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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References
 ~  Article Figures

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  Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 30  |  Issue : 3  |  Page : 370-372
 

Urinary tract infection by Chryseobacterium indologenes


1 Department of Microbiology, RDGMC, Ujjain, Madhya Pradesh, India
2 Department of Surgery, RDGMC, Ujjain, Madhya Pradesh, India

Date of Submission14-Jun-2011
Date of Acceptance03-Sep-2011
Date of Web Publication8-Aug-2012

Correspondence Address:
G Bhuyar
Department of Microbiology, RDGMC, Ujjain, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.99511

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 ~ Abstract 

Chryseobacterium species is an uncommon human pathogen although recovered from various sources in the hospital environment. Most infections have been detected in hospitalized patients with severe underlying diseases and who had indwelling devices or implants. Despite their low virulence, chryseobacteria are inherently resistant to many antimicrobial agents. We report a rare case of urinary tract infection by Chryseobacterium indologenes in a young girl, operated for renal calculus and successfully treated with piperacillin-tazobactam combination.


Keywords: Chryseobacterium indologenes, metallo β-lactamase, urinary tract infection


How to cite this article:
Bhuyar G, Jain S, Shah H, Mehta V K. Urinary tract infection by Chryseobacterium indologenes. Indian J Med Microbiol 2012;30:370-2

How to cite this URL:
Bhuyar G, Jain S, Shah H, Mehta V K. Urinary tract infection by Chryseobacterium indologenes. Indian J Med Microbiol [serial online] 2012 [cited 2018 Oct 18];30:370-2. Available from: http://www.ijmm.org/text.asp?2012/30/3/370/99511



 ~ Introduction Top


Chryseobacterium species is Gram-negative bacillus widely distributed in soil and water. In hospital environments, they have been recovered from water systems and humid surfaces. Chryseobacterium indologenes is an uncommon human pathogen. Most infections have been detected in hospitalized patients with severe underlying diseases who had indwelling devices or implants. [1] There is scarcity of data in the Indian literature regarding infections by Chryseobacterium species. We report a case of catheter-associated urinary tract infection (UTI) by Chryseobacterium indologenes.


 ~ Case Report Top


A 19-year-old girl reported to the hospital complaining of intermittent abdominal pain suggestive of ureteric colic since 3 months. On physical examination, the patient was afebrile and had normal vital parameters. Abdominal examination revealed tenderness in left flank. No mass was palpable. Laboratory investigations revealed Hb of 12 gm%, TLC - 16,300/cu.mm with 65% polymorphs, blood urea 18.3 mg/dl and serum creatinine marginally elevated at 1 mg/dl. Urine routine microscopy showed occasional pus cells, 4-6 RBCs/high power field, and calcium oxalate crystals. Initial urine culture did not show any growth. USG abdomen showed left renal calculus of 2 ×1.5 cm size. Final diagnosis of left renal calculus was made. She underwent a conventional pyelolithotomy. A Malicot's catheter was placed during operation and kept in-situ postoperatively for 7 days. Injection gentamicin and lincomycin were started and continued for 5 days. On 5 th postoperative day, she developed high grade fever and burning micturition. Suspecting an infection, parenteral ciprofloxacin was started. Urine drained from catheter was received for microscopy and culture. Microscopy showed 6-8 pus cells and 4-5 RBCs per high power field. Urine was inoculated on Blood agar and MacConkey agar and incubated at 37° C for 24 h. Blood agar grew dark yellow colored, 1-2 mm, low-convex, circular colonies with regular margins [Figure 1]. No growth was observed on MacConkey agar. The organisms grown were Gram negative bacilli that were non-motile, catalase, and oxidase positive. The oxidative fermentative (OF) test of Hugh and Leifson yielded oxidative reaction. Indole was produced in tryptophan broth; methyl red, urease production and citrate utilization were negative.
Figure 1: Showing dark yellow coloured, low convex, circular colonies on blood agar

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Similar yellow-pigmented colonies were also observed on peptone medium. The flexirubin type of pigment was confirmed by adding 1 drop of 10% KOH solution to a bit of cell paste. [2] The color of the colonies changed from yellow to red [Figure 2]. Blood culture was negative. The organism was identified as C. indologenes by both conventional biochemical reactions and mini API identification system (version B, Biomerieux, France). Antimicrobial susceptibility testing was done on Muller Hinton agar by Kirby Bauer disc diffusion method. For interpretation we used the zone diameters used for Pseudomonas aeruginosa (CLSI 2011). It was susceptible to piperacillin-tazobactam and resistant to norfloxacin, ciprofloxacin, ceftazidime, cefotaxime, imipenem, aztreonam, gentamicin, amikacin, tobramycin, colistin, and polymyxin. Metallo β-lactamase (MBL) was detected by double disc synergy method using imipenem and imipenem+EDTA. We also tested susceptibility to vancomycin and found the isolate sensitive.
Figure 2: Yellow-pigmented colonies of C. indologenes in nutrient agar, turns to red after pouring 10% KOH solution

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The patient's fever did not subside with the given antibiotic therapy. Repeat urine culture showed pure growth of the same organism. Ciprofloxacin was discontinued and Piperacillin-tazobactam (intraveinous 4.5 g 8 hourly) was started and continued for 10 days. Fever subsided within two days of changing the antibiotic. Follow-up urine culture after 10 days of revised antibiotic therapy did not yield any growth.


 ~ Discussion Top


The genus Chryseobacterium belongs to the family Flavobacteriaceae. Six species of Chryseobacterium are more commonly isolated from clinical specimens: C. meningosepticum, C. odoratum, C. multivorum, C. breve and group IIb Chryseobacterium species, which includes C. indologenes and C. gleum. Members of genus Chryseobacterium are Gram-negative, aerobic, non-fermentative, oxidase and catalase-positive, non-motile bacilli that produce a distinct yellow to orange pigment. [3] They are readily distinguished from other non-fermenters by their ability to produce indole in tryptophan broth, but the reaction often is weak and difficult to demonstrate. [4]

C. indologenes
is commonly found in soil, water, plants and foodstuffs. They can survive in chlorinated waters, and in the hospital environment, they exist in water systems and wet surfaces and serve as potential reservoirs of infection. Colonization of patients via contaminated medical devices involving fluids such as respirators, intubation tubes, mist tents, humidifiers, incubators for newborns, ice chests, syringes, etc. has been documented. [5]

Although chryseobacteria are of low pathogenicity, the production of biofilm on foreign materials and protease activity may play an important role in the virulence of invasive infections due to C. indologenes.[6] C. indologenes is an uncommon human pathogen. The clinical significance of C. indologenes has not been fully established yet because this bacterium has not been frequently recovered from clinical specimens. Reported infections include bacterimia, ventilator-associated pneumonia, indwelling device-associated infection, urinary tract infections, biliary tract infection, peritonitis, lumboperitoneal shunt infection, ocular infections, surgical and burn wound infections. Infections have often been associated with a high mortality rate. [1],[2],[6],[7],[8],[9] Our patient was operated for renal calculus for which she subsequently underwent catheterization and instrumentation.

Chryseobacteria represent only 0.27% (50 of 18,569) of the processed nonfermentative gram negative bacilli and 0.03% (50 of 1,55,811) of all bacterial isolates collected by the SENTRY Program [10] during the 5 year period 1997 to 2001. The most frequently isolated species was C. meningosepticum followed by C. indologenes and C. gleum. All 50 isolates were from hospitalized patients, and the vast majority was recovered from either lower respiratory tract (52.0%) or blood cultures (46.0%). Among the isolates from bloodstream infections, 30.4% were C. indologenes. Conversely, one-half of the isolates from the respiratory tract was C. indologenes. The highest frequency of Chryseobacterium species infection occurred among the elderly (>65 years old) and the lowest frequency occurred among children <5 years of age. [10] Our isolate was recovered from a case of hospital acquired urinary tract infection in a young immunocompetent patient following surgery for renal calculus.

Cases reported were mainly due to C. meningosepticum in the Indian literature; however, recently Sudharani et al[11] have reported C. indologenes bacteremia in a preterm baby.

Antimicrobial susceptibility data on Chryseobacterium species remain very limited. In addition, results of susceptibility testing vary when different methods are used. [12] Our isolate was resistant to most commonly used antibiotics. It was sensitive to piperacillin-tazobactam. Despite their low virulence, chryseobacteria are inherently resistant to many antimicrobial agents, which makes them potential candidates for nosocomial infections. [6]

According to the results of the SENTRY Antimicrobial Surveillance Program, [10]the most active agents against C. indologenes are the quinolones (garenoxacin, gatifloxacin, and levofloxacin) and trimethoprim-sulfamethoxazole(≥95% susceptibility), followed by piperacillin-tazobactam (90% susceptibility). Ciprofloxacin, cefepime, ceftazidime, piperacillin, and rifampin showed reasonable activity (85% susceptibility). On the contrary, aminoglycosides, other β-lactams, chloramphenicol, linezolid, and glycopeptides are not appropriate for treating infections by this organism. [10]

Many studies have shown that vancomycin has marginal in vitro activity against Chryseobacterium species. In addition, some reports have documented the successful use of vancomycin to treat C. meningosepticum infections, and this antimicrobial agent has been recommended as a therapeutic choice. [1],[12] Our isolate was found sensitive to vancomycin.

Our strain was found resistant to imipenem and an MBL-producer. Several species of Flavobacteriaceae, including Chryseobacterium indologenes, are naturally resistant to β-lactam antibiotics (including carbapenems), due to production of a resident MBL. Six variant of MBLs (IND-1 to IND-5 and IND-2a) have been detected in C. indologenes.[13] A new IND-type variant named IND-6, has also been recently reported from Burkina Faso (2009) in C. indologenes isolated from UTI.[13]

To conclude, C. indologenes although uncommon, is an important pathogen causing urinary tract infection in hospitalized patients. Proper management of infection by this relatively resistant organism warrants correct identification and antimicrobial susceptibility testing.

 
 ~ References Top

1.Du Moulin GC. Airway colonization by Flavobacterium in an intensive care unit. J Clin Microbiol 1979;10:155-60.  Back to cited text no. 1
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2.Christakis GB, Perlorentzou SP, Chalkiopoulou I, Athanasiou A, Legakis NJ. Chryseobacterium indologenes non-catheter-related bacteremia in a patient with a solid tumor. J Clin Microbiol 2005;43:2021-3.  Back to cited text no. 2
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3.Murray PR, Pfaller MA, Tenover FC, Yolken RH. Manual of Clinical Microbiology. 6 th ed. Washington, DC: ASM Press; 1995. p. 528-30.  Back to cited text no. 3
    
4.The non-fermentative Gram-negative bacilli. In: Koneman EW, Allen SD, Janda WM, Schreckenberger PC, Winn WC. Color atlas and textbook of diagnostic microbiology. 6 th ed. Philadelphia: Lippincott; 2006. p. 345-52.  Back to cited text no. 4
    
5.Mandell GL, Dolin R. Principles and Practice of Infective Disease. 6 th ed. New York: Elsevier; 2005. p. 2757-9.  Back to cited text no. 5
    
6.Hsueh PR, Teng LJ, Ho SW, Hsieh WC, Luh KT. Clinical and microbiological characteristics of Flavobacterium indologenes infections associated with indwelling devices. J Clin Microbiol 1996;34:1908-13.   Back to cited text no. 6
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7.Lu PC, Chan JC. Flavobacterium indologenes keratitis. Ophthalmologica 1997; 211:98-100.   Back to cited text no. 7
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8.Cascio A, Stassi G, Costa GB, Crisafulli G, Rulli I, Ruggeri C, et al. Chryseobacterium indologenes bacteraemia in a diabetic child. J Med Microbiol 2005;54:677-80.  Back to cited text no. 8
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9.Bayraktar MR, Aktas E, Ersay Y, Cicek A, Durmaz R. Postoperative Chryseobacterium indologenes bloodstream infection caused by contamination of distillate water. Infect Control Hosp Epidemiol 2007;28:368-9.  Back to cited text no. 9
    
10.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. 10
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11.Sudharani V, Asiya, Saxena NK. Chryseobacterium indologenes bacteremia in a preterm baby. Indian J Med Microbiol 2011;29:196-8.  Back to cited text no. 11
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12.Di Pentima MC, Mason EO, Kaplan SL. In vitro antibiotic synergy against Flavobacterium meningosepticum: Implications for therapeutic options. Clin Infect Dis 1998;26:1169-76.  Back to cited text no. 12
    
13.Boukaré Z, Filomena DL, Alain D, Delmarcelle M, Simporé J. IND-6, a Highly Divergent IND-Type Metallo-â-Lactamase from Chryseobacterium indologenes Strain 597. Antimicrob Agents Chemother 2009;53:4320-6.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]

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