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  Table of Contents    
CASE REPORT  
Year : 2014  |  Volume : 57  |  Issue : 3  |  Page : 486-488
Hospital acquired urinary tract infection by multidrug-resistant Brevundimonas vesicularis


1 Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication14-Aug-2014
 

   Abstract 

Infections caused by Brevundimonas vesicularis, a nonfermenting Gram-negative bacterium, are very rare. Here, we report the first case of multidrug-resistant hospital acquired urinary tract infection by B. vesicularis. Patient was successfully treated with antimicrobial therapy with piperacillin-tazobactam and amikacin.

Keywords: Brevundimonas vesicularis, urinary tract infection, multidrug-resistant

How to cite this article:
Gupta PK, Appannanavar SB, Kaur H, Gupta V, Mohan B, Taneja N. Hospital acquired urinary tract infection by multidrug-resistant Brevundimonas vesicularis. Indian J Pathol Microbiol 2014;57:486-8

How to cite this URL:
Gupta PK, Appannanavar SB, Kaur H, Gupta V, Mohan B, Taneja N. Hospital acquired urinary tract infection by multidrug-resistant Brevundimonas vesicularis. Indian J Pathol Microbiol [serial online] 2014 [cited 2020 May 29];57:486-8. Available from: http://www.ijpmonline.org/text.asp?2014/57/3/486/138789



   Introduction Top


The genus Brevundimonas is classified in the rRNA group 4 of Pseudomonas. Of the nine species in this genus, Brevundimonas vesicularis, Brevundimonas diminuta, and Brevundimonas nasdae are implicated as rare causes of human infections. [1],[2] Infection is either hospital or community acquired. [1],[3] Previously Brevundimonas infections have been reported from cases of bacteremia, skin and soft tissue infections, liver abscess, meningitis, peritonitis, septic arthritis, keratitis, and endocarditis. [1],[2],[3],[4],[5] To the best of our knowledge, we have found only a single case of urinary tract infection (UTI) caused by B. diminuta. [6] Here, we present the first case report of hospital acquired UTI caused by multidrug-resistant B. vesicularis.


   Case report Top


A 24-year-old male patient presented to the emergency department with history of sudden onset of pain in the abdomen of 1 week duration. The pain was moderate to severe in intensity and was associated with nonbilious nonprojectile vomiting with decreased urinary output. Patient had shortness of breath but no orthopnea or paroxysmal nocturnal dyspnea. There was no history suggestive of upper and lower gastrointestinal bleed, UTI, hypertension, diabetes mellitus, and tuberculosis. Patient also gave a history of consumption of alcohol (about 250 ml daily) for last 3-4 years. Initial investigation revealed the following values: serum urea 157 mg/dl, creatinine 6.8 mg/dl, and amylase 1058 U/L. He was diagnosed as a case of severe pancreatitis with acute kidney injury and acute respiratory illness and was managed conservatively. During the hospital stay, he started developing pleural effusion and ascites. His condition started deteriorating and finally on the 40 th day of admission, an exploratory laparotomy and necrosectomy of body and tail of pancreas was performed. The lesser sac drain, pelvic drain, and per urethral catheter were left in situ postoperatively. Candida tropicalis was isolated from the intraoperative fluid for which the patient was given amphotericin B. Nine days after the first surgery; a diversion loop ileostomy was performed for post pancreatectomy fecal fistula. On the day of the second surgery, the patient developed moderate degree fever for which microbiological evaluations of urine and drain fluid were carried out. Acinetobacter spp. was isolated from the drain fluid while a nonfermenting Gram-negative bacteria was isolated from the urine sample (count >10 5 colony forming units/ml).

The colony of the nonfermenter on cysteine lactose electrolyte deficient medium was orange in color. Subculture on to nutrient, blood and Mac Conkey's agar also showed orange pigmented colonies [Figure 1]. The organism was further characterized and was found to be a Gram-negative coccobacillus, motile, catalase and oxidase positive, hydrolyzed esculin, was a saccharolytic for fructose, lactose and mannitol, negative for indole, urease and lysine decarboxylase, did not grow in 6.5% NaCl and was noncitrate utilizing. Based on these characteristics, the pigmented nonfermenting isolate was identified as B. vesicularis. [2] The organism was differentiated from other esculin hydrolysing pigmented nonfermenters like Massilia timonae and Sphingomonas paucimobilis by pigmentation (Massilia timonae and Sphingomonas paucimobilis colonies are pale yellow) and saccharolytic reaction for fructose in S. paucimobilis. [2]
Figure 1: Orange pigmented hemolytic colonies of Brevundimonas vesicularis on blood agar with oxidase positive reaction

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Antibiotic susceptibility was performed using Kirby Bauer disc diffusion assay according to the Clinical and Laboratory Standards Institute guidelines. [7] The isolate was susceptible to piperacillin-tazobactam (100/10 μg), minocycline (30 μg) and co-trimoxazole (1.25/23.75 μg), and resistant to amikacin (30 μg), gentamicin (10 μg), tobramycin (10 μg), netilmicin (30 μg), amoxicillin (30 μg), amoxicillin-clavulanic acid (20/10 μg), cefoxitin (30 μg), cefotaxime (30 μg), cefoperazone (75 μg), ceftazidime (30 μg), cefoperazone-sulbactam (75/30 μg), imipenem (10 μg), meropenem (10 μg), ertapenem (10 μg), aztreonam (30 μg), norfloxacin (10 μg), levofloxacin (5 μg), and colistin (10 μg). The patient was treated with piperacillin-tazobactam and amikacin. The patient's condition improved and was discharged after removing the per-urethral catheter and drains.


   Discussion Top


0Brevundimonas vesicularis is an aerobic, nonsporulating and glucose nonfermenting Gram-negative bacillus with characteristic nutritional requirements, biochemical characteristics and forms orange pigmented colonies on blood and chocolate agar within 48 h. Although, most of the strains fail to grow on Mac Conkey's Agar; however, the current isolate grew well. [2] B. vesicularis was previously known as Corynebacterium vesiculare and Pseudomonas vesicularis. In 1994, Pseudomonas diminuta and P. vesicularis were re-classified into a new genus Brevundimonas. [8]

In a report by Center for Disease Control and Prevention, 50 clinical isolates of B. vesicularis from clinical samples have been described; including seven isolates each from blood and cerebrospinal fluid, and less commonly from urine, eye, wound and vaginal cultures without any clinical descriptions. [9] The factor responsible for infection by these organisms remains unknown as it has been isolated from both immunocompetent as well as immunocompromised hosts. Among the immunocompromised cases, it was isolated from patients of end stage renal disease, systemic lupus erythematosus, prolonged steroid therapy, sickle cell anemia, hematological malignancy, and neutropenia. [3] Our patient had acute kidney injury and was in the postoperative period with multiple devices in situ.

Previous review has shown varying drug susceptibility patterns of Brevundimonas isolates. [3] No resistance to co-trimoxazole has been reported as also observed with the present strain. However, there is no therapeutic experience with this drug. Piperacillin-tazobactam and carbapenems appear to be more reliable antibiotics for empiric treatment of hospital-acquired infections. [3] Shang et al. observed that the strains that were susceptible to aminopenicillins, antipseudomonal penicillins, cephalosporins, carbapenems, and aminoglycosides had higher resistance to aztreonam, ceftazidime, and ciprofloxacin among the hospital acquired strains as compared to the community-acquired strains. [3] The present strain was hospital acquired and only susceptible to piperacillin-tazobactam, minocycline and co-trimoxazole and resistant to all other class of drugs second-or third-generation cephalosporin, aminoglycoside, monobactam, carbapenems, colistin, and quinolones. Our patient improved on piperacillin-tazobactam and amikacin therapy.

Brevundimonas vesicularis has also been isolated from various environmental sources such as soil, the seminal vesicle of medicinal leeches, hospital instruments, tap water, aerators, and hospital sinks. [1],[3],[4],[9],[10] In the present case, we could not look for the source of this hospital acquired infection. Previously, water taps and wash basin have been implicated as sources of infection in a hospital acquired case of meningitis due to B. vesicularis. After proper cleaning and decontamination no new isolates were obtained from these water sources. [4] Therefore, good environmental hygiene can prevent acquisition of such multidrug-resistant organisms. In conclusion, we report a hospital acquired infection due to a rare nonfermenting Gram-negative multidrug-resistant organism, which is not difficult to identify in a routine microbiology laboratory.

 
   References Top

1.
Lee MR, Huang YT, Liao CH, Chuang TY, Lin CK, Lee SW, et al. Bacteremia caused by Brevundimonas species at a tertiary care hospital in Taiwan, 2000-2010. Eur J Clin Microbiol Infect Dis 2011;30:1185-91.  Back to cited text no. 1
    
2.
The nonfermentative gram negative bacilli. In: Washington WJ, Stephen A, William J, Elmer K, Gary P, Paul S, et al., editors. Koneman's Color Atlas and Textbook of Diagnostic Microbiology. 6 th ed. Baltimore: Lippincott Williams & Wilkins; 2006. p. 303-91.  Back to cited text no. 2
    
3.
Shang ST, Chiu SK, Chan MC, Wang NC, Yang YS, Lin JC, et al. Invasive Brevundimonas vesicularis bacteremia: Two case reports and review of the literature. J Microbiol Immunol Infect 2012;45:468-72.  Back to cited text no. 3
    
4.
Mondello P, Ferrari L, Carnevale G. Nosocomial Brevundimonas vesicularis meningitis. Infez Med 2006;14:235-7.  Back to cited text no. 4
    
5.
Yoo SH, Kim MJ, Roh KH, Kim SH, Park DW, Sohn JW, et al. Liver abscess caused by Brevundimonas vesicularis in an immunocompetent patient. J Med Microbiol 2012;61:1476-9.  Back to cited text no. 5
    
6.
Han XY, Andrade RA. Brevundimonas diminuta infections and its resistance to fluoroquinolones. J Antimicrob Chemother 2005;55:853-9.  Back to cited text no. 6
    
7.
Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing. Nineteenth Informational Supplement, M100-S19. Wayne, PA: Clinical and Laboratory Standards Institute; 2009.  Back to cited text no. 7
    
8.
Segers P, Vancanneyt M, Pot B, Torck U, Hoste B, Dewettinck D, et al. Classification of Pseudomonas diminuta Leifson and Hugh 1954 and Pseudomonas vesicularis Büsing, Döll, and Freytag 1953 in Brevundimonas gen. nov. as Brevundimonas diminuta comb. nov. and Brevundimonas vesicularis comb. nov., respectively. Int J Syst Bacteriol 1994;44:499-510.  Back to cited text no. 8
    
9.
Clark WA, Hollis DC, Weaver RE. Identification of unusual pathologic gram-negative aerobic and facultatively anaerobic bacteria. In: Department of Health and Human Services CDC, editor. Atlanta, USA: US Government Printing Office; 1984, 286-87  Back to cited text no. 9
    
10.
Szyman´ska J. Bacterial contamination of water in dental unit reservoirs. Ann Agric Environ Med 2007;14:137-40.  Back to cited text no. 10
    

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Correspondence Address:
Neelam Taneja
Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.138789

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