International Journal of Infectious Diseases 22 (2014) 65–66 Contents lists available at ScienceDirect International Journal of Infectious Diseases jou rnal homepage: www.elsevier.com/locate/ijid Short Communication Post-cesarean surgical site infection due to Buttiauxella agrestis a, a b Vicente Sperb Antonello *, Jessica Dalle´ , Guilherme Campos Domingues , c c d Jorge Alberto Santiago Ferreira , Maria do Carmo Queiroz Fontoura , Fa´bio Borges Knapp a Department of Infection Prevention and Control, Hospital Feˆmina, Rua Mostardeiro, 17, Bairro: Independeˆncia, Porto Alegre, RS 90430-001, Brazil b Department of Infectious Diseases, Hospital Nossa Senhora da Conceic¸a˜o, Porto Alegre, RS, Brazil c Department of Microbiology, Hospital Nossa Senhora da Conceic¸a˜o, Porto Alegre, Brazil d bioMe´rieux, Sa˜o Paulo, Brazil A R T I C L E I N F O S U M M A R Y Article history: Surgical site infections (SSI) are postoperative complications that constitute a major public health Received 27 September 2013 problem. We present a rare case report of infection by Buttiauxella agrestis, a member of the Received in revised form 26 January 2014 Enterobacteriaceae family, occurring after a cesarean delivery in a young woman with no comorbidities. Accepted 28 January 2014 The authors further discuss the origin of this infection. Corresponding Editor: Eskild Petersen, ß 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. Aarhus, Denmark This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/3.0/). Keywords: Surgical site infection Buttiauxella agrestis Obstetric infection Cesarean delivery 1. Introduction prior to the skin incision and the cesarean section was completed without complications. The patient was discharged 3 days after Surgical site infections (SSI) are postoperative complications admission and given standard recommendations as to postoperative that constitute a major public health problem. The Centers for precautions and care. Disease Control and Prevention (CDC) report that SSIs represent The patient was readmitted to hospital 6 days later complaining the most common healthcare-associated infection in the USA, with of fever and reporting an oozing discharge from the incision site for 1 an overall SSI rate of 1.9% and an associated mortality rate of 3%. the previous 2 days. On physical examination, a deep surgical site From an obstetrics viewpoint, wound infection is diagnosed in 6% infection (SSI) was diagnosed with drainage of purulent secretions. 2 to 27% of patients, generally four to seven days after cesarean. The A sample was collected and referred to the department of most commonly reported pathogens in post-cesarean SSIs are microbiology for detailed analysis. Direct microscopy examination Staphylococcus aureus (anaerobic), Enterobacteriaceae and Strep- was carried out and revealed the presence of leukocytes and Gram- 1 tococcus. We present the first known report of a Buttiauxella negative organisms. The vials were processed using an automated agrestis infection occurring after cesarean delivery in a young culture system (bioMe´rieux). A surgical drainage approach was woman with no comorbidity. adopted plus intravenous administration of a two-drug combina- tion of clindamycin plus gentamicin for 5 days in accordance with the hospital protocol. At the end of the 5-day period, the patient 2. Case report was asymptomatic and afebrile, with complete clinical improve- ment. The patient was discharged from hospital with oral We present the interesting case of a 17-year-old primigravida at clindamycin plus cefuroxime for a further 9-day period. 40 weeks of gestation who presented to the hospital maternity unit Subsequent to patient discharge, test results conducted by the in July 2013. Antibiotic prophylaxis (2 g cefazolin) was administered department of microbiology using a Vitek 2 automated system for bacterial identification and antibiotic susceptibility, identified the growth of Buttiauxella agrestis in the purulent material taken from * Corresponding author. Tel.: +55 51 33145239; fax: +55 51 33421330. the SSI. This was further identified and confirmed using the Vitek E-mail addresses: [email protected], [email protected] MS v2.0 matrix-assisted laser desorption ionization time-of-flight (V.S. Antonello). http://dx.doi.org/10.1016/j.ijid.2014.01.025 1201-9712/ß 2014 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). 66 V.S. Antonello et al. / International Journal of Infectious Diseases 22 (2014) 65–66 (MALDITOF) mass spectrometry system. Minimum inhibitory of prompt surgical drainage of the SSI and correct empiric concentration (MIC) testing confirmed the bacteria to be suscepti- administration of intravenous gentamicin for 5 days, with ble to all antibiotics tested, including gentamicin, ciprofloxacin, subsequent oral prescription of cefuroxime for a further 9 days. amoxicillin–clavulanic acid, ampicillin, cefoxitin, ceftriaxone, The present report is an unusual case in the literature of a B. piperacillin–tazobactam, and ertapenem. agrestis infection occurring at a post-cesarean surgical site. The A patient interview was conducted to ascertain the possible first and most probable explanation of the origin of this infection is source of infection and to understand the epidemiology of B. that the patient became infected with B. agrestis during her stay at agrestis infection at the post-cesarean surgical site. The patient is home. This is likely due to the proximity to the woodland and the employed as a supermarket cashier and lives in the city of Viama˜o, local humidity, given that the causative bacterium is found in 2 in the southern-most state of Brazil. Although an urban area, water, soil, and earthworks. The second and more remote Viama˜o is also close to regions of woodland and is subject to possibility is that the infection was hospital acquired, however extreme damp. The house where the patient lives is of masonry the healthcare setting does not provide the usual habitat for B. construction and has adequate sanitation. Lastly, the patient agrestis and there have been no previous reports of the isolation of described her care of the wound site as having used soap and water B. agrestis in a hospital environment. only and she denied using well water in her daily life. Written In summary, the authors believe this report contributes to the informed consent from the patient was obtained for the publica- understanding of infections caused by germs previously consid- tion of this case report. ered to be non-pathogenic in humans and to indicate an appropriate choice of antimicrobial treatment. 3. Discussion Conflict of interest: Fa´bio Borges Knapp works for bioMe´rieux Brazil; his only contribution to this paper was the analysis of the Buttiauxella agrestis, a member of the Enterobacteriaceae family, specimens. All of the other authors have no conflicts of interest. No is a small Gram-negative rod-shaped facultative anaerobic author received any financial support for preparing the article. organism found in a variety of places in nature: soil, water, fish, 3 cockroaches, and mollusks, including slugs and snails. Only a few cases with clinical relevance involving B. agrestis have been References described in the medical literature to date – appendicitis and 1. Centers for Disease Control and Prevention. 2013 CDC/NHSN protocol correc- wound infection – although it is difficult to distinguish between an 4 tions, clarification, and additions. Atlanta, GA: CDC; 2013. Available at: http:// etiological agent and colonizer of a pre-existing disease focus. www.cdc.gov/nhsn/acutecarehospital/ssi/index.html (accessed January 19, Limited susceptibility studies have been performed on B. 2014). 2. Srun S, Sinath Y, Seng AT, Chea M, Borin M, Nhem S, et al. Surveillance of post- agrestis. The results for strains tested by broth microdilution have caesarean surgical site infections in a hospital with limited resources, Cambodia. indicated that the isolates were resistant to ampicillin, amoxicil- J Infect Dev Ctries 2013;7(8):579–85. lin–clavulanic acid, ticarcillin, cephalothin, cefoxitin, cefotaxime, 3. Michael Janda J. New members of the family Enterobacteriaceae. In: Dworkin M, Falkow S, Rosenberg E, Schleifer KH, Stackebrandt E, editors. The prokaryotes: a doxycycline, trimethoprim, and chloramphenicol, based upon handbook on the biology of bacteria. 3rd ed., Proteobacteria: gamma subclass, Vol. MIC90 values. However, MIC50 has indicated that many isolates are 6. Singapore: Springer; 2006. p. 10–1. 5 susceptible to gentamicin, amikacin, and colistin. Another report 4. Dionisio D, Belli A, Dionisio A, Poggiali G, Corradini S, Pierotti P, et al. Appendi- citis: microbial interactions and new pathogens. 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