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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 42-45

Elizabethkingia meningoseptica bacteremia in a neonate: A case report and mini-review of the literature


1 Department of Microbiology, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Department of Paediatrics, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission23-Feb-2016
Date of Acceptance23-May-2016
Date of Web Publication16-Jun-2016

Correspondence Address:
K Sandhya Bhat
Department of Microbiology, Pondicherry Institute of Medical Sciences, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-3069.184130

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  Abstract 

Elizabethkingia meningoseptica is a nonfermentative Gram-negative bacillus that is ubiquitously found in hospital environments, and it has been associated with various nosocomial infections. Immunocompromised individuals are particularly at increased risk for developing severe infections due to E. meningoseptica, including bacteremia. E. meningoseptica is resistant to multiple antimicrobials commonly used for Gram-negative bacteria. Rapid diagnosis and early institution of appropriate therapy for prolonged period are essential in management of such infections. We report a case of bacteremia due to E. meningoseptica in a neonate who presented with clinical findings suggestive of epidermolysis bullosa. Based on the clinical diagnosis and preliminary blood culture report, baby was started on syrup cefixime, topical fucidin cream along with fluid correction for electrolyte imbalance. As baby's general and systemic status were stable, the baby was discharged with the advice to review after 3 days. Awareness among clinicians along with correct identification by the diagnostic microbiology laboratory is required to reduce the fatal outcome associated with E. meningoseptica infections.

Keywords: Bacteremia, Elizabethkingia meningoseptica, immunocompromised, multidrug resistant


How to cite this article:
Bhat K S, Priya R, Krishnan L, Kanungo R. Elizabethkingia meningoseptica bacteremia in a neonate: A case report and mini-review of the literature. J Curr Res Sci Med 2016;2:42-5

How to cite this URL:
Bhat K S, Priya R, Krishnan L, Kanungo R. Elizabethkingia meningoseptica bacteremia in a neonate: A case report and mini-review of the literature. J Curr Res Sci Med [serial online] 2016 [cited 2019 May 25];2:42-5. Available from: http://www.jcrsmed.org/text.asp?2016/2/1/42/184130


  Introduction Top


Elizabethkingia meningoseptica (previously known as Chryseobacterium meningosepticum) is a ubiquitous Gram-negative bacillus, widely distributed in nature, particularly in soil and water. [1] Although infections caused by this bacterium are common among immunocompromised hosts, few case reports are available even among immunocompetent hosts. Limited clinical data are available from India. It is associated with neonatal meningitis with higher mortality rate of about 57%. E. meningoseptica is less commonly associated with nosocomial pneumonia and sepsis both in immunocompromised neonates and adults. [2]

E. meningoseptica is commonly found in saline solutions used for the reconstitution of antibiotics and as well as in the water sinks and tanks in health-care settings. Immunosuppression, underlying co-morbid medical conditions, prolonged hospital stay, indwelling central venous catheter or other invasive devices are some of the risk factors associated with the acquisition of this infection. [3],[4] Another major contributing factor is the prolonged use of broad spectrum antibiotics.

E. meningoseptica has a unique antibiotic susceptibility pattern. It is resistant to many antibiotics commonly used to treat infections caused by Gram-negative bacteria such as aminoglycosides, beta-lactam antibiotics, tetracycline and chloramphenicol. However, they are highly susceptible to clindamycin, erythromycin, cotrimoxazole, and quinolones, generally used to treat Gram-positive bacterial infections. [6],[7] This often leads to inappropriate selection of antibiotics for initial empirical therapy posing a challenge to treat clinicians often leading to treatment failures.

Early and accurate identification with appropriate susceptibility testing is mandatory to reduce morbidity and mortality in patients with E. meningoseptica infections.


  Case report Top


We report an uncommon case of nosocomial septicemia due to E. meningoseptica in a 10-day-old out born neonate. He presented with history of peeling of skin and fluid-filled lesions all over the body. The baby was born through normal vaginal delivery. On examination, there was an extensive necrolysis with erythematous base present over the upper and lower limbs. Few large intact bullae were present over the left leg and over the hands. Few erosions were present over the face and lips. Other general physical examination and systemic examinations were within normal limits. Maternal history revealed similar complaints in the first baby also, who had similar skin lesions since birth and died on day 2 of life.

Laboratory investigations at the time of admission revealed a total leukocyte count of 3800/dL (with a neutrophil count of 15%, lymphocytes 66%, eosinophil 1%, monocyte 4%, metamyelocyte 3%), platelets 304 × 10 3 /μl, C-reactive protein was positive, bilirubin (total) 3.3 mg/dL, bilirubin (direct) 0.1 mg/dL, blood urea 76 mg/dL, creatinine 0.7 mg/dL, sodium 160 mEq/L, potassium 5.1 mEq/L, chloride 122 mEq/L, and calcium 9.9 mg/dL, FT4 1.4 ng/dL, TSH 3.3 μIU/ml. Peripheral smear study showed macrocytic normochromic red blood cell with leukopenia.

With the above clinical findings and family history, the baby was diagnosed to have autosomal recessive dystrophic epidermolysis bullosa. The baby was started on syrup cefixime (5 ml/50 mg) 1.5 ml BD for 3 days, topical fucidin cream, and liquid paraffin along with fluid correction for electrolyte imbalance. As baby's general and systemic status were stable, he was discharged with the advice to review after 3 days.

Blood for culture sent prior to the initiation of treatment demonstrated growth of 1-2 mm in diameter light yellow colored colonies of Gram-negative bacilli on blood agar and chocolate agar. There was no growth on MacConkey agar. Based on the growth characteristics, biochemical reactions, drug susceptibility pattern, and identification by Vitek 2 system (Biomerieux), the isolate was identified as E. meningoseptica. Clinical and Laboratory Standards Institute criteria for Gram-negative and Gram-positive bacteria were used to interpret the antimicrobial susceptibility, as no standard recommendations are available regarding breakpoints for this rare pathogen. The isolate was sensitive to ciprofloxacin (minimum inhibitory concentration [MIC] 0.5 μg/ml), levofloxacin (MIC 0.5 μg/ml), minocycline (MIC <1 μg/ml), cotrimoxazole (MIC 40 μg/ml), and intermediate to tigecycline with MIC 4 μg/ ml; but resistant to ampicillin/sulbactam, piperacillin/tazobactam, ceftazidime, ceftriaxone, cefepime, aztreonam, imipenem, doripenem, meropenem, amikacin, gentamicin, and colistin.

As the baby was not brought for further review visits, further clinical outcome could not be recorded.


  Discussion Top


E. meningoseptica, formerly known as Flavobacterium meningosepticum, was first reported by bacteriologist Elizabeth O. King in 1959 at Centers for Disease Control Atlanta. It was reclassified in the genus Chryseobacterium and later on, placed in the new genus Elizabethkingia named after the original discoverer. [6],[8] It is a Gram-negative, obligate aerobe, nonfastidious, nonspore forming, nonfermentative, slender, slightly curved, and nonmotile rod that is catalase, oxidase, and urease positive. E. meningoseptica is generally indole positive in contrast to most other nonfermenters; however, reaction may be slow. E. meningoseptica grows well on blood and chocolate agar at 37°C. It produces dull yellow to orange nondiffusible flexirubin type pigment. Strains growing well at higher temperatures of up to 40°C are usually associated with invasive, fatal type of infections. They grow poorly or not at all on MacConkey agar. [6],[10]

E. meningoseptica is widely distributed in nature. In the literature, most of the reported cases of infections associated with this organism are hospital acquired and commonly documented in immunocompromised patients. In the present case, the infection was presumed to be nosocomial in origin, probably acquired from the hospital environment, where delivery was conducted. Several cases of E. meningoseptica infections have been reported as part of outbreaks and source was traced to as contaminated hospital water supply, saline, disinfectants, antibiotic solutions, water sinks, and respirators. [1],[11] As this child was out born, no source could be traced.

It has generally been reported as a causative agent of outbreaks of meningitis mainly in premature newborns and infants in neonatal Intensive Care Units (ICUs). The organism has been isolated from the cases of pneumonia, endocarditis, and meningitis, form adult immunocompromised patients with some underlying severe illness and soft tissue infection. There have also been reports of sepsis in immunocompetent individuals. [7],[12]

Recent reports suggest E. meningoseptica to be an emerging pathogen in patients with severe head injury/multiple fractures and who undergo neurosurgical procedures. Risk for infection increases as these patients are hospitalized for long duration and invariably on invasive medical devices, such as central venous catheters, urinary catheters, ventilators, cerebrospinal shunts as life support measures. These critically ill-patients are also administered multiple antibiotics prophylactically and as well as in the course of treatment. [12],[13]

A study on patients with E. meningoseptica bacteremia, by Ghafur et al. from India, mentions about 75% patients were admitted in ICU at the time of development of bacteremia, and all were patients with malignancies with about 45% mortality. [12] In another study by Lin et al., nosocomial infection was recorded in about 86% of patients and 60% of these patients were admitted in ICUs, and 36% of the patients were diagnosed to have malignancies, whereas 25% were diabetics with an overall mortality of 23.4%. [14]

E. meningoseptica infection is very challenging to both clinicians and microbiologists. It is resistant to commonly used antibiotics for treating Gram-negative bacterial infections, including extended-spectrum β-lactam (ESBL) agents (due to production of two beta-lactamases: One ESBL and one carbapenem-hydrolyzing metallo β-lactamase), aminoglycosides, tetracycline, and chloramphenicol. Only limited antibiotic classes are available as treatment options. Presently, ciprofloxacin, cotrimoxazole, minocycline, and rifampin are being considered as good alternatives. Most of these are drugs are used for Gram-positive bacteria and not routinely tested on Gram-negative organisms. [6],[7]

Some studies have shown that susceptibility of E. meningoseptica was relatively high (>50%) to piperacillin, piperacillin-tazobactam, cotrimoxazole, ciprofloxacin, moxifloxacin, levofloxacin, tigecycline, vancomycin and showed multidrug resistance to ampicillin-sulbactam, ticarcillin, ceftazidime, ceftriaxone, cefepime, cefoperazone-sulbactam, cefepime-tazobactam, tetracycline, chloramphenicol, imipenem, meropenem, amikacin, gentamicin, tobramycin, and colistin. [3],[4] The present study showed similar susceptibility result, except for resistance was shown to piperacillin/tazobactam.

The laboratory often faces the difficulty of identifying the organism to species level, often stopping at the level of nonfermenting Gram-negative bacteria. Hence, the antibiotic panel tested also becomes restricted. This leads to incorrect choice of an effective drug for the empiric treatment of E. meningoseptica infections. Even though rifampicin or fluoroquinolones are effective in treating infections with this bacterium; they are not widely recommended in India, because of endemic tuberculosis.

Infection with this pathogen is potentially fatal unless diagnosed and treated early. The incidence of E. meningoseptica may be underreported because of lack of wide availability of an automated bacterial identification system. All oxidase and urease positive, multidrug resistant, nonfermenters from neonates, immunocompromised or critically ill patients should be started on combination therapy with an additional quinolone, or cotrimoxazole until confirmed laboratory identification of the isolate. Awareness among clinicians about this organism along with correct identification and sensitivity testing by the diagnostic Microbiology laboratory is required to reduce the morbidity and mortality associated with E. meningoseptica infections.


  Conclusion Top


E. meningoseptica infections are emerging, especially among premature newborns, immunocompromised or critically ill patients, because of its resistance to multiple antibiotics. Several reports have been emerging in recent literature documenting infections by this organism. It is essential that laboratories have the facility to identify the organism correctly. Good communication between treating clinicians and laboratory staff is very important for the correct management of infected patients. A high degree of suspicion, rapid diagnosis, and prompt institution of appropriate therapy for prolonged period (about 3-4 weeks) are key factors in management of such infections.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Issack MI, Neetoo Y. An outbreak of Elizabethkingia meningoseptica neonatal meningitis in Mauritius. J Infect Dev Ctries 2011;5:834-9.  Back to cited text no. 1
    
2.
Ceyhan M, Celik M. Elizabethkingia meningosepticum (Chryseobacterium meningosepticum) Infections in Children. Int J Pediatr 2011;2011:215237.  Back to cited text no. 2
    
3.
Tak V, Mathur P, Varghese P, Misra MC. Elizabethkingia meningoseptica: An emerging pathogen causing meningitis in a hospitalized adult trauma patient. Indian J Med Microbiol 2013;31:293-5.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Hsu MS, Liao CH, Huang YT, Liu CY, Yang CJ, Kao KL, et al. Clinical features, antimicrobial susceptibilities, and outcomes of Elizabethkingia meningoseptica (Chryseobacterium meningosepticum) bacteremia at a medical center in Taiwan, 1999-2006. Eur J Clin Microbiol Infect Dis 2011;30:1271-8.  Back to cited text no. 4
    
5.
Kirby JT, Sader HS, Walsh TR, Jones RN. Antimicrobial susceptibility and epidemiology of a worldwide collection of Chryseobacterium spp: Report from the SENTRY Antimicrobial Surveillance Program (1997-2001). J Clin Microbiol 2004;42:445-8.  Back to cited text no. 5
    
6.
Sarma S, Kumar N, Jha A, Baveja U, Sharma S. Elizabethkingia meningosepticum: An emerging cause of septicemia in critically III patients. J Lab Physicians 2011;3:62-3.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Lin PY, Chu C, Su LH, Huang CT, Chang WY, Chiu CH. Clinical and microbiological analysis of bloodstream infections caused by Chryseobacterium meningosepticum in nonneonatal patients. J Clin Microbiol 2004;42:3353-5.  Back to cited text no. 7
    
8.
Ozkalay N, Anil M, Agus N, Helvaci M, Sirti S. Community-acquired meningitis and sepsis caused by Chryseobacterium meningosepticum in a patient diagnosed with thalassemia major. J Clin Microbiol 2006;44:3037-9.  Back to cited text no. 8
    
9.
Bernardet JF, Hugo C, Bruun B. The genera Chryseobacterium and Elizabethkingia. The Prokaryotes. New York: Springer. 2011. p. 638-76.  Back to cited text no. 9
    
10.
Winn WC, Allen SD, Janda WM, Koneman EW, Procop GW, Schreekenberger PC, et al. The nonfermentative gram-negative bacilli. In: Koneman′s Color Atlas and Textbook of Diagnostic Microbiology. 6 th ed. Lippincott Williams and Wilkins; 2006. p. 345-8.  Back to cited text no. 10
    
11.
Güngör S, Ozen M, Akinci A, Durmaz R. A Chryseobacterium meningosepticum outbreak in a neonatal ward. Infect Control Hosp Epidemiol 2003;24:613-7.  Back to cited text no. 11
    
12.
Ghafur A, Vidyalakshmi PR, Priyadarshini K, Easow JM, Raj R, Raja T. Elizabethkingia meningoseptica bacteremia in immunocompromised hosts: The first case series from India. South Asian J Cancer 2013;2:211-5.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
13.
Hoque SN, Graham J, Kaufmann ME, Tabaqchali S. Chryseobacterium (Flavobacterium) meningosepticum outbreak associated with colonization of water taps in a neonatal intensive care unit. J Hosp Infect 2001;47:188-92.  Back to cited text no. 13
    
14.
Lin YT, Chiu CH, Chan YJ, Lin ML, Yu KW, Wang FD, et al. Clinical and microbiological analysis of Elizabethkingia meningoseptica bacteremia in adult patients in Taiwan. Scand J Infect Dis 2009;41:628-34.  Back to cited text no. 14
    




 

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