|Year : 2015 | Volume
| Issue : 3 | Page : 437-439
Kluyvera ascorbata sepsis in an extremely low birth weight infant
D Sharma1, T Dasi2, S Murki1, TP Oleti1
1 Department of Neonatology, Fernandez Hospital, Hyderguda, Hyderabad - 500 029, Telangana, India
2 Department of Microbiology, Fernandez Hospital, Hyderguda, Hyderabad - 500 029, Telangana, India
|Date of Submission||28-Oct-2014|
|Date of Acceptance||05-Feb-2015|
|Date of Web Publication||12-Jun-2015|
Department of Neonatology, Fernandez Hospital, Hyderguda, Hyderabad - 500 029, Telangana
Source of Support: None, Conflict of Interest: None
Kluyvera ascorbata belongs to Enterobacteriaceae family and is a gram negative micro-organism. This bacteria is usually considered a commensal, however it can cause significant infections rarely. This organism is usually resistant to most commonly used antibiotics used as first line in neonatal units. Antimicrobial agents active against Kluyvera strains include third-generation cephalosporins, fluoroquinolones, and aminoglycosides. We report a case of an extremely low birth weight male infant who presented on day 4 of life with clinical features of sepsis, multi-organ dysfunction, shock and pulmonary haemorrhage. Neonatal sepsis was associated with marked elevation of C-reactive protein and a falling platelet count. Infant expired on day 5 of life in spite of aggressive supportive care and treatment with meropenem. with growth of Kluyvera ascorbataon blood culture.
Keywords: Extremely low birth weight infant, kluyvera, neonatal mortality, sepsis
|How to cite this article:|
Sharma D, Dasi T, Murki S, Oleti T P. Kluyvera ascorbata sepsis in an extremely low birth weight infant. Indian J Med Microbiol 2015;33:437-9
|How to cite this URL:|
Sharma D, Dasi T, Murki S, Oleti T P. Kluyvera ascorbata sepsis in an extremely low birth weight infant. Indian J Med Microbiol [serial online] 2015 [cited 2019 Jan 23];33:437-9. Available from: http://www.ijmm.org/text.asp?2015/33/3/437/158585
| ~ Introduction|| |
Kluyvera ascorbata belongs to Enterobacteriaceae family and is a gram negative micro-organism.  In the past, Kluyvera Sp. was considered non-pathogenic and saprophytic in nature, but few reports in the recent period have shown its association with severe bacteraemia, soft tissue infection, intra-abdominal abscess, septic shock and urinary tract infection. , So, in cases of Kluyvera sepsis in neonates, early and targeted treatment with appropriate antibiotics would reduce neonatal morbidity and mortality. 
| ~ Case Report|| |
An extremely low birth weight male infant was born with a birth weight of 800 grams at 30 weeks of gestation to a 27-year-old primi-gravida mother. Mother was referred to our hospital for an anticipated preterm delivery with foetal doppler abnormality. The infant was delivered by caesarean section for intrauterine growth restriction and absent end diastolic blood flow (AEDF) in the umbilical artery. He cried immediately after birth and had an APGAR score of 7/8/8 at 1, 5 and 10 minutes of life respectively. At birth he was noted to have a single umbilical artery. On examination there was no dysmorphism or malformations. For respiratory distress starting soon after birth, he was started on bubble continuous positive airway pressure (CPAP) and received one dose of surfactant by Intubation surfactant and extubation (INSURE) method. Infant continued to be on CPAP for mild respiratory distress and oxygen requirement of 30% FiO2. At 30 hours of life, infant had an acute deterioration with increasing respiratory distress, increase in oxygen requirement, pallor, cool and dusky periphery, feeble pulses, delayed capillary refill time and low blood pressures. Haematocrit dropped from 43.5% on day 1 to 34.5%. Vital parameters included heart rate of 190 beats/min (tachycardia), respiratory rate of 68/min (tachypnea), blood pressure of 40/24 mm Hg (low blood pressure) and capillary refill time of 4 seconds. Chest X-ray showed bilateral diffuse opacity suggestive of pulmonary haemorrhage. Sepsis screen showed white blood cell (WBC) count of 11,500/mm 3 with 45% neutrophils, Immature neutrophil/total neutrophil (I/T) ratio of 0.15, platelet count of 180,000/mm 3 , C- reactive protein (CRP) value of 0.1 mg/dl and cultures showed no growth of organism. Infant was started on invasive ventilation, inotropic support, packed cell transfusion and intravenous pipericillin-tazobactum. However, on day 4 of life, nearly 60 hours after the first deterioration, infant again had dusky and cold peripheries, prolonged capillary refill time (around 4 sec), off colour, sclerema over the face, petechial spots over chest and abdomen, acidotic breathing (base deficit of -14, pH 7.08), tachycardia (heart rate of 182 beats/min), tachypnea (respiratory rates of 70-72/min) and hypotension (mean BP of 24 mmHg). Sepsis work up showed elevated CRP (6.1mg/dl), leucopenia (WBC counts 3400/mm 3 ), absolute neutrophil count of 864/mm 3 , I/T ratio of 0.23, platelet count of 7000/mm3, toxic granulations on peripheral smear and coagulation profile was grossly deranged. The infant was revaluated with repeat blood cultures, two separate blood cultures were sent from two different sites after taking all aspetic precautions to rule out contamination. Antibiotics were upgraded from pipericillin-tazobactum to Meropenem in view of clinical deterioration. The infant expired on day 5 of life. Repeated both blood cultures done at second deterioration (on day 4) showed growth of Kluyvera ascorbata sensitive to Amikacin, Colistin, Imipenem, Meropenem and Tigecycline. The organism was resistant to Gentamicin, Piperacillin-tazobactum, Amoxyclav, Ciprofloxacin, Cefazolin, Cefuroxime, Ceftazidime and Cefotaxime. Consent was obtained form the parents for case report publication.
| ~ Discussion|| |
Kluyvera species are present ubiquitously in the environment and distributed predominantly in soil and water. These organisms are also considered by many as normal commensal in human being gastro intestinal tract.  In 1936, Kluyver and van Neil discovered the Kluyvera spp,  but its complete discovery of genetic characteristic and molecular features were done by 1981. 
Virulence factors in the pathogenesis of the Kluyvera species, are attributed to lipopolysaccharide and surface antigens, which are characteristic feature of Enterobacteriaceae family members.  In the recent past, Kluyvera ascorbata has become increasingly more clinically significant due to a wide range of clinical manifestations in neonates and also because of its inherent property to transfer CTX-M- type extended spectrum B-lactamases (ESBLs) genes to other members of the Enterobacteriaceae family. 
Neonates are prone to infections and the risk increases further inpremature infants because of the immunological immaturity.  The clinical significance of Kluyvera infections in the pediatric population has been recently reviewed by Carter et al. 
In our patient, the bacterium was sensitive only to Amikacin, Imipenem, Meropenem, Colistin and Tigecycline and resistant to all third generation cephalosporins and fluoroquinolones.
In the present case, the infant was extremely low birth weight and had co-morbid conditions such as respiratory distress syndrome (RDS) and patent ductus arteriosus (PDA) which could have been responsible for mortality besides sepsis. The possible source of infection in this case could be from health care personal or from water, though we were not able to identify the source of infection.
| ~ Conclusion|| |
Kluyvera ascorbata is a commensal organism, in immunocompromised situations or individuals it can cause fulminant sepsis.
| ~ References|| |
Moonah S, Deonarine K, Freeman C. Multidrug resistant Kluyvera ascorbata septicemia in an adult patient: A case report. J Med Case Rep 2010;4:197.
Carter JE, Laurini JA, Mizell KN. Kluyvera infections in the paediatric population. Pediatr Infect Dis J 2008;27:839-41.
Carter JE, Evans TN. Clinically significant Kluyvera infections: A report of seven cases. Am J Clin Pathol 2005;123:334-8.
Bolat F, Kilic SC, Abaci C, Cevit O, Gultekin A. A neonate with kluyvera sepsis: A case report. Iran J Pediatr 2013;23:371-2.
Farmer JJ 3 rd
, Fanning GR, Huntley-Carter GP, Holmes B, Hickman FW, Richard C, et al
. Kluyvera, a new (redefined) genus in the family Enterobacteriaceae: Identification of Kluyvera ascorbata sp. nov. and Kluyvera cryocrescens sp. nov. in clinical specimens. J Clin Microbiol 1981;13:919-33.
Kluyver AJ, van Neil CB. Prospects for a natural system of classification of bacteria. Zentralbl Bakteriol Parasitenkd Infektionskr Hyg Abt II 1936;95:369-403.
Altun Koroglu O, Yalaz M, Ozalkaya E, Polat DC, Akisu M, Kultursay N. Kluyvera cryocrescens sepsis in a preterm infant. Jpn J Infect Dis 2010;63:195-6.