| Abstract|| |
Chryseobacterium species are gaining importance as an emerging opportunistic nosocomial pathogen. Limited availability of clinical data necessitates reporting of such isolates. We report a case of nosocomial urinary tract infection by metallo-β-lactamase-producing Chryseobacterium gleum in an elderly diabetic male with chronic renal disease. Identification and antibiotic sensitivity test performed by conventional methods were confirmed by Matrix-assisted Laser Desorption Ionization Time-of-Flight and VITEK-2 systems, respectively. The patient responded well to intravenous ciprofloxacin therapy.
Keywords: Chryseobacterium gleum, metallo-β-lactamase, nosocomial infection
|How to cite this article:|
Rajendran P, Muthusamy S, Balaji VK, Rakesh GJ, Easow JM. Urinary tract infection due to Chryseobacterium gleum, an uncommon pathogen. Indian J Pathol Microbiol 2016;59:551-3
|How to cite this URL:|
Rajendran P, Muthusamy S, Balaji VK, Rakesh GJ, Easow JM. Urinary tract infection due to Chryseobacterium gleum, an uncommon pathogen. Indian J Pathol Microbiol [serial online] 2016 [cited 2019 Jul 17];59:551-3. Available from: http://www.ijpmonline.org/text.asp?2016/59/4/551/191800
| Introduction|| |
Chryseobacterium species are ubiquitous, known to survive in hospital environment leading to nosocomial infections.  They are aerobic, nonfermentative Gram-negative Bacilli. Clinically important species of Chryseobacterium include Chryseobacterium meningosepticum, Chryseobacterium indologenes, Chryseobacterium multivorum, Chryseobacterium odoratum, Chryseobacterium breve, and Chryseobacterium gleum.  Among these, C. meningosepticum (now known as Elizabethkingia meningosepticum) is considered to be the most pathogenic species.  Most of the reports have documented isolation of Chryseobacterium from immunocompromised individuals; however, these bacteria have also been reported to cause infections in immunocompetent individuals. , They have been associated with ventilator-associated pneumonia,  septicemia,  and urinary tract infection (UTI)  and are resistant to various classes of antibiotics. Clinical reports of C. gleum are very few, especially from India. Since no standard guidelines are available for antibiotic susceptibility testing and interpretation, researchers are using guidelines of nonfermenters for reporting the susceptibility results of Chryseobacterium isolates.
| Case Report|| |
A 58-year-old diabetic male presented to the emergency room with abdominal discomfort and hiccups for the past 3 days. He was a known case of cerebrovascular and chronic renal disease. Other than bilateral pitting pedal edema, vitals and systems examination were within normal limits. Preliminary diagnosis on admission was type II diabetes mellitus with chronic renal failure. STAT blood investigations revealed random blood sugar of 14.3 mmol/L, urea 32.48 mmol/L, and creatinine 256.36 μmol/L with low serum electrolytes (Na+ 114 mmol/L; K+ 2.7 mmol/L). Urine routine showed 3+ sugars with no albumin and ketones. Further blood investigations revealed raised erythrocyte sedimentation rate (70 mm at the end of 1 h), marginal leukocytosis with elevated neutrophils (88%), reduced lymphocytes (7%), and eosinophils and monocytes contributing to 3% and 2%, respectively. Urine microscopy showed 2-3 pus cells/high power field. Foley's catheterization was done on the 3 rd day of admission when the patient was shifted to the intensive care unit for management of metabolic encephalopathy. He developed fever the following day for which blood and catheterized urine sample were sent for culture and sensitivity before initiating antibiotic therapy.
Urine was cultured on cysteine lactose electrolyte deficient agar; significant growth of yellow colonies was seen after 24 h of incubation. Preliminary tests showed nonmotile Gram-negative Bacilli, which was positive for catalase and cytochrome oxidase. Nutrient agar grew yellow-colored colonies which turned red (flexirubin) on addition of 10% potassium hydroxide (KOH) [Figure 1]. Blood agar grew moist, sticky nonhemolytic colonies and MacConkey agar had nonlactose fermenting colonies. In Hugh and Leifson oxidative-fermentative (OF) medium, glucose was oxidatively utilized. In Triple Sugar Iron agar, no sugars were fermented neither gas nor hydrogen sulfide produced, and also were negative for citrate utilization, urease activity, methyl red, and Voges-Proskauer. Indole production was detected by Ehrlich's reagent. Glucose, lactose, sucrose, maltose, and mannitol were not fermented, nitrate was not reduced, and amino acids were not decarboxylated. The isolate was identified as a nonfermentative Gram-negative Bacilli belonging to family Flavobacteriaceae, genus Chryseobacterium due to production of indole since no other nonfermenters produce indole from tryptophan. It belonged to species C. gleum due to the absence of growth at 42°C, hydrolysis of urea and asaccharolytic reaction in OF-mannitol. Identification done by conventional method was confirmed by Matrix-assisted Laser Desorption Ionization Time-of-Flight (MALDI-TOF) proteomic study (MALDI-TOF MS system-Biotyper version 2.02, Bruker Corporation, Massachusetts, USA, July 2005) with a log score value of 2.214. The case report by Brkic et al. has also used MALDI-TOF biotyper for identifying C. gleum from tracheal aspirate and blood.  Results of antibiotic sensitivity test performed by Kirby-Bauer's disk diffusion were confirmed by VITEK-2 system. Susceptibility results by disk diffusion and VITEK-2 system were in concordance. Minimum inhibitory concentration (MIC) values by VITEK-2 system were sensitive to imipenem (4 μg/ml), minocycline (1≤ μg/ml), levofloxacin (0.5 μg/ml), ciprofloxacin (0.5 μg/ml), cotrimoxazole (≤20 μg/ml), resistant to gentamicin (≥16 μg/ml), amikacin (≥64 μg/ml), meropenem (≥16 μg/ml), doripenem (≥8 μg/ml), aztreonam (≥64 μg/ml), colistin (≥16 μg/ml), and intermediately sensitive to cefoperazone-sulbactam (32 μg/ml). Since our isolate was resistant to meropenem and doripenem by disk diffusion, we performed imipenem EDTA double-disk synergy test for detecting metallo-β-lactamase (MBL) production.  Our isolate was found to be an MBL producer.
|Figure 1: Nutrient agar showing yellow colonies turning red with addition of potassium hydroxide|
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On the 4 th day, the patient was empirically started on intravenous ceftriaxone 1 g twice daily and was changed to intravenous ciprofloxacin 400 mg twice daily on day 6, based on antibiotic susceptibility test results. Clinical improvement was evident after administering intravenous ciprofloxacin. Conventional blood culture with brain heart infusion broth showed no growth after 7 days of incubation. The patient got discharged against medical advice on the 11 th day with a request to follow-up. Follow-up urine culture was not done since the patient did not turn up after discharge from our hospital.
| Discussion|| |
Flavobacterium IIb strains distinct from other named species of Flavobacterium were placed in separate taxon based on phenotypic characteristics, DNA base compositions, DNA-DNA relatedness levels, and named as Flavobacterium gleum by Holmes et al. in 1984.  The genus Flavobacterium was renamed as Chryseobacterium based on rRNA cistron studies by Vandamme et al. in 1994.  Chryseobacterium are not part of normal flora and exists naturally in soil, water, and wet surfaces and are known to survive even in chlorinated water. 
Risk factors for Chryseobacterium infections are extremes of age, chronic medical illness, indwelling intravascular devices, underlying immunocompromised conditions, and prolonged antibiotic usage. , Patient in our case is an elderly with type II diabetes mellitus, chronic renal, and cerebrovascular disease, who was hospitalized for more than 3 days before he developed symptoms of UTI.
In Taiwan, C. gleum has been isolated mostly from urine followed by sputum.  To the best of our knowledge, this is the first report of nosocomial UTI by C. gleum from India. The ability of C. gleum to grow on MacConkey agar is variable; Garg et al.  reported that C. gleum fails to grow in MacConkey agar, but our isolate grew. Our isolate was identified by conventional method and confirmed by MALDI-TOF. The ability and accuracy of MALDI-TOF to identify C. gleum is 100%. 
We have found that antibiotic sensitivity testing by disk diffusion correlates well with MIC values of VITEK-2 system. Currently, no standard MIC breakpoints have been described by the Clinical and Laboratory Standards Institute for Chryseobacterium; MIC results were interpreted using breakpoints for non-Enterobacteriaceae. SENTRY reported that among beta-lactams, piperacillin-tazobactam was most active (MIC 50 , 4 μg/ml; 80.0% susceptibility), and least active were carbapenems and aminoglycosides; however, our isolate was resistant to piperacillin-tazobactam, carbapenems, and aminoglycosides. Susceptibility to piperacillin-tazobactam in North America was 100%, but only 50% in Asia-Pacific region. Newer fluoroquinolones represented the appropriate antibiotic for Chryseobacterium,  which was true with our isolate. However, Garg et al. reported that fluoroquinolone was not an appropriate choice.  C. gleum possesses class B MBLs rendering them inherently resistant to carbapenems.  Our isolate was sensitive to imipenem but resistant to meropenem and doripenem. Loss of Opr D alone is responsible for imipenem resistance, but overexpression of Mex A and loss of Opr D are responsible for doripenem resistance. Overexpression of Mex AB-Opr M, Mex XY-Opr M, and Mex CD-Opr J efflux systems have accounted for meropenem resistance. , MBL production was confirmed in our isolate by imipenem-EDTA double-disk diffusion test, and with known inherent resistance, all the carbapenems were reported as resistant.
Literature search revealed that most researchers performed disk diffusion rather than MIC. Because of the nonuniformity in antibiotic susceptibility testing, there is difficulty in compiling the antibiogram of Chryseobacterium isolates for epidemiological and surveillance purposes.
| Conclusion|| |
C. gleum should be considered as a possible etiological agent in nososcomial UTI. Antibiotic susceptibility testing for Chryseobacterium is mandatory since its susceptibility pattern is often unpredictable. Establishing standard guidelines and interpretive breakpoints for susceptibility testing of Chryseobacterium deserves attention.
We would like to acknowledge the Microbiological Laboratory, Coimbatore, for MALDI-TOF (MS) identification and antibiotic sensitivity testing by the VITEK-2 system.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Joshy M Easow
Department of Microbiology, Sri Venkateshwaraa Medical College Hospital and Research Centre, Ariyur, Puducherry - 605 102
Source of Support: None, Conflict of Interest: None