|Year : 2015 | Volume
| Issue : 2 | Page : 311-313
Pyonephrosis due to Chryseobacterium gleum: A first case report
S Garg, SB Appannanavar, B Mohan, N Taneja
Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||24-Dec-2013|
|Date of Acceptance||19-Mar-2014|
|Date of Web Publication||10-Apr-2015|
Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
Chryseobacterium spp are widely distributed in nature but data of their isolation from clinical samples is scanty. Here, we report the first case of AmpC producing C. gleum causing pyonephrosis in a patient having bilateral nephrolithiasis on double J (DJ) stent. The present isolate was resistant to vancomycin, erythromycin, clindamycin, carbapenems and ciprofloxacin and susceptible to tetracycline and minocycline. The patient was treated with tetracycline and recovered without the need for removal of the DJ stent. The environmental surveillance carried out to trace the nosocomial origin of the isolate was negative. Since antimicrobial susceptibility of this isolate is different from previous reports, we emphasise that in vitro susceptibility testing should be sought to choose optimal antimicrobial agents for these Nonfermentative Gram-Negative Bacilli (NFGNBs) with different susceptibility patterns.
Keywords: Chryseobacterium gleum, non-fermenter, urinary tract infections
|How to cite this article:|
Garg S, Appannanavar S B, Mohan B, Taneja N. Pyonephrosis due to Chryseobacterium gleum: A first case report. Indian J Med Microbiol 2015;33:311-3
|How to cite this URL:|
Garg S, Appannanavar S B, Mohan B, Taneja N. Pyonephrosis due to Chryseobacterium gleum: A first case report. Indian J Med Microbiol [serial online] 2015 [cited 2019 Dec 12];33:311-3. Available from: http://www.ijmm.org/text.asp?2015/33/2/311/154894
| ~ Introduction|| |
Urinary tract infections (UTIs) caused by Nonfermentative Gram-Negative Bacilli (NFGNBs) belonging to Chryseobacterium spp (previously Flavobacterium) are rare. Among the various species, Chryseobacterium indologenes is the most frequently encountered in urine specimens.  C. gleum, another species under the genus Chryseobacterium (previously Flavobacterium gleum) was first described by Holmes et al. in 1984.  It has 98-99% of similarity with C. indologenes by 16S rRNA gene sequencing but in 1990, this organism was clearly differentiated from C. indologenes by DNA-DNA homology data and phenotypic characterstics.  Vandamme et al. proposed the novel genus Chryseobacterium in 1994, and C. gleum was considered as the type species for this newer genus.  Till date, it has been isolated from a variety of clinical specimens such as sputum, wound swabs and high vaginal swabs,  but no reports are available from urine specimens and percutaneous nephrostomy (PCN) fluid. Currently, the data on antimicrobial susceptibility of this organism are limited, though Chryseobacterium spp. are known to exhibit resistance to various antimicrobials.  To the best our knowledge this is the first case report of AmpC producing C. gleum causing pyonephrosis.
| ~ Case Report|| |
A 48-year-old man with a past history of bilateral renal and ureteric calculi presented to the emergency department of our tertiary care hospital with complaints of fever and decreased urine output for six days. The patient underwent double J (DJ) stenting in a private hospital about a week ago. At our centre, kidney, ureter and bladder X-ray (KUB) showed that the right side stent had migrated down while the left stent was in its proper place. Residual stones were also noted in the right kidney. On day 2, the ultrasonography (USG) examination showed small hypoechoic lesions suggestive of pyonephrosis. Complete blood count showed leukocytosis (17600/mm3) with raised neutrophil (82%) and decreased lymphocytes (14%). Blood urea (182 mg/dl) and creatinine (7.2 mg/dl) were elevated. The urine microscopy revealed haematuria (50-60 RBC/HPF) and pyuria (80-90 WBC/HPF) in uncentrifuged specimen. Patient did not have any other chronic medical illness and there was no history of diabetes mellitus, alcohol, tobacco or any intravenous drug abuse. There were no other indwelling devices. The patient was started with imipenem (250 mg intravenously twice daily). On the same day an USG guided PCN fluid was sent for culture and sensitivity, which showed yellow pigmented colonies on cysteine lactose electrolyte deficient (CLED) media after overnight incubation (day 3). The growth was subsequently sub-cultured on blood and MacConkey agar (MAC) plates and incubated at 37° C and 42° C for 24 hours. Small, circular, opaque, non-haemolytic, yellow-orange coloured, low convex colonies with entire edges and glistening surface appeared on blood agar plates incubated at 37° C [Figure 1], whereas no growth was observed at 42° C (day 4) and in MAC. The gram-stain revealed Gram-negative rods, shorter and thinner than Escherichia More Details coli ATCC 25922 control. The organism was found to be non-motile when tested at two temperatures (37° C and 22° C). Further characterisation was done by conventional biochemical methods. The organism was catalase and oxidase-positive and produced indole using Ehrlich reagent, thus was differentiated from other common oxidase-positive, non-motile, pigmented rod shaped bacilli like Sphingobacterium, Sphingomonas and Myroides spp. The strain was also positive for esculin hydrolysis, ONPG and gelatine liquefaction and negative for nitrate reduction. By production of urease and asacchrolytic reaction for mannitol, the organism was identified as C. gleum and differentiated from C. meningosepticum and C. indologenes.  These results were confirmed using MALDI-TOF assay (Bruker Daltonik, Bremen, Germany). Material from freshly sub-cultured colonies was smeared on MALDI plate using a toothpick, overlaid with saturated HCCA (Cyano-4-hydroxycinnaminic acid) and allowed to dry at room temperature. The device parameters were adjusted as recommended by the manufacturer. Final spectra were analysed by MALDI Biotyper real-time classification (RTC) 3.0 software. A log score of 2.506 was obtained which was considered as a reliable species identification. Antimicrobial susceptibility testing was done by Kirby-Bauer disc diffusion method as per clinical and laboratory standards institute (CLSI) for non-fermenting organisms. The organism was resistant to polymyxin (300 U), amoxycillin (10 μg), cefotaxime (30 μg), ceftazidime (30 μg), cefoperazone (75 μg), cefepime (30 μg), cefoperazone-sulbactam (75/10 μg), imipenem (10 μg), meropenem (10 μg), gentamicin (10 μg), tobramycin (10 μg), amikacin (30 μg), norfloxacin (10 μg), ciprofloxacin (5 μg), levofloxacin (5 μg), vancomycin (30 μg), clindamycin (15 μg) and erythromycin (15 μg) and susceptible to tetracycline (30 μg), minocycline (30 μg) and nitrofurantoin (300 μg). Intermediate susceptibility was noted for piperacillin-tazobactam (100/10 μg), chloramphenicol (30 μg) and nalidixic acid (30 μg). We also performed phenotypic tests to detect the production of extended spectrum beta lactamase (ESBL), Metallo beta lactamase (MBL) and AmpC carbapenemase. The strain was found to be an AmpC producer.  During this period, the patient received imipenem but did not show signs of improvement and had high leucocyte counts. Repeat sampling of PCN fluid also grew the same isolate. Based on the susceptibility pattern (day 5), clinicians were advised to change the antibiotic to tetracycline (tab 500 mg twice daily for 7 days). Following therapy with tetracycline, the patient's condition improved and Total leucocyte count (TLC) reverted to normal limits by next day (day 6).
To trace the source and routes of transmission, surveillance cultures were taken from disinfectant solutions, wash basins, taps, medicine trolleys, dressing trolleys, handles of the refrigerator, OT tables, ultrasound machine of emergency operation theatre and procedure room. However, none of the surveillance samples grew C. gleum.
| ~ Discussion|| |
Chryseobacterium spp are widely distributed in nature especially in chlorine-treated municipal water supplies and hospital environment. However, limited data is available of their isolation from clinical samples. According to SENTRY antimicrobial surveillance programme, Chryseobacterium spp. represented only 0.27% (50 of 18569) of the processed NFGNBs and 0.03% (50 of 155811) of all bacterial isolates collected during the 5-year period (1997 to 2001) from 33 medical centres in 16 countries from which only 2 isolates (4%) were identified as C. gleum.  Chryseobacterium spp. can cause severe nosocomial infections especially in immunocompromised critically ill patients.  Prolonged catheterisation and invasive interventions have also been identified as risk factors.  Our patient had chronic renal disease and may have acquired the infection nosocomially, though we could not trace the source in our hospital. Therefore the infection was presumably acquired from the previous health-care facility. It can survive in and can colonise the sinks and tap water of the hospitals.  The organism spreads to close contacts primarily by hand. 
Currently, antibiotic susceptibility testing for Chryseobacterium spp. is limited by lack of minimum inhibitory concentration (MIC) breakpoints and zone diameters by CLSI. We used resistance zone diameter breakpoints available for other NFGNBs. Both, C. meningosepticum, and C. indologenes, are resistant to most antimicrobial agents used to treat Gram-negative bacteria but are susceptible to agents used to treat Gram-positive bacterial infections like vancomycin, erythromycin and clindamycin.  However, the present strain of C. gleum, was resistant to vancomycin, erythromycin and clindamycin which is consistent with an earlier study,  emphasising the need for speciation and antimicrobial susceptibility for these group of NFGNBs. Though ciprofloxacin and newer fluoroquinolones (garenoxacin, gatifloxacin and levofloxacin) have been cited as the most appropriate antimicrobial agents to treat Chryseobacterium spp. Infections,  in the present study, in-vitro activity of levofloxacin and ciprofloxacin was disappointing. Our patient recovered with the change of antibiotic to tetracycline. Tetracycline is previously documented to have varied effectiveness against Chryseobacterium spp.  The isolate was also susceptible to minocycline which can be another alternative to treat invasive infections. Though strains producing ESBL (a clavulanic acid-inhibited β-lactamase) CGA-1 of Ambler class A and chromosome-borne class B-β-lactamase have been reported from France, , we demonstrate for the first time that C. gleum is able to produce AmpC.
The removal of indwelling device is recommended in the presence of pyuria and if the clinical symptoms of indwelling catheter related infection do not improve after appropriate antibiotic therapy. Our patient was successfully treated with tetracycline while the DJ stent was kept in situ, indicating that indwelling catheter related infection caused by Chryseobacterium spp. do not always require removal of devices. This conclusion agrees well with the report of Hsueh et al. in which 6 out of 7 patients recovered well with only antibiotic treatment when the devices were kept in place. 
| ~ Conclusion|| |
We emphasise that isolation of a rare organism such as C. gleum from clinical specimens, should alert the possibility of nosocomial infection of the implanted devices and in vitro susceptibility testing should be sought to choose optimal antimicrobial agents for these NFGNBs with different susceptibility patterns. However, choice of effective drug for the empirical treatment of infection due to Chryseobacterium spp. is difficult due to limited published data. Therefore, awareness among the clinicians and the clinical microbiologists is warranted so that more epidemiological and susceptibility data is generated.
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