case report pbp-2 negative methicillin resistant ......case report pbp-2 negative methicillin...

Case ReportPBP-2 Negative Methicillin Resistant Staphylococcus schleiferiBacteremia from a Prostate Abscess An Unusual Occurrence

Chandni Merchant1 Daphne-Dominique Villanueva1 Ishan Lalani1

Margaret Eng1 and Yong Kang2

1Department of Internal Medicine Monmouth Medical Center Long Branch NJ 07740 USA2Department of Pathology Monmouth Medical Center Long Branch NJ 07740 USA

Correspondence should be addressed to Chandni Merchant chand m16yahoocom

Received 15 September 2015 Revised 17 December 2015 Accepted 3 February 2016

Academic Editor OguzR Sipahi

Copyright copy 2016 Chandni Merchant et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

Staphylococcus schleiferi subsp schleiferi is a coagulase-negative Staphylococcuswhich has been described as a pathogen responsiblefor various nosocomial infections including bacteremia brain abscess and infection of intravenous pacemakers Recently suchbacteria have been described to be found typically on skin and mucosal surfaces It is also believed to be a part of the preaxillaryhumanflora andmore frequently found inmen It is very similar in its pathogenicitywith Staphylococcus aureus group and expressesa fibronectin binding protein Literature on this pathogen reveals that it commonly causes otitis among dogs because of its locationin the auditory meatus of canines Also it has strong association with pyoderma in dogs The prime concern with this organism isthe antibiotic resistance and relapse even after appropriate treatment Very rarely if any cases have been reported about prostaticabscess (PA) with this microbe Our patient had a history of recurrent UTIs and subsequent PA resulting in S schleiferi bacteremiain contrast to gram negative bacteremia commonly associated with UTI This organism was found to be resistant to methicillin inspite of being negative for PBP2 which is a rare phenomenon and needs further studies

1 Introduction

Urinary tract infections are a less common phenomenon inmale patients Occasionally we come across cases of prostaticabscess in adult males which can result in bacteremia causedby common urinary pathogens We present a case of PA inan uncontrolled diabetic patient with S schleiferi bacteremiawhich is an uncommon organism in humans It is morefrequently found in men Immunosuppression is a riskfactor especiallymalignant neoplasms for infectionwith thisorganism It can be nosocomial or community acquired

2 Case Presentation

This is a case of a 49-year-old Caucasian male with past med-ical history significant for diabetes mellitus hypertensionbenign prostatic hyperplasia and recurrent folliculitis whopresented to the Emergency Department (ED) complainingof fever and chills of three-day duration The patient was

apparently well until two months priorly the patient soughtconsult at the ED for one-week history of gross hematuriaincreased frequency dysuria and suprapubic and perinealdiscomfort He was diagnosed to have acute prostatitis andwas sent home on a 2-week course of ciprofloxacin 500mgBID In the interim the patient reported occasional episodesof gross hematuria and consulted his primary care physician(PCP) who prescribed an additional 1-week course of thesame antibiotic Three days prior to admission the patientdeveloped fever (119879max 1027 F) and chills associated withnonbilious vomiting loose bowel movement poor appetiteand generalized body weakness The patient also reporteddysuria intermittency and hesitancy He had no sick contactsand no history of recent travel The patient works as alandscaper and lives at home with his wife He used tooccasionally drink alcohol (stopped at age 46) and is a formersmoker (stopped at age 21) and he denies illicit drug use

At the ED the patient had low-grade fever (1007 F) Heis obese and on further inspection had very large tattoos on

Hindawi Publishing CorporationCase Reports in Infectious DiseasesVolume 2016 Article ID 8979656 3 pageshttpdxdoiorg10115520168979656

2 Case Reports in Infectious Diseases

his back and arms On digital rectal examination externalhaemorrhoids were seen and the prostate was noted to beenlarged and nontender Blood work revealed leukocytosis(WBC 141 Kmm3) with bandemia (20) Urinalysis waspositive for 30mgdL urinary protein small amount of blood15mgdL of ketones moderate amount of leukocyte esterasetoo numerous to count WBC and 1+ bacteria At the EDthe patient was managed as a case of complicated UTI forwhich he received one dose of IV levofloxacin 750mg Onadmission to the medical floor diagnosis was fever andleukocytosis possibly due to prostatitisabscess ruling outClostridium difficile diarrhea Antibiotic was shifted to IVcefepime 1 g daily Urine stool and blood cultures weresent Clostridium difficile toxin PCR returned positive andtwo sets of blood culture grew gram positive cocci inclusters In addition CT scan of the abdomen and pelvisshowed lobulated fluid density within the prostate glandextending to the right superior aspectTheworking diagnosisat this time was prostate abscess methicillin-sensitive Saureus (MSSA) bacteremia andClostridium difficile diarrheaAntibiotic was shifted to IV vancomycin 1 g q12 and POvancomycin 125mg q6 Infectious disease (ID) and geni-tourinary (GU) specialists were consulted IV vancomycinwas changed to IV cefazolin 2 g q8 for S aureus subspaureus bacteremia likely from prostate abscess The S aureussubsp aureus bacteremia was found to be negative for PBP-2 an immune-chromatographic assay Alere PBP2a SACulture Colony Test On his fourth hospital day the patientunderwent cystoscopy with transurethral resection of theprostate (TURP) deroofing of the abscess and foley catheterinsertion The specimen that consisted of multiple fragmentsof gray-tan soft tissue measuring 35 times 17 times 03 cm inaggregate was submitted for microscopic examination Itshowed an organizing abscess As S aureus prostatitis is nota common condition and may be related to haematogenousspread a transthoracic echocardiogram (TTE) was doneand it revealed normal left ventricular systolic functionwith no evidence of infective endocarditis Blood culturewas noted to grow coagulase negative S schleiferi subspschleiferi using the machine BacTec 9240 Maryland USA Itwas found to be resistant to cefazolin hence antibiotic wasshifted back from IV cefazolin to IV vancomycin 1 g q12Antibiotic susceptibility results for S schleiferi demonstratedsensitivity to clindamycin gentamycin levofloxacin tetracy-cline sulfamethoxazoletrimethoprim and vancomycin Thetechnique used to detect antibiotic susceptibility was theFDA-approved Microscan Illinois USA

Working diagnosis at this timewas S schleiferi bacteremiafrom prostate abscess status after cystoscopy TURP withderoofing of abscess and Clostridium difficile diarrhea WBCand fever were noted to trend down and the patient hadvoiding trial without difficulty On his 8th hospital day thepatient was discharged on sulfamethoxazoletrimethoprimBID for 21 days and vancomycin 125mg q6 to complete14 days The patient came back to the ED one week afterdischarge complaining of two-day history of diarrhea andhematuria He was readmitted forClostridium difficile relapseand started on treatment with oral vancomycin 125mg every6 hours He was reassured that hematuria is expected after

a genitourinary procedure andmay be seen intermittently for4 to 6 weeks He was then discharged to complete a course oforal vancomycin with a stable follow-up course with his PCPand Urologist

3 Discussion

Staphylococcus schleiferi subsp schleiferi is coagulase-negativeStaphylococcus first described in April 1988 It has beenimplicated as the causative pathogen in a range of nosocomialinfections like bacteremia brain abscess pacemaker- andother intravenous-device-related infections and infections ofthe urinary tract orthopedic implants and surgical wounds[1] S schleiferi subsp coagulans is coagulase positive butinstead S schleiferi subsp schleiferi is coagulase negative It isrecently discovered that skin and multiple mucosal surfacesare the typical sites where the bacteria can be found It isalso believed to be a part of the preaxillary human flora Itcauses otitis in dogs due to its location in the auditory meatusof dogs [2] Antibiotic resistance has resulted in increasedpathogenicity of this organism It was newly found to bepathogenic to humans and other mammals Infection tendsto relapse even after antibiotic treatment In a Europeanstudy it was found that in 07 of the studied patientsrsquourine samples S schleiferi was found This study comprised4905 patients in total whose urine samples were analyzed[3] All of these 3 cases a 64-year-old female a 68-year-old male and a 3-month-old male with colony countsof 468000 cfumL 324000 cfumL and 764000 cfumLrespectively were inpatients This fact leads us to the hypo-thesis that among coagulase-negative staphylococci Sschleiferi a newly described species of coagulase-negativestaphylococci not previously reported as a uropathogen mayalso cause hospital-acquired urinary tract infection Aftermeticulous review of the literature we did not come acrossany case of prostate abscess being caused by coagulase-negative S schleiferi

This case illustrates an example of thinking out of thenorms and delivering precise treatment Our patient hadlong-standing history of urinary tract infection and wasfound to have bacteremia during the course of his hos-pital stay The blood cultures were positive for a growthof coagulase-negative S schleiferi Bacteremia after urinarytract infection is mostly associated with gram negativeorganisms S schleiferi is differentiated from S aureus byproduction of a heat stable nuclease Other identificationtests used are novobiocin susceptibility coagulase negativityand fibrinogen affinity factor On detailed workup for apossible source of Staphylococcal sepsis the only sourcewas found to be a prostate abscess The virulence factors ofthese bacteria are the production of beta-hemolysin lipaseand esterase [4] The mechanisms by which S schleifericause these infections are unknown but there is a degreeof similarity between the spectrum of infections caused bythis organism and those associated with S aureus Isolationof S schleiferi from cultures of prosthetic material suggeststhe presence of one or more bacterial cell surface-expressedadhesins with a host protein specificity similar to that of Saureus S schleiferi has been reported to bind fibrinogen but

Case Reports in Infectious Diseases 3

adherence to fibronectin and the identification of cell wall-associated adhesins have not previously been described forthis organism [1] In our patient the isolated bacteria fromblood cultures were found to be negative for PBP-2 (penicillinbinding protein-2) which is encoded by MecA gene whichis the mechanism for resistance to methicillin and otherpenicillin or beta-lactam antibiotics [5] Surprisingly inthis case in spite of absence of PBP-2 the susceptibilityresults revealed that the S schleiferi bacteria were resistant tocefazolin and oxacillin A review article in 2014 describes theemergence of mecC MRSA cases of which have only beenreported in Europe till date and they pose a challenge indiagnosis where only mecA or PBP2a21015840 are used for MRSAdetection [6] In the future laboratories will need to startusing the universal mec gene primers for PCR amplificationof both the mecA and mecC gene In a recent study in 2015which studied 217 isolates from canine specimens from mid-Atlantic and regions across the USA it was found that ofthe mid-Atlantic isolates 62 (72 of 116) were methicillinresistant (MR) and 16 (18 of 116) were multidrug resistant(MDR) Of the isolates from the other geographic regions73 (74 of 101) were MR and 24 (24 of 101) were MDR [7]This reflects the prevalence of antibiotic resistance pattern inthis organism across USA It has been recently studied thatmethicillin resistance is common with S schleiferi isolates inveterinarian studies Fluoroquinolone resistance is also notedin methicillin resistant S schleiferi (MRSS) [7] However inour hospital the antibiogram for S schleiferi reveals 100sensitivity to fluoroquinolones which included ciprofloxacinlevofloxacin and moxifloxacin

In the preantibiotic decades prostate abscesses (PA)frequently had a dramatic presentation and were usuallycaused byNeisseria gonorrhoeae In the present times PAmaybe difficult to differentiate from prostatitis and other diseasesof the lower urogenital tract The organisms most frequentlyisolated from PA are Escherichia coli and other gram negativebacilli other isolates include Staphylococcus species and anincreasing range of various bacteria and fungi PA due toStaphylococcus species may also occur in neonates [8] Thepatient denied having any pets or exposure to dogs in hiscommunity Our patient was a poorly controlled diabeticwhich could lead to immune suppressionHedid not have anyhistory of recent hospitalizations Antibiotics were changedmultiple times in his case This happens in situations whenrare microorganisms play a role in disease causation and onehas to be prudent about selection of the right antimicrobialagents With advent of antibiotic overuse we should be readyfor infections caused by newer unusual pathogens and usethe latest tests to detect serious infections like mecA negativeMRSA or MRSS

Competing Interests

The authors declare that there are no competing interestsregarding the publication of this paper

References

[1] S J Peacock G Lina J Etienne and T J Foster ldquoStaphylococcusschleiferi subsp schleiferi expresses a fibronectin- binding pro-teinrdquo Infection and Immunity vol 67 no 8 pp 4272ndash4275 1999

[2] H Ozturkeri O Kocabeyoglu Y Z Yergok E Kosan O SYenen and K Keskin ldquoDistribution of coagulase-negativestaphylococci including the newly described species Staphylo-coccus schleiferi in nosocomial and community acquired uri-nary tract infectionsrdquo European Journal of Clinical Microbiologyamp Infectious Diseases vol 13 no 12 pp 1076ndash1079 1994

[3] G K Paterson E M Harrison and M A Holmes ldquoTheemergence of mecCmethicillin-resistantStaphylococcus aureusrdquoTrends in Microbiology vol 22 no 1 pp 42ndash47 2014

[4] J Huebner and D A Goldmann ldquoCoagulase-negative staphy-lococci role as pathogensrdquo Annual Review of Medicine vol 50no 1 pp 223ndash236 1999

[5] D A Kunder C L Cain K OrsquoShea S D Cole and S CRankin ldquoGenotypic relatedness and antimicrobial resistanceof Staphylococcus schleiferi in clinical samples from dogs indifferent geographic regions of the United Statesrdquo VeterinaryDermatology vol 26 no 6 p 406ndashe94 2015

[6] MWeinberger S Cytron C Servadio C Block J B Rosenfeldand S D Pitlik ldquoProstatic abscess in the antibiotic erardquo Reviewsof Infectious Diseases vol 10 no 2 pp 239ndash249 1988

[7] DOMorris KA Rook andF S Shofer ldquoScreenng of S auruesS intermedius and S Schleiferi isolates obtained from smallcompanion animals for ani-microbial resistance a retrospectivereview of 749 isolates (2003-04)rdquo Vet Dermatlolgy vol 17 pp332ndash337 2006

[8] R H Deurenberg and E E Stobberingh ldquoThe evolution ofStaphylococcus aureusrdquo Infection Genetics and Evolution vol 8no 6 pp 747ndash763 2008

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

2 Case Reports in Infectious Diseases

his back and arms On digital rectal examination externalhaemorrhoids were seen and the prostate was noted to beenlarged and nontender Blood work revealed leukocytosis(WBC 141 Kmm3) with bandemia (20) Urinalysis waspositive for 30mgdL urinary protein small amount of blood15mgdL of ketones moderate amount of leukocyte esterasetoo numerous to count WBC and 1+ bacteria At the EDthe patient was managed as a case of complicated UTI forwhich he received one dose of IV levofloxacin 750mg Onadmission to the medical floor diagnosis was fever andleukocytosis possibly due to prostatitisabscess ruling outClostridium difficile diarrhea Antibiotic was shifted to IVcefepime 1 g daily Urine stool and blood cultures weresent Clostridium difficile toxin PCR returned positive andtwo sets of blood culture grew gram positive cocci inclusters In addition CT scan of the abdomen and pelvisshowed lobulated fluid density within the prostate glandextending to the right superior aspectTheworking diagnosisat this time was prostate abscess methicillin-sensitive Saureus (MSSA) bacteremia andClostridium difficile diarrheaAntibiotic was shifted to IV vancomycin 1 g q12 and POvancomycin 125mg q6 Infectious disease (ID) and geni-tourinary (GU) specialists were consulted IV vancomycinwas changed to IV cefazolin 2 g q8 for S aureus subspaureus bacteremia likely from prostate abscess The S aureussubsp aureus bacteremia was found to be negative for PBP-2 an immune-chromatographic assay Alere PBP2a SACulture Colony Test On his fourth hospital day the patientunderwent cystoscopy with transurethral resection of theprostate (TURP) deroofing of the abscess and foley catheterinsertion The specimen that consisted of multiple fragmentsof gray-tan soft tissue measuring 35 times 17 times 03 cm inaggregate was submitted for microscopic examination Itshowed an organizing abscess As S aureus prostatitis is nota common condition and may be related to haematogenousspread a transthoracic echocardiogram (TTE) was doneand it revealed normal left ventricular systolic functionwith no evidence of infective endocarditis Blood culturewas noted to grow coagulase negative S schleiferi subspschleiferi using the machine BacTec 9240 Maryland USA Itwas found to be resistant to cefazolin hence antibiotic wasshifted back from IV cefazolin to IV vancomycin 1 g q12Antibiotic susceptibility results for S schleiferi demonstratedsensitivity to clindamycin gentamycin levofloxacin tetracy-cline sulfamethoxazoletrimethoprim and vancomycin Thetechnique used to detect antibiotic susceptibility was theFDA-approved Microscan Illinois USA

Working diagnosis at this timewas S schleiferi bacteremiafrom prostate abscess status after cystoscopy TURP withderoofing of abscess and Clostridium difficile diarrhea WBCand fever were noted to trend down and the patient hadvoiding trial without difficulty On his 8th hospital day thepatient was discharged on sulfamethoxazoletrimethoprimBID for 21 days and vancomycin 125mg q6 to complete14 days The patient came back to the ED one week afterdischarge complaining of two-day history of diarrhea andhematuria He was readmitted forClostridium difficile relapseand started on treatment with oral vancomycin 125mg every6 hours He was reassured that hematuria is expected after

a genitourinary procedure andmay be seen intermittently for4 to 6 weeks He was then discharged to complete a course oforal vancomycin with a stable follow-up course with his PCPand Urologist

3 Discussion

Staphylococcus schleiferi subsp schleiferi is coagulase-negativeStaphylococcus first described in April 1988 It has beenimplicated as the causative pathogen in a range of nosocomialinfections like bacteremia brain abscess pacemaker- andother intravenous-device-related infections and infections ofthe urinary tract orthopedic implants and surgical wounds[1] S schleiferi subsp coagulans is coagulase positive butinstead S schleiferi subsp schleiferi is coagulase negative It isrecently discovered that skin and multiple mucosal surfacesare the typical sites where the bacteria can be found It isalso believed to be a part of the preaxillary human flora Itcauses otitis in dogs due to its location in the auditory meatusof dogs [2] Antibiotic resistance has resulted in increasedpathogenicity of this organism It was newly found to bepathogenic to humans and other mammals Infection tendsto relapse even after antibiotic treatment In a Europeanstudy it was found that in 07 of the studied patientsrsquourine samples S schleiferi was found This study comprised4905 patients in total whose urine samples were analyzed[3] All of these 3 cases a 64-year-old female a 68-year-old male and a 3-month-old male with colony countsof 468000 cfumL 324000 cfumL and 764000 cfumLrespectively were inpatients This fact leads us to the hypo-thesis that among coagulase-negative staphylococci Sschleiferi a newly described species of coagulase-negativestaphylococci not previously reported as a uropathogen mayalso cause hospital-acquired urinary tract infection Aftermeticulous review of the literature we did not come acrossany case of prostate abscess being caused by coagulase-negative S schleiferi

This case illustrates an example of thinking out of thenorms and delivering precise treatment Our patient hadlong-standing history of urinary tract infection and wasfound to have bacteremia during the course of his hos-pital stay The blood cultures were positive for a growthof coagulase-negative S schleiferi Bacteremia after urinarytract infection is mostly associated with gram negativeorganisms S schleiferi is differentiated from S aureus byproduction of a heat stable nuclease Other identificationtests used are novobiocin susceptibility coagulase negativityand fibrinogen affinity factor On detailed workup for apossible source of Staphylococcal sepsis the only sourcewas found to be a prostate abscess The virulence factors ofthese bacteria are the production of beta-hemolysin lipaseand esterase [4] The mechanisms by which S schleifericause these infections are unknown but there is a degreeof similarity between the spectrum of infections caused bythis organism and those associated with S aureus Isolationof S schleiferi from cultures of prosthetic material suggeststhe presence of one or more bacterial cell surface-expressedadhesins with a host protein specificity similar to that of Saureus S schleiferi has been reported to bind fibrinogen but




Competing Interests


References














of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















Competing Interests


References














of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















case report pbp-2 negative methicillin resistant ......case report pbp-2 negative methicillin...

Documents