Received May 13, 2013; Accepted February 5, 2013
Recovery from Pseudomonas putida sepsis in a 91-year-old man : A case report
Hirochiyo Sawaguchi, Shouta Wada, Takeshi Ohno, Souichirou Hanada, Masato Muraki, Shigenori Nakajima, Hirokazu Nakajima and Yuji Tohda
Department of Respiratory Medicine and Allergy Nara Hospital, Kinki University Faculty of Medicine
1248-1 Otoda-cho, Ikoma City, Nara 630-0293, Japan
Department of Respiratory Medicine and Allergy Kinki University Faculty of Medicine 377-1 Ohnohigashi, Osakasayama City, Osaka 589-8511, Japan
Abstract
Pseudomonas putida is a gram-negative rod-shaped bacterium widely distributed in water networks. It is not an unusual cause of sepsis in immunocompromised hosts. However, few cases in adult patients have been reported and clinical courses of bacteremia with Pseudomonas putida have not been reported in aged patients either suffering from a malignant disease or under immunosuppressive treatment.
We report a 91-year-old man who survived an episode of sepsis caused by Pseudomonas putida
after recovery from aspiration pneumonia. The intramuscular injection of amikacin and nutri- tional support were successful despite the pres- ence of multiple-drug resistant bacteremia.
This is the first clinical case report of new quinolone-resistant P. putida. This case sug- gests that aged patients may develop an oppor- tunistic infection as do immunocompromised hosts.
Key words:Pseudomonas putida, Sepsis, M ultiple-drug resistant
Introduction
Pseudomonas putida (P. putida) is a gram- negative rod-shaped bacterium widely distribut- ed in moist environments, often in water net- works. This bacterium is recognized as a cause of opportunistic infection and sometimes path- ogen sepsis. P. putida can acquire broad resis- tance toβ-lactam antibiotics. We report a case of P. putida sepsis involving an aged man.
Clinical cours
In January 2007,a 91-year-old man with symp- toms of diarrhea, vomiting, and high fever was diagnosed with infectious gastroenteritis by his family doctor. The patient was medicated with oral fosfomicin and lactomin. Two days later,
the patient suffered from vomiting again,and on the next day the patient had a wet cough. His family doctor was called again and noticed bilateral rhonchi in the patientʼ s chest. The doctor immediately consulted us and the patient was admitted into our hospital on the same day.
On admission, his temperature was 37.7°C, and chest X-ray images showed infiltrative shadows of pneumonia at the bilateral lower lung fields and right upper lung field. (Fig.1). Many species of normal oral flora were identified in sputum culture, however assessed as Geckler classification 5. Laboratory data on admission indicated severe inflammation (Table 1). He was diagnosed as suffering from aspiration pneumo- nia. After antibiotic therapy with ampicillin/ sulbactam and clindamycin for 8 days following admission, his fever subsided. His diarrhea,
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vomiting, and cough also disappeared. His condition was stable and he was able to use the toilet room without any assistance. However on day 9, his temperature suddenly rose to 40.9° C, despite improvement in the infiltrative shadow
shown on the chest X-ray(Fig.1).P.putida was identified in 2 sets of blood culture (Table 2).
We investigated the primary infection site.
Because P. putida was not detected on sputum culture and the infiltration shadow on the chest X-ray had improved,we thought that the respira- tory tract was not the primary infection site.
Since P. putida was detected neither in urinary culture nor in stool culture,we inferred that the location where the protection of the epidermis had failed was likely to be the primary infection site. We speculated that P. putida invaded into the peripheral blood through the peripheral vessel catheter. The catheter was removed. Other P. putida bacteremia was not detected in the ward. In this case,P. putida was resistant to cefotaxime, aztoreonam, imipenem /cilastatin, levofloxiacin, ciprofloxacin, pazufloxacin, and gentamicin,was intermediate to piperacillin,and was susceptible to amikacin and isepamicin (Fig 2). Intravenous infusion of ampicillin/ sul- bactam and clindamycin was replaced by intramuscular infusion of amikacin. Nutrition support included pasty liquid food of high vis- cosity for prevention against miss-swallowing and for better nutrition. His condition gradually improved. The clinical course is shown in Fig.
Table 1 Laboratory data on admission Hematology
White blood cell 14800 /μl
(Stab. 4.0%, Seg. 79.0%, Lym. 5.0%, Mono. 12.0%, Eos. 0%, Baso. 0%) Red blood cell 4.65×10/μl
Hb 13.5 g/dl
Platelet cell 21.4×10/μl Biochemistry
Total protein 6.1 g/dl
BUN 13.7 mg/dl
Creatinine 0.7 mg/dl
Na 133 mEq/L
K 3.6 mEq/L
GOT 22 U/L
GPT 15 U/L
Serology
CRP 21.25 mg/dl
Sputum culture usual oral flora 1＋; Streptococcus species,Lactobacillus species,Corynebacter- ium species, Neisseria species, Bacteroides species
MRSA≦＋
(≦＋is corresponding to 10〜10 CFU/ml. 1＋is corresponding to 10〜10 CFU/ml.) (Any pathogenic fungus was not detected after cultivation for 7 days in sputum.)
Urinary culture negative finding Blood culture negative findings
Fig.1 Clinical course and Chest X-ray graphs
Consolidation at bilateral lower lobes and right upper lobe of the patientʼs lung was Found on chest X-ray graph on day 1. Infiltration shadow on chest X-ray graph had Improved on day 9. On day 9 the second fever up was occurred.
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1. The patient fully recovered and was dischar- ged on the day 59.
Discussion
P. putida, which belongs to the fluorescent group of the pseudomonas species , widely exists in soil, moist environments, and contaminated water outlets. Occasionally, P. puida causes opportunistic infection in compromised hosts.
Several cases of bacteremia with P. putida have been reported, including an outbreak as- sociated with contaminated water outlets in a pediatric oncohematology unit and an outbreak with contaminated heparin catheter-lock solu- tion. According to Yoshino et al., as high as 62% of primary infection sites in reported P.
putida bacteremia were device related. Among these cases, 93% involved a catheter-related bloodstream infection. Ability to adhere to materials and to promote the formation of a biofilm appear to be the most important features of the pathogenicity of device-associated infec- tions. Ability of P. putida to form biofilms is related to device-associated infection. Decline in immune protection of the peripheral blood stream in the patient related to his old age must be contribute to infection. Most reported adult
Table 2 laboratory data on day9 at second fever up Hematology
White blood cell 23400 /μl
(Stab. 6.0%, Seg. 84.0%, Lym. 6.0%, Mono. 3.0%, Eos. 0%, Baso. 1.0%) Red blood cell 3.32×10/μl
Hb 10.0 g/dl
Platelet cell 42.4×10/μl Biochemistry
Total protein 5.5 g/dl
BUN 18.7 mg/dl
Creatinine 0.6 mg/dl
Na 130 mEq/L
K 3.7 mEq/L
GOT 107 U/L
GPT 116 U/L
Serology
CRP 4.06 mg/dl
Sputum culture MRSA≦＋
Candida albicans 2＋ Urinary culture negative finding
Blood culture (2 sets)Pseudomonas putida 1＋
Stool culture MRSA≦＋
Candida albicans 2＋
Penicillium species several CFU/ml
(≦＋is corresponding to 10〜10 CFU/ml. 1＋is corresponding to 10〜10 CFU/ml. 2＋is correspond- ing to 10〜10 CFU/ml.)
Fig.2 Susceptibility of P. putida from blood culture to antibiotics.
P. putida in this case was multiple-drug resisitant.
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cases involve malignant diseases,such as cancer, leukemia, and malignant lymphoma, and other cases involve immunosuppressive treatments, such as receiving a large quantity of methyl prednisolone. While mortality of Pseudomo- nas aeruginosa (P. aeruginosa) bacteremia has been reported to be over 30%, in 28 reported cases of P. putida bacteremia, 26 patients were cured, excluding pediatric and outbreak cases.
However,a greater number of cases are required in order to conclude that P.putida bacteremia is easier to cure than P. aeruginosa bacteremia in sporadic adult cases. This case involved a single aged patient neither suffering from a malignant disease nor under immunosuppressive treatment.
Immunities decline with age. According to Isobe et al., the function of T cells belonging to Th1 and Th2 decline and the ability of B cells weaken as we age. This is the first reported case of an aged patient over 90 years old who recovered from P. putida sepsis. Furthermore,in this case, P. putida was resistant to cefotaxime, aztor- eonam, imipenem/cilastatin, levofloxiacin, ci- profloxacin, pazufloxacin, and gentamicin, was intermediate to piperacillin,and was susceptible to (Fig.2). P. putida in this case was multiple- drug resistant.
The clinical characteristics of P.putida bacter- emia can be summarized as follows: 1) high susceptibility of strains to β-lactams; 2) device relatedness; 3) occurrence in immunocom- promised hosts; and 4) a good prognosis compared with P. aeruginosa, according to Yoshino et al. This is the first reported clinical case of bacteremia caused by P. putida which was resistant to new quinolone. Despite the resistance to mostβ-lactams and new quinolone, the patient in our case was cured. The reason for a better prognosis of suffering from P. putida bacteremia remains unclear yet. However some investigators suspected that a lack of exotoxin A, pyocianin, type III secretion system, and others in P. putida,which are present in P. aeruginosa may account for the prognostic difference. It is necessary to be careful of opportunistic infection while treating aged patients. Furthermore, it is
possible that P. putida will acquire new resis- tibility to antibiotics, and eventually become resistant to all existing antibiotics.
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