Carbapenemase-Producing Raoultella Planticola: A Rare Cause of Pneumonia and Bacteremia
<p>An 85-year-old woman presented to the hospital after sustaining burn injuries and smoke exposure from a house fire. On admission, she was tachypneic, with a respiratory rate of 20 breaths per minute. Her physical exam was significant for 2nd degree burns along the dorsal and palmar aspects of her first three fingers on the right hand and partially on the index finger and thumb of her left hand. She had 1st degree burns on the rest of her hands and both forearms, as well as on the entire face and neck. Her wounds were debrided and silvedene was applied on her hands and forearms, while bacitracin was used for her face. Shortly after admission, the patient experienced difficulty breathing, trouble swallowing, voice changes and swelling around her mouth and tongue. She was intubated for airway protection and was transferred to the intensive care unit (ICU). She was extubated 2 days later, but re-intubated after an episode of projectile vomiting and aspiration. Due to the development of fevers, blood and urine cultures were taken. She was started on cefepime 2 g every 12 h and vancomycin 15 mg/kg every 12 h for aspiration pneumonia. Blood culture grew methicillin-sensitive <span class="html-italic">Staphylococcus aureus</span> and urine culture was positive for <span class="html-italic">Morganella morganii.</span> Four days later, she developed spontaneous pneumothorax that required chest tube placement. Persistence of fever and worsening leukocytosis prompted antibiotic escalation to meropenem with continuation of vancomycin. Over the next 2 days, the patient developed acute renal failure and was started on continuous veno-venous hemodialysis. She completed 12 days of antibiotics. Over the next week, she developed a central line bloodstream infection caused by <span class="html-italic">Enterococcus faecalis</span> and ventilator associated pneumonia caused by methicillin-sensitive <span class="html-italic">Staphylococcus aureus</span>, for which she was treated with ampicillin/sulbactam for 7 days. Three days later, the patient developed a new episode of fever and worsening bilateral infiltrates in chest X-ray (<b>A</b>). Cultures were obtained, and gram stain from blood culture and endotracheal aspirate revealed gram-negative bacilli (<b>B</b>). The Mac Conckey agar demonstrated a pink color, which is characteristic of lactose-fermenting organisms (<b>C</b>). The patient was started empirically on cefepime 2 g every 12 h, and the central lines were removed (one of the potential sources of infection). The gram-negative rod was identified as <span class="html-italic">Raoultella planticola</span> by MALDI-TOF (matrix-assisted laser desorption ionization time of flight), and further in-vitro susceptibility testing by the Vitek<sup>®</sup> 2 system (BioMérieux, Inc., Hazelwood, MO, USA) revealed resistance to most antibiotics, except for colistin, polymyxin B, aminoglycosides, tetracycline, and tigecycline (<b>D</b>). We performed additional phenotypic tests and detected carbapenemase production by the Carbapenem Inactivation Method (<b>E</b>). Supplementary antibiotic susceptibility studies by E-test showed susceptibility to ceftazidime/avibactam (<b>F</b>, left side) and meropenem/vaborbactam (<b>F</b>, right side). Confirmation of carbapenemase production was carried out by genotypic analysis using Verigene system (Luminex Corp, Austin, TX, USA), which identified bla<sub>KPC</sub> and bla<sub>CTX-M</sub> genes. Treatment with cefepime was discontinued and the patient was started on combination therapy with ceftazidime/avibactam and polymyxin B. Follow-up blood cultures were negative and her respiratory status improved over the following days. Finally, she was transferred to a LTAC (long-term acute care) facility to complete 2 weeks of antibiotic therapy.</p> "> Figure 1 Cont.
<p>An 85-year-old woman presented to the hospital after sustaining burn injuries and smoke exposure from a house fire. On admission, she was tachypneic, with a respiratory rate of 20 breaths per minute. Her physical exam was significant for 2nd degree burns along the dorsal and palmar aspects of her first three fingers on the right hand and partially on the index finger and thumb of her left hand. She had 1st degree burns on the rest of her hands and both forearms, as well as on the entire face and neck. Her wounds were debrided and silvedene was applied on her hands and forearms, while bacitracin was used for her face. Shortly after admission, the patient experienced difficulty breathing, trouble swallowing, voice changes and swelling around her mouth and tongue. She was intubated for airway protection and was transferred to the intensive care unit (ICU). She was extubated 2 days later, but re-intubated after an episode of projectile vomiting and aspiration. Due to the development of fevers, blood and urine cultures were taken. She was started on cefepime 2 g every 12 h and vancomycin 15 mg/kg every 12 h for aspiration pneumonia. Blood culture grew methicillin-sensitive <span class="html-italic">Staphylococcus aureus</span> and urine culture was positive for <span class="html-italic">Morganella morganii.</span> Four days later, she developed spontaneous pneumothorax that required chest tube placement. Persistence of fever and worsening leukocytosis prompted antibiotic escalation to meropenem with continuation of vancomycin. Over the next 2 days, the patient developed acute renal failure and was started on continuous veno-venous hemodialysis. She completed 12 days of antibiotics. Over the next week, she developed a central line bloodstream infection caused by <span class="html-italic">Enterococcus faecalis</span> and ventilator associated pneumonia caused by methicillin-sensitive <span class="html-italic">Staphylococcus aureus</span>, for which she was treated with ampicillin/sulbactam for 7 days. Three days later, the patient developed a new episode of fever and worsening bilateral infiltrates in chest X-ray (<b>A</b>). Cultures were obtained, and gram stain from blood culture and endotracheal aspirate revealed gram-negative bacilli (<b>B</b>). The Mac Conckey agar demonstrated a pink color, which is characteristic of lactose-fermenting organisms (<b>C</b>). The patient was started empirically on cefepime 2 g every 12 h, and the central lines were removed (one of the potential sources of infection). The gram-negative rod was identified as <span class="html-italic">Raoultella planticola</span> by MALDI-TOF (matrix-assisted laser desorption ionization time of flight), and further in-vitro susceptibility testing by the Vitek<sup>®</sup> 2 system (BioMérieux, Inc., Hazelwood, MO, USA) revealed resistance to most antibiotics, except for colistin, polymyxin B, aminoglycosides, tetracycline, and tigecycline (<b>D</b>). We performed additional phenotypic tests and detected carbapenemase production by the Carbapenem Inactivation Method (<b>E</b>). Supplementary antibiotic susceptibility studies by E-test showed susceptibility to ceftazidime/avibactam (<b>F</b>, left side) and meropenem/vaborbactam (<b>F</b>, right side). Confirmation of carbapenemase production was carried out by genotypic analysis using Verigene system (Luminex Corp, Austin, TX, USA), which identified bla<sub>KPC</sub> and bla<sub>CTX-M</sub> genes. Treatment with cefepime was discontinued and the patient was started on combination therapy with ceftazidime/avibactam and polymyxin B. Follow-up blood cultures were negative and her respiratory status improved over the following days. Finally, she was transferred to a LTAC (long-term acute care) facility to complete 2 weeks of antibiotic therapy.</p> ">
Abstract
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References
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Gonzales Zamora, J.A.; Corzo-Pedroza, M.; Romero Alvarez, M.; Martinez, O.V. Carbapenemase-Producing Raoultella Planticola: A Rare Cause of Pneumonia and Bacteremia. Diseases 2018, 6, 94. https://doi.org/10.3390/diseases6040094
Gonzales Zamora JA, Corzo-Pedroza M, Romero Alvarez M, Martinez OV. Carbapenemase-Producing Raoultella Planticola: A Rare Cause of Pneumonia and Bacteremia. Diseases. 2018; 6(4):94. https://doi.org/10.3390/diseases6040094
Chicago/Turabian StyleGonzales Zamora, Jose Armando, Monica Corzo-Pedroza, Maria Romero Alvarez, and Octavio V. Martinez. 2018. "Carbapenemase-Producing Raoultella Planticola: A Rare Cause of Pneumonia and Bacteremia" Diseases 6, no. 4: 94. https://doi.org/10.3390/diseases6040094