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Vol. 35. Issue 2.
Pages 131-133 (February 2017)
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Vol. 35. Issue 2.
Pages 131-133 (February 2017)
Scientific letter
DOI: 10.1016/j.eimce.2017.01.032
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First description of late recurrence of catheter-associated bacteraemia due to Cellulosimicrobium cellulans
Primer caso de bacteriemia asociada a catéter con recurrencia tardía debido a Cellulosimicrobium cellulans
Manuel Ponce-Alonsoa,
Corresponding author

Corresponding author.
, Rosa Del Campoa, Jesus Fortunb, Rafael Cantóna, María-Isabel Morosinia
a Department of Microbiology and Parasitology, Ramón y Cajal University Hospital, Spain
b Department of Infectious Diseases, Ramón y Cajal University Hospital, Spain
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Tables (1)
Table 1. Clinical and microbiological characteristics of the 22 cases of C. cellulans infections reported up to date.
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Cellulosimicrobium cellulans (formerly Oerskovia xanthineolytica), a nocardia-like bacillus widely distributed in the environment, is rarely associated with human infections.1 Cases reported so far in the literature are mostly related with the presence of foreign bodies in immunocompromised patients.2 We describe a case of long-term recurrent catheter infection by C. cellulans.

A 59-year-old woman with rectal adenocarcinoma and lung metastases, treated with bevazizumab through a Port-a-Cath™, presented to the emergency department with a 24-h history of fever. On examination, her temperature was 37.8°C and diffuse abdominal pain, related to current treatment, was observed. Inflammatory signs were not observed in catheter's insertion. C-reactive protein (CRP) levels were elevated (63.4mg/L) with normal blood cell count. A chest X-ray showed no other findings except those related with patient's basal condition. After admission, two sets of aerobic and anaerobic BD BACTEC Plus Blood Culture Bottles (Becton Dickinson, Sparks, MD) were obtained and antipyretics were initiated. Twenty-four hours later, both blood cultures (BC) were positive for C. cellulans. Differential quantitative BC were subsequently obtained and an intravenous vancomycin regimen (15mg/kg/12h) was initiated. On day +3 after admission, a differential time to positivity (DTP) between both BC was recorded, demonstrating a catheter-related bloodstream infection caused by C. cellulans. Antimicrobial therapy was immediately switched to vancomycin plus imipenem and conservative management of the catheter with antibiotic lock therapy was carried out. Lock therapy consisted of a 14-day course of instillations (5mL of solution) with vancomycin (2mg/mL solution) plus heparin (20IU/mL solution). On day +5, the patient was discharged considering her clinical improvement. Lock therapy was completed after 14 days and control-BC were negative. However, 15 months later she returned to the emergency department with a 5-day history of fever, and was diagnosed of a device-related sepsis. Biochemical tests showed elevated levels of CRP (327mg/L) and procalcitonin (2.17μg/L), which suggested a more severe infectious process than the precedent. C. cellulans grew again from both the peripheral-BC and the catheter-BC, exhibiting the same antimicrobial susceptibility pattern than the previous isolate. Vancomycin regimen (15mg/kg/12h) was initiated, catheter's removal was carried out, and the infection was finally eradicated.

In both episodes, Gram staining of positive BC showed Gram-positive filamentous rods. BC aliquots were plated onto blood agar, which showed growth of smooth, yellow colonies after overnight incubation. Identification of the isolate was primarily carried out using MALDI-TOF (Brucker Daltonics, Leipzig, Germany; score>2). Furthermore, identification was confirmed by API®Coryne (bioMérieux, Marcy-l’Étoile, France; code=7572727) and 16S rRNA gene amplification and sequencing3 (100% identity according to GenBank database). The isolates exhibited in vitro resistance to rifampicin, gentamicin, clindamycin, tetracycline and ciprofloxacin, and susceptibility to vancomycin, following EUCAST disk diffusion criteria for Corynebacterium.

Table 1 summarizes the 23 cases of C. cellulans infection reported so far in the literature. As shown, most patients had some kind of immunosuppression or severe underlying condition, in particular end-stage renal disease (ESRD) (n=5; 22%). Focus of infection was mostly related to the presence of a foreign body (n=16; 70%), which was finally removed in the majority of cases (n=11; 69%) for complete recovery. Antibiotic susceptibility testing showed universal susceptibility to vancomycin, which was the antibiotic of choice in most cases. All cases in which it was not necessary to remove the foreign body, vancomycin was included as a part of the antibiotic regimen.

Table 1.

Clinical and microbiological characteristics of the 22 cases of C. cellulans infections reported up to date.

Reference  Age/Sex  Basal condition  Type of infection  Foreign body/removal  Antibiotic therapy  Antimicrobial resistance  Clinical outcome 
Hussain, 1987  47, M  None  Endophtalmitis  Metallic piece/Yes  AFB+GENPENCFL  CDA, GEN 
Kailath, 1988  38, F  Ventricular shunt  Meningitis  Shunt/Yes  PEN+RIF  None 
Rihs, 1990  70, M  ESRD  Peritonitis  PC/Yes  VAN+GEN  GEN, ERO, CDA, CTX, DOX, CFT 
Truant, 1992  40, M  Cirrhosis  Bacteraemia  None  CFT+CDACFT+VAN+GEN  ERO, CDA, GEN 
McDonald, 1994  54, F  Solid organ cancer  Bacteraemia  CVC/No  CXMVAN  PEN, AMP, OXA 
Funke, 1995  72, M  Cholecystitis  Bacteraemia  ERCP  FOX  PEN, ERO, CDA, GEN, CIP 
Funke, 1995  53, F  Arthropathy  Soft tissue infection  Intramuscular Injections  DOX  PEN, ERO, CDA, GEN, CIP 
Maguire, 1996  49, F  Solid organ cancer  CRB  CVC/No  VAN  Unknown 
Harrington, 1996  72, M  Knee prosthesis  Prosthetic joint infection  Prosthesis/Yes  VAN+SXT  PEN, ERO, CDA, SXT, CIP 
Shah,1996  28, F  None  Keratitis  Contact lens/Yes  GEN+CFZ  ERO, SXT 
Borra, 1996  59, F  ESRD, DM  Peritonitis  PC/No  VAN+TOBDOX  PEN 
Ellerbroek, 1998  53, F  Lymphoma in BMT  CRB+endocarditis  CVC/Yes  DOXCDAMERAMX+SXTPEN  CFT 
Lujan-Zilbermann, 1999  13, F  ESRD  Peritonitis  PC/No  VAN  PEN, AMP, OXA, CFT, CDA, TOB 
Niamut, 2003  64, F  Immunocompromised  Bacteraemia  None  P/T+NETNET+VAN→P/T  PEN, ERO, NET, TET 
Urbina, 2003  31, M  Renal transplant, ESRD  Endocarditis  None  VAN+A/S  PEN, AMP, CFT, CDA 
Heym, 2005  48, M  HIV +  Chronic tongue ulcer  None  AZT+PEN  None 
Rowlinson, 2006  13, M  Short-bowel syndrome  CRB  CVC/No  VAN+RIF  CFT, CTX, CDA 
Yilmaz, 2006  44, M  Ventricular shunt  Meningitis  Shunt/Yes  VAN+RIF  Unknown 
Tucker, 2008  5, M  None  Pyogenic flexor tenosynovitis  None  CFLSXT+RIF  CFZ, CIP 
Casanova-Román, 2010  0, M  None  Neonatal sepsis  None  CTX+AMPVAN  PEN, AMP, CTX, ERO, CDA, CIP 
Haydushka, 2010  0, M  Premature  Pneumonia  None  GEN+CTX  PEN, AMP, CIP, RIF, TET, CTX, CDA 
Magro-Checa, 2011  81, M  Chronic renal disease, HT  Septic Arthritis  Palm tree thorn/Unknown  LEVVAN  None 
Kim, 2015  50, F  ESRD  Peritonitis  PC/Yes  CAZ+CFZTOB+CAZ+VANVAN  CFZ 

Abbreviations: F: female, M: male, BMT: bone marrow transplantation, DM: diabetes mellitus, ESRD: end-stage renal disease, HIV: human immunodeficiency virus, CVC: central venous catheter, ERCP: endoscopic retrograde cholangiopancreatography, AFB: amphotericin B, AMP: ampicillin, AMX: amoxicillin, A/S: ampicillin-sulbactam, AZT: azithromycin, CAZ: ceftazidime, CDA: clindamycin, CIP: ciprofloxacin, CFL: cephalexin, CFT: ceftriaxone, CFZ: cefazolin, CRB: catheter-related bacteraemia, CTX: cefotaxime, CXM: cefuroxime, DOX: doxycycline, ERO: erythromycin, FOX: cefoxitin, GEN: gentamicin, HT: hypertension, LEV: levofloxacin, MER: meropenem, NET: netilmicin, OXA: oxacillin, PEN: penicillin, PC: peritoneal catheter, P/T: piperacillin-tazobactam, RIF: rifampicin, SXT: trimethoprim-sulfamethoxazole, TET: tetracycline, TOB: tobramycin, VAN: vancomycin.

The case we report here reflects not only the expected features of an infection caused by C. cellulans but also the probable long-term asymptomatic colonization of the catheter for more than a year, and the subsequent recurrence. It seems unlikely that both episodes could be independently trigger from a peripheral focus. Certain features of the microorganism such as low pathogenicity and biofilm formation could be involved in that long-term colonization. The presence of biofilm implies not only the lower effectiveness of antibiotics but also a diminished host immune response.4 Most cases of C. cellulans infections led to catheter's removal for the complete eradication of the pathogen, whereas some authors have reported fully recovery by using vancomycin therapy (alone or in combination) and conservative management of the catheter.2,5-8 However, in the case we report, this strategy was discouraged. Persistence of these microorganisms despite the use of antibiotics with in vitro activity may be partially explained by biofilm formation into the catheter's lumen.4,9 Opportunistic pathogens like C. cellulans could increasingly being encountered due to the extensive use of long-term medical devices and a high survival rate of immunocompromised patients.

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

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Copyright © 2016. Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Mirobiologia Clinica
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