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SN Comprehensive Clinical Medicine

, Volume 1, Issue 2, pp 142–145 | Cite as

Description of the First Case of Catheter-Related Bloodstream Infection Due To Pantoea eucrina in a Cancer Patient

  • L. Lotte
  • A. Sindt
  • R. Ruimy
  • D. Neri
  • R. Lotte
  • N. Weiss
  • Matteo VassalloEmail author
Medicine
  • 85 Downloads
Part of the following topical collections:
  1. Topical Collection on Medicine

Abstract

We describe here the first case of catheter-related bloodstream infection due to Pantoea eucrina in a 23-year-old female patient with colon adenocarcinoma and congenital hypogammaglobulinemia. In May 2018, she was admitted for fever and abdominal pain. Blood cultures withdrawn from peripheral inserted central catheter and periphery revealed the presence of Pantoea eucrina, with differential time of positivity in favor of catheter-related bloodstream infection. Catheter was removed and antibiotic started, with rapid recovery. Species of genus Pantoea are mainly environmental strains and plant pathogens, rarely responsible for human infection. Patient’s comorbid conditions and gut microbiota imbalance could have been responsible for such bacteremia. Identification of Pantoea eucrina was performed using the MALDI-TOF technique. Infections due to Pantoea eucrina were probably until recently underestimated, as older methods such as Phoenix frequently lead to false identification.

Keywords

Catheter-related bloodstream infection Pantoea eucrina 

Background

Pantoea spp. are Gram-negative motile rods of the Enterobacteriaceae family. The species belonging to this genus are usually isolated from soil, fruits, and vegetables [1, 2, 3, 4], but can be ubiquitously found in host-associated microbiome such as the human gut [5, 6] and plant microbiome [7]. Pantoea species can occasionally be involved in human infections and have been recently described as causing nosocomial outbreaks [3, 8, 9, 10]. The species Pantoea eucrina has rarely been isolated from humans. A strain isolated from a trashcan on a US university campus was sequenced and annotated for the first time by Moghadam et al. in 2016 [7]. To our knowledge, there is no description of Pantoea eucrina bacteremia to date. We describe the first case of catheter-related bloodstream infection due to this bacterium.

Case Presentation

In May 2018, a 24-year-old woman was admitted to our department for fever and abdominal pain of 3-week duration. She had undergone surgery for colon adenocarcinoma in March 2018 and chemotherapy was started in May. The main comorbid condition was congenital hypogammaglobinemia, which was supplemented by monthly intravenous immunoglobulin infusions. One month before her admission, a peripheral inserted central catheter (PICC) line was positioned for chemotherapy. On admission, body temperature was 38.5°. Laboratory investigations revealed elevated C-reactive protein (53 mg/L) and procalcitonin (10.95 ng/mL). Two sets of blood cultures were simultaneously drawn on peripheral venous access and on the PICC line and sent to the laboratory for analysis. They were processed with a Bactalert 3D® system (BioMérieux®, Marcy l’Etoile, France). Aerobic and anaerobic bottles were positive, with a differential time of positivity of 20 h, in favor of PICC line-related bloodstream infection. Gram staining directly performed on the positive blood cultures yielded bipolar Gram-negative rods suggestive of Enterobacteriaceae (Fig. 1). Cultures grew aerobically and anaerobically on Columbia agar plates supplemented with 5% sheep blood (BD®, Le Pont de Claix, France) after 24-h incubation as non-hemolytic, gray, mucosal colonies. Bacterial identification of the isolated strain was performed with Matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) mass spectrometry using Microflex LT with Biotyper v2.3 database (Brüker Daltonics®, Bremen, Germany) directly on colonies. The ethanol/formic acid extraction procedure (Brüker Daltonics®) did not provide any reliable identification. Using the Phoenix® (BD®) automated microbiology system, the strain was identified as P. agglomerans with 100% reliability. As the MALDI-TOF technique failed to identify the strain, it was sent to the Nice University Hospital microbiology laboratory to reliably identify the strain at the species level using molecular methods. 16S rDNA gene sequencing was performed from colonies using forward A2 and reverse S15 primers as previously described [11]. Blast analysis of the partial 16S rDNA sequence of our strain showed 99.9% identity with the 16S rDNA sequence of Pantoea eucrina LMG 2781 deposited in GenBank under the accession number NR_116246.1. Antimicrobial susceptibility testing (AST) was performed using the antibiotic disk diffusion method on Mueller-Hinton agar (BD®) incubated at 36 °C in aerobic atmosphere for 16 h according to the CASFM 2017 interpretative standards for Enterobacteriaceae [12]. The strain was susceptible to all tested antibiotics: amoxicillin, amoxicillin/clavulanic acid, ticarcillin, piperacillin/tazobactam, cefoxitin, cefotaxime, cefepime, ceftazidime, aztreonam, imipenem, ertapenem nalidixic acid, ofloxacin, gentamicin, amikacin, and trimethoprim/sulfamethoxazole. The patient was initially treated empirically with intravenous piperacilline/tazobactam 4 g three times daily. Once results of the blood cultures were available, antibiotic therapy was narrowed to cefoxitin, as one additional set of peripheral blood culture, drawn before her admission, was positive for three Enterobacteriaceae including Pantoea eucrina, thus arguing in favor of a gastrointestinal origin. The PICC line was removed and culture was negative, but antibiotic therapy was started before device removal. The patient rapidly recovered and was discharged, completing a 14-day total antibiotic course at home.
Fig. 1

Gram staining directly performed on the positive blood cultures yielded bipolar Gram-negative rods suggestive of Enterobacteriaceae

Discussion

To our knowledge, this is the first description of a catheter-related bloodstream infection (CLABSI) caused by P. eucrina, although a few strains have already been isolated in human samples [13]. The P. eucrina LMG 2781T strain was isolated from a human trachea and three other strains, P. eucrina LMG 24529, 24530, and 24531 were isolated respectively from human samples: a cyst, urine, and spinal fluid [13]. In our report, a blood-borne contamination of the PICC line by gut microbial translocation is likely. Indeed, species of the genus Pantoea are mainly environmental strains and plant pathogens and are rarely responsible for human infection [1, 2, 3, 4], but they could reflect human gut microbiota imbalance, defined as dysbiosis [5, 6, 7], which has been associated with a higher risk of microbial translocation. Indeed, the imbalance between anti-inflammatory and pro-inflammatory gut bacteria could be responsible for intestinal macrophage activation and gut barrier damage, thus increasing the risk of bacterial entry into the bloodstream, especially in immunocompromised subjects such as this patient [6]. The presence of genes encoding for a complete flagellum assembly and a type I pilus system in the genome of P. eucrina may explain its ability to form biofilms and to colonize catheters [7], with a potential for causing a catheter-related bloodstream infection. Increasingly frequent identification of such previously unknown species can be accounted for by the spread of tools such as routine MALDI-TOF MS technology or 16s rDNA sequencing in bacteriology laboratories: the MALDI Biotyper-IVD 7171 database contains 408 genera and 2428 species of bacteria and is periodically incremented. Until recently, infections caused by P. eucrina were probably underestimated. Indeed, older automated methods of identification such as the Phoenix® system based on the inclusion of biochemical tests in miniaturized supports, in association with a reading and an interpretation integrated in the system, frequently lead to false identification. In our case, the Phoenix® system identified the bacterium as P. agglomerans with an identification reliability of 100%. Our report also shows the limits of the MALDI-TOF technique, which was unable to identify the species. In fact, the Brüker® database, even though it is periodically incremented, still does not contain the Pantoea eucrina species. Currently, it contains six species of Pantoea: Pantoea agglomerans, Pantoea ananatis, Pantoea calida, Pantoea dispersa, Pantoea gaviniae, and Pantoea septica. Even if the identification log score was not high enough (≤ 1.7) to lead to reliable identification, results for P. dispersa, P. spectica, P. ananatis, and P. agglomerans were provided among other Enterobacteriaceae. This observation suggests that the MALDI-TOF specters of various Pantoea species are close but, reassuringly, not enough to lead to incorrect identification, unlike methods using biochemical characteristics such as the API® gallery or phenotypical automated techniques (Phoenix®, Vitek®). Thus, 16s rDNA sequencing was used to achieve reliable identification down to the species level. Concerning AST, P. agglomerans is part of Group III Enterobacteriaceae and produces a chromosomic cephalosporinase. No AST on P. eucrina has been published yet, but considering our antibiogram results, the strain does not appear to naturally produce any resistance enzyme to β-lactams that we were able to detect using the disk diffusion test. To confirm this, whole genome sequencing of this strain would be necessary to look for antibiotic resistance genes. Moghadam et al. published a draft genome analysis of a strain of P. eucrina and showed that its genome clustered with Pantoea sp. PSNIH1 which was previously isolated from hospitalized patients and shown to carry plasmids with antibiotic resistance cassettes [7].

We describe here a case of CLABSI due to P. eucrina in an immunocompromised patient. This bacterium, mostly known as a phytopathogen, could be responsible for severe human infections notably because of its ability to form biofilm. The rapid spread of molecular 16S-based methods or MALDI-TOF mass spectrometry in routine bacterial identification procedures will likely lead to more accurate diagnosis [14] and better knowledge of the epidemiology of Pantoea spp. infection.

Strategies aiming at improving the management of intravascular catheters and proper infection control measures are needed, in order to optimize diagnosis accuracy and to reduce incidence and costs of CLABSI [15, 16]. Among strategies for reducing CLABSI, the instillation of highly concentrated antimicrobials directly in the catheter lumen, defined as “lock therapy,” has been shown to reduce the incidence of CLABSI and to prolong catheter survival, especially in hemodialysis-dependent patients. Several antimicrobials but also antiseptic agents, such as taurolodin and ethanol, showed some benefits in the prevention of device infections in cancer patients, especially in those with history of multiple CLABSI, but higher quality evidence is needed for specific recommendations in this population [16].

Notes

Acknowledgments

This work is dedicated to all cancer patients who fight their illness day after day. We particularly wish to thank the patient described in this work.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Research Involving Human Participants and/or Animals

NA

Informed Consent

Patient gave her consent for this study.

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Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • L. Lotte
    • 1
  • A. Sindt
    • 1
  • R. Ruimy
    • 2
  • D. Neri
    • 1
  • R. Lotte
    • 2
  • N. Weiss
    • 3
  • Matteo Vassallo
    • 3
    Email author
  1. 1.Laboratory of BacteriologyCannes General HospitalCannesFrance
  2. 2.Laboratory of BacteriologyNice University HospitalNiceFrance
  3. 3.Department of Internal Medicine/Infectious DiseasesCannes General HospitalCannesFrance

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