Ann Pharmacother. 2013 Dec;47(12):1736-9. doi: 10.1177/1060028013508745.

Treatment of Chryseobacterium indologenes ventilator-associated pneumonia in a critically ill trauma patient.

Monteen MR, Ponnapula S, Wood GC, Croce MA, Swanson JM, Boucher BA, Fabian TC.

University of Tennessee Health Science Center, Memphis, TN, USA.

 

Abstract

OBJECTIVE: To report a case of Chryseobacterium indologenes ventilator-associated pneumonia (VAP) in a critically ill trauma patient.

CASE SUMMARY: This report describes a 66-year-old critically ill trauma patient who developed VAP, which was caused by C indologenes. The patient was injured in a riding lawn mower accident that trapped him underwater in a pond. The patient required surgery for intra-abdominal injuries and was mechanically ventilated in the trauma intensive care unit. On hospital day 5, the patient developed signs and symptoms of VAP. A diagnosis of C indologenes VAP was confirmed based on a quantitative culture from a bronchoscopic bronchoalveolar lavage. The patient’s infection was successfully treated with moxifloxacin for 2 days followed by cefepime for 7 days.

DISCUSSION: Formally known as Flavobacterium indologenes, C indologenes is a Gram-negative bacillus normally found in plants, soil, foodstuffs, and fresh and marine water sources. Recently, worldwide reports of C indologenes infections in humans have been increasing, though reports from the United States are still rare. Bacteremia and pneumonia are the most commonly reported infections, and most patients are immunocompromised. The current case differs from most previous reports because this patient was in the United States and did not have any traditional immunocompromised states (eg, transplant, cancer, HIV/AIDS, or corticosteroid use).

CONCLUSION: This case report demonstrates that C indologenes can cause VAP in a trauma ICU patient.

KEYWORDS: Chryseobacterium indologenes; critical illness; trauma; ventilator-associated pneumonia

PMID: 24259621

 

SUPPLEMENT:

In the past decade the multifaceted problem of hospital-acquired infections (HAIs) has been extensively covered in the medical literature and lay press. Most of this attention has been focused on the public health problem of unexpectedly high mortality thought to be associated with HAIs, as well as the development of multidrug-resistant (MDR) organisms with a resultant lack of new antibiotic development. However, this case report focuses attention on a somewhat different problem regarding the emergence of unusual pathogens as causes of HAIs. The current case report is the latest in a series of publications from our level 1 trauma ICU in this area. The isolation of an unusual organism can present several general challenges: is the organism truly pathogenic or just an incidental finding, what is the ideal antibiotic selection (especially if the organism also happens to be highly drug resistant), and is there a special circumstance or underlying disease state that placed this patient at risk for this organism?

Our investigative group discussed the problem of an unusual drug-resistant organism in a study of 101 patients with Stenotrophomonas maltophilia ventilator-associated pneumonia (VAP).[1] This is one of the largest studies of S. maltophilia infections in the literature. This organism is still rare, and nonexistent in many ICUs, but is generally becoming more common. The major problem with S. maltophilia is that it has a high level of intrinsic resistance to most empiric antibiotics used for VAP. This is problematic because inappropriate empiric antibiotic therapy is generally associated with higher mortality. Thus, identification of S. maltophilia infections often requires immediate modification of antibiotic therapy. Other problems include the inaccuracy of automated sensitivity testing, and dosing problems and adverse events with the drug of choice (high-dose trimethoprim/sulfamethoxazole).

We also published a series of case reports (including the current one) describing the occurrence of HAIs caused by organisms that were normally only reported in patients with immunocompromised states such as AIDS, cancer, or organ transplants. The first report was a case of lactobacillus VAP.[2] This was a classic case of not knowing if the culture results indicated a true pathogen or not because lactobacilli are normal human flora. However, a quick literature search indicated that in immunocompromised patients lactobacillus can be pathogenic and cause death. As such, we chose to treat the patient with a full course of vancomycin and the treatment was successful. A second case report described the treatment of bacteremia caused by Rhizobium radiobacter.[3] Similar to the situation with lactobacillus, this is an organism widely found in nature and is generally pathogenic only in immunocompromised patients or patients with long-term device placement. We again chose to treat the patient with a full course of antibiotics and were successful.

The current case report of Chryseobacterium indologenes VAP follows the same theme.[4] C. indologenes has been reported in trauma patients before, but only from countries outside the U.S. This patient was interesting because he had the unusual circumstance of being trapped underwater. Because C. indologenes is often found in water, this could have been a factor in the subsequent infection. However, a more general concern is a new body of data suggesting that major trauma induces a temporary state of relative immunosuppression.[5] In addition, trauma ICU patients develop HAIs more often than most other critically ill patient populations.[6] Our investigative group suspects that trauma-induced immune dysfunction may be clinically relevant and could allow for infections caused by organisms usually associated with immunosuppression.

As such, these are some “take home” messages from these publications:

1) It is critical to work closely with antimicrobial stewardship personnel to know if unusual organisms are occurring in your ICU, and if so, how they should be managed.
2) Specifically related to trauma ICU patients, if unusual organisms such as C. indologenes occur that are usually seen in immunocompromised patients, a conservative approach is assume that they may be true pathogens and require treatment.
3) If S. maltophilia is emerging in your ICU, strategies need to be in place for accurate sensitivity testing and rapid antibiotic optimization.

 

References:

1. Czosnowski QA, Wood GC, Magnotti LJ, et al. Clinical and microbiologic outcomes in trauma patients treated for Stenotrophomonas maltophilia ventilator-associated pneumonia. Pharmacother, 2011. 31: p. 338-45.

2. Wood GC, Boucher BA, Croce MA, Fabian TC. Lactobacillus species as a cause of ventilator-associated pneumonia in a critically ill trauma patient. Pharmacother, 2002. 22: p. 1180-2.

3. Ponnapula S, Swanson JM, Wood GC, et al. Treatment of Rhizobium radiobacter bacteremia in a critically ill trauma patient. Ann Pharmacother, 2013. 47: p. 1584-7.

4. Monteen MR, Ponnapula S, Wood GC, et al. Treatment of Chryseobacterium indologenes ventilator-associated pneumonia in a critically ill trauma patient. Ann Pharmacother, 2013. 47: p. 1736-9.

5. Marik PE, Flemmer M. The immune response to surgery and trauma: implications for treatment. J Trauma, 2012. 73: p. 801-8.

6. Michetti CP, Fakhry SM, Ferguson PL, et al. Ventilator-associated pneumonia rates at major trauma centers compared with a national benchmark: a multi-institutional study of the AAST. J Trauma, 2012. 72: p. 1165-73.

 

Contact information:

G. Christopher Wood, Pharm.D., FCCP, FCCM, BCPS
Associate Professor of Clinical Pharmacy
University of Tennessee College of Pharmacy
881 Madison, Room 335
Memphis, TN 38163

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