Emergence of meningoseptica nosocomial and role of intravenous minocycline therapy Mukherjee Dip Narayan1, Agarwal Lalit Kumar2 , Mandal Kaushik3

1.Consultant Clinical Microbiologist, Woodlands Multispeciality Hospital, Kolkata, India; 2.Consultant Nephrologist, Woodlands Multispeciality Hospital, Kolkata, India; 3. Alumni, Calcutta Medical College, Kolkata, India

Background Methods & Materials (contd.) Results cont. Conclusion Elizabethkingia meningosepticum typically Elizabethkingia meningoseptica, previously bottle were processed in microbiology causes in neonates, but its known as meningosepticum laboratory. The bacterial identification was occurrence in adult specially in and meningosepticum, is a done in VITEK 2 instrument along with MIC immunocompromised patients is increasing.13 ubiquitous non-fermenting, non-motile, based sensitivity. Few more antibiotic Based on the evidence of clinical experience oxidase-positive, Gram-negative bacillus, sensitivity were done by E-strip method. As and available studies, intravenous minocycline widely distributed in nature, particularly in soil there is no consensus on standardized 1-4 therapy may be considered as a therapeutic and water. This bacterium is resistant to susceptibility breakpoint for this pathogen, option along with co-trimoxazole for the multiple and may cause neonatal breakpoints for Staphyloccus aureus (ATCC treatment of MDR Elizabethkingia meningitis, nosocomial , 25923) were used to interpret MIC of meningoseptica , where choices of bacteraemia and sepsis specially in . The bacterial isolates were antibiotics are limited.11 The success of immunocompromised patients with significant resistant to penicillin, cephalosporins, Image 1: Colonies of Elizabethkingia meningoseptium in blood agar 5-6 therapy is encouraging in selected group of morbidity and mortality rates. Several cases carbapenems, and patients. Further studies are required to of E. meningoseptica infections have been quinolones but sensitive to co-trimoxazole, establish the most effective therapeutic reported as part of outbreaks which have been minocycline and tigecycline. Vancomycin was -ents had history of colistin therapy for MDR approach. Early diagnosis, adequate antibiotic attributed to contamination of hospital tap- intermediately sensitive. All the patients were bacterial infection. So, colistin seems to have therapy along with reinforcement of standard water, saline, disinfectants antibiotic solutions, treated with injectable minocycline and co- acted as a selective factor that allowed this infection control measures including lipid solution, sink drains and respiratory trimoxazole. Mean duration of antibiotic bacterium to emerge in hospital environment. 4,7-8 environmental surveillance are essential to equipment. Infection with this pathogen are therapy was 12.3 days. Improvement with The predisposing factors for infection with this reduce the morbidity and mortality associated associated with high mortality rates (23-52%), therapy was seen in four patients, one patients pathogen in our study were old age with some 6,9-10 with this infection. Infection control measures partly due to multidrug resistance. With expired & one took discharged against underlying illness, invasive devices like are an essential part of the management of continuing advances in healthcare system, medical advice. Three out of four patients of endotracheal tube, central line, prolonged outbreaks of E. meningospetica infection to patients in intensive care units (ICUs) are at VAP, recovered completely from pneumonia exposure to broad spectrum antibiotics and limit spread of the organism to other patients. high risk of E. meningoseptica infections so, with complete clinical and microbiological renal failure. Infection with E. meningoseptica Environmental sampling is required to attempt there should be heightened awareness is cure. Weaning from ventilator possible with is clinically important as the organism is to identify the possible source. essential against organism like this emerging early shift back to ward. One patient with VAP intrinsically resistant to multiple antibiotics, opportunistic pathogen in these settings.11 We such as b-lactams, aminoglycosides, colistin, was shifted out of hospital for economical References present here an analysis of six nosocomial and carbapenems However, it is susceptible constrain and his follow up was not possible. 1. King, E. O. (1959). Studies on a group of previously unclassified associated with meningitis in infants. Am J Clin Pathol 31,241–247. infections with this organism in adults. to the agents used to treat Gram-positive 2. Kim, K. K., Kim, M. K., Lim, J. H., Park, H. Y. & Lee, S. T. (2005). Transfer of Chryseobacterium Out of two bacteraemic patient one died on meningosepticum and Chryseobacterium miricola to Elizabethkingia gen. nov. as the 3rd day of antibiotic therapy and the other bacteria: rifampicin, ciprofloxacin, vancomycin Elizabethkingia meningoseptica comb. nov. and comb. nov. Int J Syst 12 Evol Microbiol 55, 1287–1293 and trimethoprim–sulfamethoxazole. Yet 3. Vandamme, P., Bernardet, J. F., Segers, P., Kersters, K. & Holmes, B.(1994). New perspectives patient recovered completely. Repeat blood in the classification of the flavobacteria: Description of Chryseobacterium gen. nov., Bergeyella adequate treatment for this organism has not gen. nov., and Empedobacter nom. rev. Int J Syst Bacteriol 44, 827–831. Methods & Materials culture was negative and antibiotic regime was 4. Steinberg JP and Burd EM (2010) Other gram-negative and gram-variable bacilli. In Mandell been outlined. Vancomycin alone or in GL, Bennett JE, Dolin R, editors. Principles and Practice of Infectious Diseases. Philadelphia: continued for two weeks. Churchill Livingstone Elsevier. 3015-3033. 5. Dipentima MC, Mason EO, Kaplan SL. 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Güngör S, Ozen M, Akinci A, Durmaz R (2003) A Chryseobacterium meningosepticum outbreak in a neonatal ward. Infect Control Hosp Epidemiol 24: 613-617. (VAP) and two had bacteraemia. All these six choice along with co-trimoxazole to treat fluoroquinolones, minocycline, tigecycline, and 9. Hsu MS, Liao CH, Huang YT, et al. Clinical features, antimicrobial susceptibilities, and outcomes of Elizabethkingia meningoseptica (Chryseobacterium meningosepticum) bacteremia patients were male with a mean age of 62.2 patients infected with multidrug resistant rifampicin display good in-vitro activity against at a medical center in Taiwan, 1999e2006. Eur J Clin Microbiol Infect Dis 2011;30:1271e1278. 11 10. Lin YT, Chiu CH, Chan YJ, et al. Clinical and microbiological analysis of Elizabethkingia (MDR) Elizabethkingia meningoseptica. In clinical E. meningoseptica isolates, anecdotal meningoseptica bacteremia in adult patients in Taiwan. Scand J Infect Dis 2009;41:628e634. years. The mean time of development of 11. S.S. Jean et al; Elizabethkingia meningoseptica: an important emerging pathogen causing reports indicate that some cases of E. healthcare-associated infections Journal of Hospital Infection 86 (2014) 244e249 infection after hospitalization was 14.1 days. our study, patients had lower mortality (20%) 12. Graziella H. Pereiraa et al; Nosocomial infections caused by Elizabethkingia meningoseptica: meningoseptica infection only respond when an emergent pathogen; brazj infect dis. 2013; 17(5):606–609 Endotracheal aspirate from patients with VAP and the reason may be early detection and 13. SS Hayek et al; Rare Elizabethkingia meningosepticum meningitis case in an immunocompetent adult; Emerging Microbes and Infections (2013) 2, e17; and blood samples in BACTEC blood culture effective antibiotic therapy. All these six pati- antibiotic combinations are employed. doi:10.1038/emi.2013.16

Acknowledgements: Potential conflicts of interest. All authors are not having any conflicts of interest. Dr. Kaushik Mandal, an alumni of Calcutta Medical College, Kolkata, India, is currently working as Senior Medical Advisor with AstraZeneca Pharma India ltd. However, the views expressed by him in this commentary are in his personal capacity not as an employee of AstraZeneca India. Contact Details: Dr Deepnarayan Mukherjee, Mobile : +91-9874580853, Email ID:[email protected] Presented at: ECCMID 2016, Amsterdam