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Leuconostoc </Emphasis> Species As a Cause of Bacteremia: Two Case

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Leuconostoc </Emphasis> Species As a Cause of Bacteremia: Two Case Vo1.10,1991 505 2. De Wit S~ Hermans P, Roth D, Van Laethem Y, Clumeck N: Natural history of HIV infection in African patients. In: Giraldo G, Beth-Giraldo E, Leuconostoc Species as a Cause of Clumeek N, Gharbi RM, Kyalwazi SK, de Thd G (ed): Bacteremia: Two Case Reports and a Second International Symposium on AIDS and As- sociated Cancers in Africa, Naples 1987. Karger, Basel, Literature Review 1988, p. 114--123. 3. Plot P, Quinn TC, Taehnan H, Feinsod FM, Milangu KB, Wobin O, Mbendi N, Mazebo P, Ndangi K, J.C.L. Bernaldo de Quir6s 1., E Mufioz 1, Stevens W, Kalambayi K , Mitchell S, Bridts C, Mc- Cormick JB: Acquired immanodefieicney syndrome E. Cercenado 1, T. Hernandez Sampelayo 2, in a heterosexual population in Zaire. Lancet 1984, S. Moreno 1, E. Bouza 1 it: 65-69. 4. Pape JW, Liautaud B, Thomas F, Mathurin JR, St. Amand MMA, Boney M, Pean V, Pamphile M, Laroche AC, Dehovitz J, Johnson WD: The acquired Two new cases of significant bacteremia caused immunodeficiency syndrome in Haiti. Annals o[ In- ternal Medicine 1985, 103: 674-678. by Leuconostoc spp. are reported and five others 5. Glatt AE, Chirgwin K, Landesman SH: Treatment of described ill the literature are reviewed. Four of infections associated with human immunodcficicncy the seven patients were under one year old and virus. New England Journal of Medicine 1988, 318: presented with prolonged diarrhea related to 1439-1448. gastrointestinal disorders. The remaining three 6. Young LS: Treatable aspects of infection due to human immunodeficiency virus. Lancet 1987, it: 1503-1506. patients were over 50 years of age and being 7. De Wit S, Clumeck N: Fluconazol¢ ill the treatment treated in intensive care units. Six patients had of fungal infections associated with AIDS. Infection nosocomially acquired catheter-related bac- 1989, 17: 121-123. teremia. Leuconostoc spp. are naturally resistant 8. De Wit S, Weerls D, Goossens H, Clumeck N: Com- to vancomycin, and five patients had received this parison of fluconazole and ketoconazole for oro- pharyngeal candidiasis in AIDS. Lancet 1989, i: 746- antibiotic for prior bacteremia caused by methi- 748. cillin-resistant staphylococci. The majority of 9. Connolly GM, Hawkins D, ltarcourt-Webster JN, Par- patients presented with fever without severe com- snns PA, Husain OAN, Gazzard BG: Ocsophagcal plications. Penicillin is the treatment of choice symptoms, their causes, treatment, and prognosis in patients with the acquired immunodcficicncy syn- and there is no report of any death directly at- drome. Gut 1989, 30: 1033-1039. tributable to infection by these microorganisms. 10. Tavitian A, Raufman JP, Rosenthal LE, Weber J, Web- Infection with Leuconostoc spp. should be sus- her CA, Dincsoy HP: Ketoconazo[e-resistant candida pected if"vancomycin-resistant streptococci" are esophagitis in patients with acquired immunodeficien- isolated from the blood, and recorded as a poten- cy syndrome. Gastroenterology 1986, 91): 443-445. 11. Lake-Bakaar G, Quadros E, Beidas S, Elsakr M, Tom tial cause of bacteremia in patients with indwell- W, Wilson DE, Dincsoy HP, Cohen P, Straus EW: ing intravenous catheters. Gastric secretory failure in patients with the acquired immunodeficiency syndrome. Annals of Internal Medicine 1988, 109: 502-504. 12. Lake-Bakaar G, Tom W, Lake-Bakaar D, Gupta N, Leuconostoc spp. are gram-positive coccobacilli Beidas S, Eisakr M, Straus E: Gastropathy and kcto- which belong to the lactic acid bacteria group (t). conazole malabsorption in the acquired immuno- deficiency syndrome. Annals of Internal Medicine They are used in industrial microbiology in the 1988, 109: 471--473. production of wine, dairy products and dextrans 13. Ityams KC, Escamilla J, Papadimos T J, Garcia Gon- (2). They are naturally resistant to vancomycin zales P, Lnzada R, Maeareno E, Bonilla N, Diaz Mar- since the cell wall fails to provide a target for this linez F: New triazole antifungal agents (fluconazole antibiotic (1). Although they have occasionally and itraconazole) in the treatment of HIV-relatcd gastrointestinal candidiasis. Scandinavian Journal of been isolated from vaginal and stool samples (3), Infectious Diseases 1989, 21: 355-356, Leuconostoc spp. are not a regular part of the nor- 14. Saag MS, Disnmkes WE: Azole antifungal agents: em- real human flora. phasis on new triazolcs. Antimicrobial Agents and Chemotherapy 1988, 32: 1-8. Leuconostoc spp. are not generally considered to 15. Chave JP, Cajot A, Bille J, Glauser MP: Single-dose be a human pathogen (4), but sporadic cases of therapy for oral candidiasis with fluconazolc in H1V- pneumonia (5, 6), meningitis (7), infection of infected adults: a pilot study. Journal of Infectious Dis- peritoneal dyalisis fluid (8), and bacteremia (5, 6, eases I989, 159: 806-807. lServicio de Mierobiotogfa Clinfca, and 2Servicio de Pcdiatria, Hospital General "Gregorio Marafidn", e/Dl: Esquerdo 46, 28007 Madrid, Spain. 506 Eur. J. Clin, Microbiol. Infect. Dis. 9-12) caused by this microorganism have recently penicillin as the strain in case no. 1 was isolated in been reported. We report two new cases of two of the three blood cultures obtained at the Leuconostoc bacteremia, and review five others onset of the fever. No focus of infection was iden- described in the literature. tified. As fever subsided after removal of the catheter, no antibiotic therapy was administered. The sudden death of the patient on the 12th day in Case Reports. Case no. 1. A 2-month-old girl was hospital was not attributable to the bacteremia. admitted to hospital in February 1988 with refrac- Permission for autopsy was denied. tory diarrhea, fever and failure to thrive. She received prolonged parentera] nutrition by dif- ferent central catheters and several courses of Microbiological Investigations. Microorganisms broad-spectrum antibiotics, until a diagnosis of were identified as Leuconostoc spp. by the follow- primary intolerance to monosaccharides was ing criteria: gram-positive coccobacilli, resistance reached at seven months of age. Her clinical to vancomycin, no production of catalase, nega- course was further complicated by two episodes of tive Voges-Proskauer test, production of gas from catheter-associated Staphylococcus epidermidis glucose in Mann, Rogosa and Sharpe broth bacteremia, treated with i.v. vancomycin on both (Oxoid, UK), non-deamination of arginine and occasions. Fifteen days after the last course ofvan- negative pyrrolidonylarylamidase activity (2, 4, comycin, the patient presented with a new episode 13-18). The identification of the strain in case no. of fever. Three blood cultures were obtained and 1 was kindly confirmed by Dr. Facklam. The MICs vancomycin was recommenced. The growth of a of the antibiotics tested were determined by the vancomycin-resistant, gram-positive coccus, later broth microdilution method applying the NCCLS identified as Leuconostoc citreum, was obtained criteria (19), as were the MBC and tolerance. after 24 hours, with the following MIC values: van- Catheters were processed for culture according to comycin _> 500 og/ml, penicillin 0.03 pg/ml, ampi- the semiquantitative method of Maki et al. (2(t). citlin 0.03 pg/ml, cefazolin 0.03 og/ml, cefotaxime Hubs and swabs of skin surrounding the catheter 0.03 ~am/ml, imipenem 0.01 pg/ml, erythromycin insertion point were processed by semiquantita- 0.03 pglml, clindamycin 2 pg/ml, gentamicin 0.25 tire techniques as described elsewhere (21, 22). pg/ml, ciprofloxacin 2 pg/ml, rifampin 1 lag/ml and The Bactec NR-660 (Johnston Laboratories, fosfomycin 32 pg/ml. No tolerance to penicillin USA) was employed for blood cultures in our was detected. Three further blood cultures were laboratory. obtained and treatment with i.v. penicillin was in- stituted. Leuconostoc was again isolated in this Discussion. In a literature search for the period second set of blood cultures, as well as in the semi- 1980 to 1989 we were able to find 12 published quantitative culture of the catheter tip and hub reports of cases of bacteremia caused by Leuco- (> 15 cfu/plate). Cultures of the skin surrounding nostoc spp. We have only included in our review the insertion point of the catheter and of the those cases in which the microbiological and clini- parenteral nutrition fluid yielded no growth. The cal data necessary to confirm the identification patient's temperature returned to normal after and clinical significance of Leuconostoc were withdrawal of the catheter and 15 days' treatment provided (9-11). Seven cases (5, 6, 9) were ex- with i.v. penicillin. Blood cultures obtained sub- cluded on these grounds. One case with an isolate sequently were found to be negative. Two years originally described as vancomycin resistant later the patient is asymptomatic and in a good Strel)tOCOCCUS sanguis (23) was not included al- clinical condition. though it might very well have been a case of Leuconostoc infection (24). The remaining five cases, as well as our two patients, were included in Case no. 2. A 72-year-old male smoker was ad- the further analysis (Table 1). mitted to the intensive care unit in October 1988 as a result of an acute myocardial infarct. While in Four of the seven patients were less than one year hospital, he developed low cardiac output and of age. All presented with underlying diseases, of acute pulmonary edema. On the ninth day in which the most common was diarrhea related to hospital he developed a high temperature which gastrointestinal pathology. lasted 48 hours. His temperature subsided consid- Bacteremia was nosocomially acquired in six erably after withdrawal of the central catheter, cases. In the remaining case endocarditis was which unfortunately was not sent for culture. A suspected in a patient with pre-existing valve microorganism, later identified as a Leuconostoc pathology, but could not be confirmed. Five spp. with the same MIC and MBC values for patients had had previous staphylococcal bac- Table 1: Clinical and microbiological characteristics of patients reported with bacteremia caused by Leuconostoc species.
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