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Ralstonia Picketti Neonatal Sepsis: a Case Report Deepak Sharma1*, Pradeep Sharma2, Priyanka Soni3 and Basudev Gupta4

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Ralstonia Picketti Neonatal Sepsis: a Case Report Deepak Sharma1*, Pradeep Sharma2, Priyanka Soni3 and Basudev Gupta4 Sharma et al. BMC Res Notes (2017) 10:28 DOI 10.1186/s13104-016-2347-1 BMC Research Notes CASE REPORT Open Access Ralstonia picketti neonatal sepsis: a case report Deepak Sharma1*, Pradeep Sharma2, Priyanka Soni3 and Basudev Gupta4 Abstract Background: Ralstonia genus are gram negative bacillus and includes four bacteria namely Ralstonia picketti, Ral- stonia Solanacearum, Ralstonia insidiosa and Ralstonia mannitolilytica. These are opportunistic pathogens and cause infections in immunocompromised host. The sources of infection are usually contaminated solutions and water. The majority of the reported cases are caused by R. picketti. It is very rare cause of neonatal sepsis with less than twenty cases reported in literature till date. Case presentation: A late preterm male infant, Indian race was admitted to the neonatal intensive care unit for respiratory distress developing soon after birth. The infant was managed with respiratory support and gradually infant improved and diagnosis of transient tachypnea of newborn was made. At age of 84 h of postnatal life, the infant developed features of neonatal sepsis and investigations were suggestive of sepsis. The infant was started on intravenous antibiotic, multiple vasopressors and steroids. The blood culture showed growth of multi-drug resistant R. picketti. The antibiotics were changed as per sensitivity pattern and infant was discharged in good condition and was accepting breast feeding at the time of discharge. There was also no other case of R. picketti in the nursery during the same time period. Conclusion: Ralstonia picketti is an uncommon cause of neonatal sepsis and usually source of infection are con- taminated solutions and medical products. The management involves early detection, treatment with appropriate antibiotics and doing surveillance culture to identify the possible source of infection. Keywords: Ralstonia picketti, Neonate, Sepsis Introduction caused by R. picketti, but there are very few case report Ralstonia was first isolated in 1973 and was included in of R. picketti infection in neonate. We here report a case the genus Pseudomonas spp. Subsequently, this microor- report of R. picketti in neonate leading to late onset neo- ganism was reclassified into the genus Burkholderia (Bur- natal sepsis. The organism was multi-drug resistant and kholderia picketti and Burkholderia solanacearum). The the infant was treated with appropriate antibiotics and genus Ralstonia was named separately in 1995 by Yabu- was discharged in good condition. uchi et al. [1]. Ralstonia are aerobic gram-negative bacil- lus, non-fermentative rods found in water and soil. They Case presentation have low-virulence and are associated with nosocomial A late preterm male infant (34 weeks), Indian race hav- sepsis by health care personal. Ralstonia genus includes ing birth weight of 2350 g (appropriate for gestational four bacteria namely Ralstonia picketti, Ralstonia Sola- age) was referred for admission to the neonatal inten- nacearum, Ralstonia insidiosa [2] and Ralstonia man- sive care unit (NICU) for respiratory distress develop- nitolilytica [3]. The majority of the reported cases are ing soon after birth. The infant was 2 h old at the time of admission to the NICU. The infant was born to 24-year old primi-gravida mother via normal vaginal delivery. *Correspondence: [email protected] 1 NEOCLINIC, TN Mishra Marg, Everest Vihar, Nirman Nagar, Jaipur, The cause of prematurity was preterm labour and there Rajasthan, India were no features of chorioamnionitis in the mother. The Full list of author information is available at the end of the article © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sharma et al. BMC Res Notes (2017) 10:28 Page 2 of 4 clinical examination of the newborn at the time of admis- sensitivity pattern of the organism showed sensitivity to sion showed respiratory rate of 68/min, heart rate of Tetracycline and Tigecycline, resistance to Cefoperazone 154 beats/min, capillary refill time of 2 s, audible grunt- sulbactum, Ciprofloxacin, Colistin, Amikacin, Amoxy- ing with subcostal and intercostal retraction, nasal flar- clav, Ampicillin, Cefazolin, Cefepime, Cefotaxime, Cef- ing, normal heart sounds and Silverman Anderson Score tazidime, Cefixime, Ertapenem, Gentamicin, Imipenem, of 5/10. The infant was started on nasal Bubble CPAP Levofloxacin, Meropenam, Piperacillin + Tazobactum, (Continuous positive airway pressure) in view of respira- Piperacillin, Ticarcillin, Trimethoprim/sulfamethoxazole tory distress and was evaluated with chest radiograph, and Tobramycin. The CSF culture was not suggestive which had features of transient tachypnea of newborn of any bacterial growth. The antibiotics were upgraded (TTNB). The infant was started on intravenous fluid and from piperacillin–tazobactum to Tigecycline as per the was investigated with sepsis screen. There was gradual sensitivity pattern. The clinical condition of the infant improvement in respiratory distress in the next 48 h, gradually improved and vasopressors were subsequently therefore nasal CPAP was removed but the infant had tapered and stopped. The repeat blood culture sent after minimal oxygen requirement for which oxygen was given day 14 of Tigecycline showed no growth. The infant was using nasal prong. The initial blood investigations [total discharged in good condition and was accepting breast leucocyte count, absolute neutrophil count, C-Reactive feeding at the time of discharge. The surveillance cultures protein (CRP)] were not suggestive of any sepsis there- were sent (hospital water supplies, saline solutions, medi- fore antibiotics were not started. The infant was started cine vials and respiratory therapy equipments) to find the on tube feeds and the feeds were gradually increased. At source of infection but we were unable to find the source age of 84 h of postnatal life, the infant developed features of infection in the index case. There was also no case of of neonatal sepsis (mottling, decreased activity, abdomi- Ralstonia in the nursery during the same time period. nal distension, cold and dusky periphery, off colour, delayed capillary refill time (>4 s), abdominal distension, Conclusions feed intolerance with altered pre-feed aspirate, low vol- Ralstonia are gram-negative bacillus and rarely causes ume pulses, tachycardia (180–184 beats/min), low blood primary bacteremia and the infection is usually second- pressure (mean blood pressure 24 mmHg) and tachyp- ary to contaminated medical products, fluids and/or nea (respiratory rate >60/min). The infant was again medications. R. picketti (formerly known as Pseudomonas evaluated with total leucocyte count, absolute neutro- picketti and Burkholderia picketti) is most commonly phil count, CRP, blood culture and chest radiograph and reported pathogen for sepsis and has been isolated from was started on antibiotic (piperacillin–tazobactum) in various clinical specimens like blood, urine and cerebro- suspicion of late onset sepsis (LOS). The infant hypoten- spinal fluid [4], from water including municipal drink- sion was managed with multiple vasopressors and ster- ing water supplies [5, 6], bottled water [7], dental water oids. The investigations showed total leucocyte count of supplies [8, 9], hospital water supplies [10], space shuttle 3200/microliter (leucopenia), absolute neutrophil count water systems, standard purified water, laboratory based 876/microliter (moderate neutropenia), platelet count high-purity water systems and industrial Ultra-pure/ of 25,000/microliter (severe thrombocytopenia), Imma- High Purity water, from plastic industrial water piping, ture neutrophil/Total neutrophil (I/T) ratio of 0.42, toxic medicine vials [11], contaminated saline solution [12], granulations on peripheral smear and very high CRP from respiratory therapy solutions and wound irrigation (220 mg/l) (normal value <10 mg/l). Blood gas analysis systems [13], and blood culture bottles [14]. This organ- showed mixed acidosis with pH of 7.242, Pco2 46 mmHg, ism is not considered as a major pathogen and therefore bicarbonate 10.2 mmol/l and base excess of −15 mmol/l. it is not routinely looked for in hospital analysis. Ral- The chest radiograph showed pneumonia of right lung stonia is an opportunistic human pathogen and seen in and the infant required invasive ventilation because of immunocompromised condition, as seen in the present impending respiratory failure for next 48 h. The infant case. The premature neonates are in an immunocompro- also received packed cell and platelet transfusion for ane- mised state making them prone to develop this infection. mia and severe thrombocytopenia. The cerebrospinal The recent studies have shown that Ralstonia is a growing fluid (CSF) analysis was done in view of LOS, which was opportunistic pathogen whole over the world [15]. suggestive of normal study (CSF sugar 84 mg/dl against Ralstonia picketti is an inhabitant of environment, blood sugar of 110 mg/dl, CSF protein being 104
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