission, the patient had undergone endoscopic biopsy followedby laparotomy and surgical resection of a noninvasive adenocar-cinomatous gastric polyp. A postoperative chest radiographshowed cardiac silhouette enlargement and a new left pleuraleffusion that were not investigated further. Two weeks postoper-atively, he developed a dry cough, chills, and dyspnea. He was
Reprints or correspondence: Dr. Kenneth A. Litwin, Department of InternalMedicine, Yale University School of Medicine, 87 LMP, P.O. Box 208033,New Haven, Connecticut 06520-8033 ([email protected]).
Clinical Infectious Diseases 1999;29:219–20© 1999 by the Infectious Diseases Society of America. All rights reserved.1058–4838/99/2901–0045$03.00
Table 1. Summary of data on reported cases of intrathoracic Actinomyces odontolyticus infection.
Reference Disease(s)
Age(y)/sex Underlying condition(s) Presentation
Chestroentgenogram
finding(s) Diagnostic procedure
[2] Lung abscess 61/F Rheumatoid arthritis,corticosteroid therapy
Fever, chest pain, dyspnea Pleural effusion,cavitary lesion
Abscess culture
[3] Pneumonia 61/M Lung transplant,immunosuppression
Chest pain LUL infiltrate Culture ofbronchoscopy brushspecimen
[3] Mediastinitis 43/M Heart-lung transplant,immunosuppression
Postoperative sternalwound
Bibasilar infiltrate Wound culture
[4] Chest wall erosion,spinal and calfabscesses,pleural lesion
58/F Dental plate Weight loss, fever, chestpain
Left anteriormidlungshadow
Culture of chest wallbiopsy specimen
[5] Empyema 38/F Periodontal disease Weight loss, fever, chestpain, cough, dyspnea
Pleural effusion Pleural fluid culture
[6] Pneumonia 52/F Bronchiectasis Weight loss, fever LUL infiltratewith cavitation
Sputum culture, lunggranule
[7] Pneumonia, skinabscess
52/M Alcoholism, periodontaldisease
Weight loss, fever,cutaneous drainage
Bilateral cavitaryapicalinfiltrates,pleuralthickening
Abscess culture
[8] Pneumonia,empyema
40/M Alcoholism, smoker Fever, chest pain,productive cough
RUL infiltrate,pleural effusion
Pleural fluid culture
[9] Empyemanecessitatis
50/M S/P pneumonectomy foraspergilloma, alcoholuse, pulmonary TB
Fever, chest pain, dyspnea Left pleuralempyema
Pleural fluid culture
[PR] Pericardial andpleural effusions
68/M S/P resection of gastricpolyp
Dyspnea on exertion,fever
Pericardial andpleuraleffusions
Pericardial fluid culture
NOTE. LUL 5 left upper lobe; PR 5 present report; RUL 5 right upper lobe; S/P 5 status post; TB 5 tuberculosis.
219Brief ReportsCID 1999;29 (July)
at Northeastern U
niversity Libraries on O
ctober 2, 2014http://cid.oxfordjournals.org/
Dow
nloaded from
