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Journal of Clinical Microbiology, November 1999, p. 3778-3779, Vol. 37, No. 11
0095-1137/99/$04.00+0
Copyright © 1999, American Society for Microbiology. All rights reserved.
Septicemia in Neutropenic Patients Infected with
Clostridium tertium Resistant to Cefepime and Other
Expanded-Spectrum Cephalosporins
Sophia
Steyaert,1,*
Renaat
Peleman,2
Mario
Vaneechoutte,1
Thierry
De
Baere,1
Geert
Claeys,1 and
Gerda
Verschraegen1
Department of Clinical Chemistry,
Microbiology and Immunology1 and
Department of Internal Medicine, Division of Infectious
Diseases,2 University Hospital, 9000 Ghent,
Belgium
Received 8 March 1999/Returned for modification 25 May
1999/Accepted 9 August 1999
 |
ABSTRACT |
Clostridium tertium was isolated from two
immunocompromised patients with septicemia, fever, and gastrointestinal
symptoms. The strains were resistant to ceftazidime, cefepime, and
clindamycin; intermediately resistant to penicillin; and susceptible to
metronidazole, quinolones, and vancomycin.
| |
CASE REPORTS |
Case 1.
A 65-year-old male was
diagnosed with acute myeloid leukemia and treated with chemotherapy.
During neutropenia, he became febrile and developed abdominal pain and
watery diarrhea after the institution of ceftazidime and amikacin. Six
sets of blood cultures revealed Clostridium tertium.
Vancomycin was administered with good therapeutic response.
Case 2.
A 55-year-old male was treated for acute lymphoblastic
leukemia with chemotherapy. The patient developed severe abdominal pain
and watery diarrhea with chills and fever up to 40°C. Cefepime and
amikacin were started with good clinical response. After a few days,
the patient developed a new episode with fever in conjunction with
bloody diarrhea. Blood culture revealed C. tertium. The
antibiotherapy was switched to vancomycin with improvement of the
patient's condition.
Blood was inoculated in BacT/Alert anaerobic and FAN aerobic
bottles and incubated at 37°C in the BacT/Alert3D instrument (Organon
Teknika, Turnhout, Belgium). Gram staining revealed gram-negative rods
with a "squarish" morphology and intracellular gram-positive granules. Subculture on blood agar (Becton Dickinson, Erembodegem, Belgium) revealed small colonies after 24 h at 37°C in a 5%
CO2-enriched atmosphere. More luxuriant growth of gray,
translucent colonies with an irregular, nonspreading edge could be seen
on the plates incubated anaerobically at 37°C in a jar by using
GasPak Plus (Becton Dickinson). Terminal oval spores could be
demonstrated in organisms incubated anaerobically. The catalase test
was negative. Both strains fermented carbohydrates, but were
nonproteolytic. No lipase or lecithinase activity was present. The
first strain reduced nitrate, while the second did not. The Api20A
(bio-Mérieux, Marcy-l'Etoile, France) strip produced a profile
number, 4 774 602 3, giving an identification as C. tertium
with a probability of 98.9% for the first strain and a profile number,
4 774 612 3, with a probability of 99.9% for the second. MICs (Table
1) were determined by using the E test
(AB Biodisk, Solna, Sweden) on brucella blood agar supplemented with
hemin and vitamin K1 (Becton Dickinson, Erembodegem,
Belgium) under anaerobic conditions for 48 h (6, 12).
Quality control was performed by the Stokes method with
Bacteroides fragilis ATCC 25285. No 
-lactamase production was detected.
The identification as C. tertium was confirmed for both
strains by means of amplified ribosomal DNA restriction analysis
(11). The AluI pattern consisted of fragments of
approximately 60, 110, 190, 210, 230, and 610 bp, and the
CfoI pattern consisted of fragments of approximately 210, 410, and 840 bp. The patterns were completely identical for reference
strain NIH 4522 and both clinical strains. Sequence determination of
the amplified 16S rRNA gene (first 800 bp) of the first clinical
strain revealed 98% identity with C. chauvoei
(GenBank U51843) and 97% identity with C. septicum (GenBank U59278) as the closest matches. However, the database contained no C. tertium sequences. Therefore, the type
strain of C. tertium (ATCC 14573) was sequenced (GenBank
AJ245413, Thierry De Baere). Comparison of the first 800 bp of 16S rRNA of the first clinical strain (GenBank AJ132605, Mario Vaneechoutte) with that of the type strain revealed 100% sequence identity.
C. tertium has been isolated from soil (
1), the
oral cavity (
4), feces of healthy neonates and infants
(
1), appendices
and feces of healthy adults (
1),
and 5 to 26% of fecal specimens
of patients (
8). This
species has been isolated in relation
to a brain abscess
(
1), meningitis (
5), neutropenic enterocolitis
(
2), soft tissue infections (
1), and war wounds
(
1).
C. tertium is usually regarded as
nonpathogenic, and no toxin
production has been described
(
1).
Clostridium species account
for 0.5 to 2%
of all clinically significant bacteria in blood
cultures, with
C. perfringens as the most common isolate (
7).
The
significance of
C. tertium in blood cultures is unclear,
particularly
in polymicrobial cultures (
3). Our patients
presented with
fever and gastrointestinal symptoms with
C. tertium as the only
isolate. Therefore, we considered both
isolates to be clinically
significant. In previous reports,
C. tertium septicemia in neutropenic
patients has been associated
with abdominal discomfort, diarrhea,
colonic bleeding, or perianal
cellulitis (
8,
9). The intestinal
mucosa is a rapidly
proliferating epithelium which can be damaged
by treatment with
antineoplastic drugs. This mucosal damage is
the most likely portal of
entry for
C. tertium. The chance of
fecal carriage of
C. tertium in the setting of neutropenia may
be related to
selection by previously administered antimicrobial
agents (
2,
3,
8-10). This could explain the emergence of
C. tertium
as a pathogen in neutropenic patients, because this
organism is
resistant to standard empirical antibiotic regimens,
such as
ceftazidime (
2a), and was shown here to be resistant
to
expanded-spectrum cephalosporins with enhanced activity against
gram-positive organisms, such as
cefepime.
C. tertium is a gram-positive organism that is easily
decolorized in gram-stained smears and can be mistaken for a
gram-negative
organism. However,
C. tertium does not grow on
selective media
for gram-negative organisms. The aerotolerance of
C. tertium can
result in the misidentification of this
organism as
Bacillus spp.
or
Lactobacillus spp. A
negative catalase test is an easy tool
to differentiate
C. tertium from
Bacillus spp., which are catalase
positive.
C. tertium will only form spores under anaerobic
conditions,
in contrast to
Bacillus spp., which will
sporulate aerobically.
Lactobacilli are catalase negative, but do not
form spores and
grow on a tomato juice agar. Other aerotolerant
Clostridium species
are
C. carnis and
C. histolyticum (Table
2). Although
penicillin
and clindamycin show excellent activity against most of the
clostridial
species, resistance can occur for
C. tertium
(
1,
8-10). In
general, metronidazole (
3,
8-10),
fluoroquinolones (
8),
and imipenem (
8,
10) are
active against
C. tertium, while
aminoglycosides
(
4), ceftazidime, and other expanded-spectrum
-lactam
drugs are not (
4,
8,
9). Although cefepime is
an
expanded-spectrum cephalosporin with enhanced activity against
gram-positive organisms, both strains reported here were resistant
to
cefepime. Vancomycin appears to be efficacious (
8,
9).
In conclusion,
C. tertium is not common and is not very
virulent, but appears to be an emerging pathogen in neutropenic
patients.
The recognition of
C. tertium is hampered by its
aerotolerance
and variable gram-staining properties, and this organism
may be
refractory to standard antimicrobial agents such as ceftazidime
and
cefepime.
| |
ACKNOWLEDGMENTS |
We thank Denis Pierard, Department of Microbiology, Academic
Hospital, Free University of Brussels, Brussels, Belgium, for performing the clindamycin E test on both isolates.
| |
FOOTNOTES |
*
Corresponding author. Mailing address: Department of
Clinical Chemistry, Microbiology and Immunology, University Hospital, De Pintelaan 185, 9000 Ghent, Belgium. Phone: 32 (0)9 240 34 22. Fax:
32 (0)9 240 49 85. E-mail:
Sophia.Steyaert{at}rug.ac.be.
| |
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Journal of Clinical Microbiology, November 1999, p. 3778-3779, Vol. 37, No. 11
0095-1137/99/$04.00+0
Copyright © 1999, American Society for Microbiology. All rights reserved.
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