Central venous catheter infection in a child: case report and review of Kluyvera infection in children. (Case Report).Abstract
Kluyvera is an opportunistic pathogen that can occur in immunosuppressed Immunosuppressed
A state in which the immune system is suppressed by medications during the treatment of other disorders, like cancer, or following an organ transplantation.
Mentioned in: Fifth Disease as well as immunocompetent im·mu·no·com·pe·tent
Having the normal bodily capacity to develop an immune response following exposure to an antigen.
im hosts. We report a case of Kluyvera species infection involving a central venous catheter central venous catheter
A catheter passed through a peripheral vein and ending in the thoracic vena cava; it is used to measure venous pressure or to infuse concentrated solutions. , and we review the literature on Kluyvera infections in children. Our case demonstrates that removal of the central venous catheter was necessary to eradicate the infection and hasten the resolution of refractory neutropenia. The spectrum of disease due to Kluyvera infection in children includes central venous catheter infection and/or sepsis, urinary tract infection urinary tract infection (UTI),
n infection in one or more of the structures that make up the urinary system. Occurs more often in women and is most commonly caused by bacteria. , enteritis enteritis (ĕn'tərī`tĭs), inflammation of the gastrointestinal tract. Acute enteritis is not usually serious except in infants and older people, in whom the accompanying diarrhea can cause dehydration through the loss of fluids. , and, in one instance, fatal peritonitis peritonitis (pĕr'ĭtənī`tĭs), acute or chronic inflammation of the peritoneum, the membrane that lines the abdominal cavity and surrounds the internal organs. . It is clear on the basis of our case report that uncommon, opportunistic organisms such as Kluyvera can be significant pathogens.
Kluyvera, a genus in the family Enterobacteriaceae, is a Gram-negative bacillus previously described as an opportunistic pathogen. Kluyvera has been isolated from a variety of human specimens (most commonly sputum, where it is unlikely to be clinically significant). Kluyvera has been found in food, water, soil, sewage, and hospital environments. After Farmer et al's (1) redefinition of the Kluyvera genus in 1981, reports of its isolation in other clinical specimens began to appear. In 1998, West et a1 (2) reviewed 18 cases of Kluyvera infection in humans (primarily in adults). We report a case of this disease in a child and review the literature regarding Kluyvera infection exclusively in children. Our case demonstrates that opportunistic organisms such as Kluyvera species can infect a central venous catheter in an immunosuppressed patient and cause significant illness.
In 1981, Farmer et al (1) proposed a new genus for the group of organisms that formerly had been termed enteric Group 8. These organisms were compared with strains of Kluyvera, a group of organisms that had been discovered in Japan and placed in the genus Escherichia. After extensive studies of the organisms, it was found that the isolates did not fit any of the existing species in the family Enterobacteriaceae. Therefore, Farmer et al (1) proposed Kluyvera as a new genus and, on the basis of DNA hybridization, further speciated it into three groups: Kluyvera ascorbate a·scor·bate
A salt of ascorbic acid.
a compound or derivative of ascorbic acid. See also sodium ascorbate. , Kluyvera cryo-crescens, and Kluyvera species Group 3. Kluyvera organisms are Gram-negative, motile mo·tile
1. Moving or having the power to move spontaneously.
2. Of or relating to mental imagery that arises primarily from sensations of bodily movement and position rather than from visual or auditory sensations. bacilli with peritrichous peritrichous /pe·rit·ri·chous/ (pe-rit´ri-kus)
1. having flagella around the entire surface; said of bacteria; sometimes used to describe the flagella themselves.
2. flagella flagella /fla·gel·la/ (flah-jel´ah) [L.] plural of flagellum.
(fl that have a biochemica[ profile similar to that of other Enterobacteriaceae. They are oxidase-negative and catalase-positive, and they ferment glucose. (3) The most common isolates in humans have been found in sputum, although urine, stool, throat swabs, and blood have grown Kluyvera species. (4)
In our review of seven pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.
Of or relating to pediatrics. cases, (4-9) we noted that four isolates were from blood (including our case), four were from urine, and one each were from peritoneal peritoneal /peri·to·ne·al/ (per?i-to-ne´al) pertaining to the peritoneum.
pertaining to the peritoneum. fluid, endo-tracheal aspirate as·pi·rate
To take in or remove by aspiration.
A substance removed by aspiration.
The removal by suction of a fluid from a body cavity using a needle. , autopsy lung tissue, and stool (Table 2). No isolates from the central nervous system have been reported in children or adults. (2) The ages of the patients ranged from 3 weeks to 17 years. Two had no underlying disease, one had a malignancy, and the remainder of the patients had a variety of other nonimmunosuppressive conditions (Table 2). The clinical presentations included diarrhea, sepsis, urinary tract infections, and peritonitis. Two of the seven patients died. One death was attributed to infection with Kluyvera species, as evidenced by the isolation of Kluyvera organisms from multiple organ sites at autopsy. (5) The other patient died as a result of cardiopulmonary arrest unrelated to the Kluyvera species infection. (6) It is apparent that Kluyvera causes infection in both immunocompromised immunocompromised /im·mu·no·com·pro·mised/ (-kom´pro-mizd) having the immune response attenuated by administration of immunosuppressive drugs, by irradiation, by malnutrition, or by certain disease processes (e.g., cancer). and immunocompet ent hosts.
In the cases in which antibiotic sensitivities were reported, the Kluyvera species was found to be resistant to ampicillin ampicillin (ăm'pĭsĭl`ĭn), a penicillin-type antibiotic that is effective against both gram-negative microorganisms and gram-positive microorganisms such as Escherichia coli. ; (2,4,5,7,8) by contrast, it was very sensitive to the aminoglycosides. The latter antibiotics should be considered the treatment of choice, pending the report of antibiotic sensitivities. In our case, the Kluyvera species was also sensitive to cephalosporins Cephalosporins Definition
Cephalosporins are medicines that kill bacteria or prevent their growth.
Cephalosporins are used to treat infections in different parts of the body—the ears, nose, throat, lungs, sinuses, and , quinolones, and trimethoprim/sulfamethoxazole.
A question might arise about the mechanism of the catheter infection in our case. Kluyvera is found in sewage, soil, food, and feces. Our patient with neutropenia had mild abdominal pain without any other clinical evidence of colitis (eg, diarrhea, bloody stool). The mild abdominal pain resolved within 24 hours. Kluyvera and B. cereus cereus: see cactus.
Any of various large cacti (genus Cereus and related genera) of the western U.S. and tropical New World, including the saguaro and the organ-pipe cactus (Lemairocereus thurberi, also L. marginatus or C. thurberi). can be found in the gastrointestinal tract. Because of the mild nature of the abdominal symptoms and their quick resolution, however, we do not think that this was the source of the CVC See CSC. infection. Furthermore, we did not consider the B. cereus as a cause of the catheter infection. The B. cereus cleared rapidly with the blood cultures negative for the organism after less than 24 hours of treatment with antibiotics to which it was not susceptible. Our laboratory did not speciate spe·ci·a·tion
The evolutionary formation of new biological species, usually by the division of a single species into two or more genetically distinct ones.
[speci(es) + -ation. the Gram-negative bacilli from the stool culture; thus, it is unknown if the gastrointestinal tract was colonized Colonized
This occurs when a microorganism is found on or in a person without causing a disease.
Mentioned in: Isolation with Kluyvera organisms. We do not think that the gastrointestinal tract was the source of the Kluyvera species infection. We propose that the patient's port site, which was found to be erythematous erythematous
characterized by erythema. at the time of admission, could have been contaminated from the environment.
There has been only one other report of a child with a central-line infection due to Kluyvera species. In 1987, Wong (6) described a 17-month-old child with congenital heart disease congenital heart disease, any defect in the heart present at birth. There is evidence that some congenital heart defects are inherited, but the cause of most cases is unknown. who developed a Kluyvera species infection in a Broviac catheter. The patient received 10 days of treatment with ampicillin and gentamicin gentamicin /gen·ta·mi·cin/ (jen?tah-mi´sin) an aminoglycoside antibiotic complex isolated from bacteria of the genus Micromonospora, through the Broviac catheter. Two days after treatment, the catheter was removed, and a culture of the tip was sterile. This case suggests that CVC infection by Kluyvera species may be managed successfully with antibiotics administered through the infected catheter. In our case, however, we noted that after apparent clearing of the CVC infection (blood cultures were negative for the Kluyvera organism while antibiotics were infused through the CVC), the patient relapsed while undergoing appropriate therapy. The relapse was temporally associated with the change in administration of antibiotics from the CVC to a peripheral vein, which was necessitated by the reappearance of inflammation at the CVC site. It seems that antibiotic therapy had only suppressed the growth of the organism, thus making it difficult to isolate the organism from the blood cultures obtained through the catheter. In retrospect, the reappearance of erythema erythema (ĕr'əthē`mə), more or less diffuse redness of the skin due to concentration of an abnormally large amount of blood within the small vessels of the skin (hyperemia), as in burns. at the CVC site on hospital Day 12 suggests that perhaps the catheter infection had persisted and that systemic therapy had not been effective. It is again noted that the CVC in this patient was not tunneled. After discontinuing the administration of antibiotics through the catheter, the infection became apparent within 24 hours, manifested as fever and a blood culture from the catheter positive for Kluyvera species. After removal of the CVC, the patient defervesced and the neutropenia improved.
One recent innovation in the treatment of catheter-related infection is antibiotic lock therapy. (10) Antibiotic lock therapy involves installing in the catheter lumen a high concentration of an antibiotic to which the causative microbe microbe /mi·crobe/ (mi´krob) a microorganism, especially a pathogenic one such as a bacterium, protozoan, or fungus.micro´bialmicro´bic
n. is susceptible. The antibiotics are installed, or "locked," into the catheter lumen during periods when the catheter is not used. Little information is available on the effectiveness of antibiotic lock therapy in the setting of nonbacteremic, nontunneled catheter infection. (10,11) Further studies are needed to determine whether antibiotic lock therapy can be used for catheter salvage.
Kluyvera is an uncommon, opportunistic pathogen in immunosuppressed and immunocompetent hosts. The spectrum of diseases caused by Kluyvera in children includes CVC infection and/or sepsis, urinary tract infection, enteritis, and, in one instance, fatal peritonitis. Our case suggests that the catheter apparently was sterile only while antibiotics were being infused through it. We speculate that a persistently infected catheter could contribute to delayed resolution of neutropenia, despite a prolonged course of granulocyte colony-stimulating factor granulocyte colony-stimulating factor See G-CSF. . Although clinical experience with CVC-associated Kluyvera species infection is limited, we think that reluctance to remove a CVC infected with this organism could potentially increase the patient's risk for refractory neutropenia. Our case shows that uncommon opportunistic organisms such as Kluyvera can be significant pathogens.
Table 1 Clinical course (a) Hospital day 1 2 3 4 5 Laboratory tests Max T ([degrees]F) 104.8 104.4 102.8 102.9 103.4 WBC (X 10 (9)/L) 0.153 0.10 0.10 0.20 0.11 CVC BAC, KLU BAC, KLU KLU -- KLU Antibiotics Oxacillin + + + Clindamycin + + Tobramycin + + + + + Vancomycin Hospital day 6 7 8 9 10 Laboratory tests Max T ([degrees]F) 103.6 101.3 99.7 98.3 98.9 WBC (X 10 (9)/L) 0.23 0.43 0.25 0.20 0.26 CVC -- -- -- -- -- Antibiotics Oxacillin Clindamycin + Tobramycin + + + + + Vancomycin + + + + + Hospital day 11 12 13 14 15 Laboratory tests Max T ([degrees]F) 98.8 99.4 99.5 100.1 98.8 WBC (X 10 (9)/L) 0.60 0.39 0.49 1.19 1.51 CVC -- -- KLU -- -- Antibiotics Oxacillin Clindamycin Tobramycin + + + + + Vancomycin + + + + + Hospital day 16 Laboratory tests Max T ([degrees]F) 99.3 WBC (X 10 (9)/L) 2.21 CVC -- Antibiotics Oxacillin Clindamycin Tobramycin + Vancomycin + (a)WBC, white blood cell count; Max T, maximum, temperature; KLU, Kluyvera species; BAC, Bacillus species; CVC, central venous catheter. (b)Access changed to peripheral. (c)CVC removed. Table 2 Pediatric cases of infection with Kluyvera species (a) Patient Underlying Case report (ref. no.) age/sex disease Aevaliotis et al, 1985 (7) 3 wk/F None Wang, 1987 (6) 17 mo/M Congenital heart disease Tristram and Forbes, 1988 (8) 11 mo/F Vesicoureteral reflux Dollberg et al, 1990 (4) 5 yr/F None Yogev and Kozlowski 13 yr/M Friedrich's ataxia 1990 (5) Ortega Calvo et al, 1999 (9) 10 y/F Proteinuria Brooks and Feldman, 2003, 17 yr/F Ewing's sarcoma present ease Clinical Source of Case report (ref. no.) diagnosis organism Aevaliotis et al, 1985 (7) Diarrhea Stool Wang, 1987 (6) CVC infection/ Blood sepsis Tristram and Forbes, 1988 (8) Sepsis/UTI Blood/urine Dollberg et al, 1990 (4) Pyelonephritis Urine Yogev and Kozlowski Peritonitis/UTI Respiratory secretions, 1990 (5) peritoneal fluid, urine, lung tissue Ortega Calvo et al, 1999 (9) UTI Urine Brooks and Feldman, 2003, CVC infection/ Blood present ease sepsis Case report (ref. no.) Treatment Outcome Aevaliotis et al, 1985 (7) Symptomatic Cured Wang, 1987 (6) Ampicillin, Died (cardiopulmonary gentamicin arrest) Tristram and Forbes, 1988 (8) Tobramycin, Cured cefoxitin Dollberg et al, 1990 (4) Cefazolin Cured Yogev and Kozlowski Moxalactam, Died (perforated 1990 (5) gentamicin ileum, peritonitis, pneumonia) Ortega Calvo et al, 1999 (9) Cefuroxime Cured axetil Brooks and Feldman, 2003, Tobramycin Cured present ease (a)UTI, uninary tract infection; CVC, central venous catheter.
Accepted January 21, 2002.
(1.) Farmer JJ III, Fanning GR, Huntley-Carter GP, Holmes B, Hickman FW, Richard C, et al. Kluyvera, a new (redefined) genus in the family Enterobacteriaceae: Identification of Kluyvera ascorbata sp. nov. and Kluyvera cryocrescens sp. nov. in clinical specimens. J Clin Microbiol 1981;13:919-933.
(2.) West BC, Vijayan H, Shekar R. Kluyvera cyocrescens finger infection: Case report and review of eighteen Kluyvera infections in human beings. Diagn Microbiol Infect Dis 1998;32:237-241.
(3.) Balows A, Hausler WJ Jr, Herrmann KL, Isenberg HD, Shadomy HJ (eds). Manual of Clinical Microbiology. Washington, DC, American Society for Microbiology The American Society for Microbiology (ASM) is a scientific organization, based in the United States although with over 43,000 members throughout the world. It is the largest single life science professional organization and its members include those whose interests encompass basic , 1991, ed 5, pp 376-377.
(4.) Dollberg S, Gandacu A, Klar A. Acute pyelonephritis due to a Kluyvera species in a child. Eur J Clin Microbial microbial
pertaining to or emanating from a microbe.
the breakdown of organic material, especially feedstuffs, by microbial organisms. Infect Dis 1990;9:281-283.
(5.) Yogev R, Kozlowski S. Peritonitis due to Kluyvera ascorbata: Case report and review. Rev Infect Dis 1990;12:399-402.
(6.) Wong VK. Broviac catheter infection with Kluyvera cryocrescens: A case report. J Clin Microbiol 1987;25:11l5-1116.
(7.) Aevaliotis A, Belle AM, Chanione JP, et al. Kluyvera ascorbata isolated from a baby with diarrhea. Clin Microbial Newsl 1985;7:51.
(8.) Tristram DA, Forbes BA. Kluyvera: A case report of urinary tract infection and sepsis. Pediatr Infect Dis J 1988;7:297-298.
(9.) Ortega Calvo M, Delgado Zamora R, Fernandez Arance P, Elgorriaga Guillen LJ, Del Valle Vazquez L, Gutierrez Caracuel J. Kluyvera cryocrescens: A positive urine culture in a young girl with persistent proteinuria proteinuria /pro·tein·uria/ (-ur´e-ah) an excess of serum proteins in the urine, as in renal disease or after strenuous exercise.proteinu´ric
1. [in Spanish]. Actas Urol Esp 1999;23:528-531.
(10.) Mermel LA, Farr BM, Sherertz RJ, Raad II, O'Grady N, Harris JS, et al. Guidelines for the management of intravascular intravascular /in·tra·vas·cu·lar/ (in?trah-vas´ku-lar) within a vessel.
Within one or more blood vessels. catheter-related infections: Society for Healthcare Epidemiology of America. Clin Infect Dis 2001;32:1249-1272.
(11.) Johnson DC, Johnson FL, Goldman S. Preliminary results treating persistent central venous catheter infections with the antibiotic lock technique in pediatric patients. Pediatr Infect Dis J 1994;13:930-931.
RELATED ARTICLE: Key Points
* Kluyvera is an uncommon, opportunistic organism that can be a significant pathogen.
* Six previously reported pediatric cases of Kluyvera infection are reviewed here.
* The new case described here demonstrates that removal of the central venous catheter was necessary to eradicate the organism and improve the patient's neutropenia.
A 17-year-old white girl with Ewing's sarcoma was admitted to the hospital with fever and neutropenia 4 days after undergoing chemotherapy with etoposide, mesna, and ifosfamide. On the previous day, the patient had been evaluated in the clinic for mild erythema of her peripheral access system port site (henceforth referred to as the central venous catheter [CVC]). The patient had a peripherally inserted, nontunneled CVC. At admission, the patient's temperature was 102[degrees]F, her pulse was 142 beats/mm, her respiratory rate was 24 breaths/mm, and her blood pressure was 110/68 mm Hg. Her physical examination was unremarkable, except for mild tenderness over the left lower abdominal quadrant and erythema over the CVC site, which were unchanged from the previous day. Hepatosplenomegaly, bruising, and petechiae Petechiae
Tiny purple or red spots on the skin associated with endocarditis, resulting from hemorrhages under the skin's surface.
Mentioned in: Endocarditis, Hantavirus Infections, Hemorrhagic Fevers, Idiopathic Thrombocytopenic Purpura
were absent. The complete blood cell count blood cell count,
n an estimation of the number and types of circulating blood cells (e.g., red blood cells [erythrocytic series], white blood cells, differential). revealed the following values: white blood cell count white blood cell count,
n a diagnostic clinical laboratory test to determine the number and types of leukocytes present in a measured sample of blood. Overall the normal number of leukocytes ranges from 5000 to 10,000/mm3. , 0.153 X [10.sup.9]/L, with an absolute neutrophil count Absolute neutrophil count (ANC) is a measure of the number of neutrophil granulocytes (also known as polymorphonuclear cells, PMN's, polys, granulocytes, segmented neutrophils or segs) present in the blood. Neutrophils are a type of white blood cell that fights against infection. (ANC ANC
African National Congress
ANC African National Congress: South African political movement instrumental in bringing an end to apartheid
ANC n abbr (= ) of 0; hemoglobin, 10.0 g/L; hematocrit Hematocrit Definition
The hematocrit measures how much space in the blood is occupied by red blood cells. It is useful when evaluating a person for anemia.
Blood is made up of red and white blood cells, and plasma. , 28 %; and platelets, 10.6 X [10.sup.9]/L. The chest x-ray film was normal. Blood cultures were obtained from the patient's CVC and from a peripheral vein. The samples were inoculated into aerobic and anaerobic anaerobic /an·aer·o·bic/ (an?ah-ro´bik)
1. lacking molecular oxygen.
2. growing, living, or occurring in the absence of molecular oxygen; pertaining to an anaerobe. blood culture collection bottles. A skin culture was obtained from an erythematous area at the CVC site. Organisms were identified with the use of routine laboratory methods.
The initial treatment consisted of tobramycin tobramycin /to·bra·my·cin/ (to?brah-mi´sin) an aminoglycoside antibiotic derived from a complex produced by Streptomyces tenebrarius, and oxacillin oxacillin /ox·a·cil·lin/ (ok?sah-sil´in) a semisynthetic penicillinase-resistant penicillin used as the sodium salt in infections due to penicillin-resistant, gram-positive organisms. . All antibiotics were infused through the CVC on an interval basis. Supportive therapy included transfusions of red blood cells Red blood cells
Cells that carry hemoglobin (the molecule that transports oxygen) and help remove wastes from tissues throughout the body.
Mentioned in: Bone Marrow Transplantation
red blood cells and platelets as well as daily treatment with granulocyte colony-stimulating factor, without apparent response in her blood cell count. Gram-positive and Gram-negative bacilli were isolated from the initial CVC blood culture. The peripheral blood culture and the culture from the CVC site were negative for microorganisms. The patient's CVC was infusing well. The patient's erythema resolved within 24 hours of admission. Despite treatment with antibiotics, however, the patient remained febrile febrile /feb·rile/ (feb´ril) pertaining to or characterized by fever.
Of, relating to, or characterized by fever; feverish. .
The Gram-positive bacillus was identified as a Bacillus cereus (B. cereus). Antibiotic treatment was changed from oxacillin to clindamycin on hospital Day 3. On the sixth hospital day, the Gram-negative bacillus was identified as Kluyvera species susceptible to tobramycin and resistant to ampicillin. At this time, the infectious disease service was consulted; the recommendation was that dindamycin therapy be discontinued and vancomycin treatment, to which the B. cereus was susceptible, be initiated. The role of B. cereus is unclear, because it cleared rapidly with blood cultures negative for B. cereus after less than 24 hours of treatment with antibiotics to which the organism was not susceptible. The patient was considered to have a CVC infection. The physicians elected to treat the infection without removing the CVC by using periodic systemic infusions of tobramycin and vancomycin through the CVC.
The blood culture from the CVC remained positive for Kluyvera species until the sixth hospital day, at which time the only additional peripheral blood culture was drawn, and it was again negative for this organism. The patient remained febrile for another 2 days, however (Table 1). There was no clinical evidence of other foci of infection. Thereafter, the patient was afebrile afebrile /afe·brile/ (a-feb´ril) without fever.
afebrile adjective Feverless , clinically stable, and the blood cultures from the CVC were negative for Kluyvera species. No additional peripheral blood cultures were obtained during this period. Throughout this time, the patient remained severely neutropenic (Table 1). She had virtually no neutrophils neutrophils (ner·ō·trōˑ·filz),
n.pl white blood cells with cytoplasmic granules that consume harmful bacteria, fungi, and other foreign materials. until hospital Day 15, when her white blood cell count rose to 1.51 X 109 and her ANG ANG
In currencies, this is the abbreviation for the NL Antillian Guilder.
The currency market, also known as the Foreign Exchange market, is the largest financial market in the world, with a daily average volume of over US $1 trillion. was 477.
On hospital Day 12, the patient's CVC site was again noted to be erythematous and mildly tender; therefore, the use of the CVC was discontinued. It is noteworthy that before this time, all antibiotics had been administered through the CVC. A blood culture obtained from the CVC on hospital Day 13 again grew Kluyvera species (Table 1). The patient's temperature reached a maximum of 100.1[degrees]F. Because of the recurrence of the Kluyvera species infection, the CVC was removed on hospital Day 14. The catheter tip was not cultured.
The patient became afebrile after the CVC was removed, and subsequent blood cultures obtained within 24 hours of removal of the CVC were negative for Kluyvera organisms. On hospital Day 16, the patient's ANC was greater than 1,000. She was then discharged to home to complete an additional 5 days of tobramycin therapy after CVC removal.
From the Department of Pediatrics, University of Mississippi Medical Center University of Mississippi Medical Center (UMC) is the health sciences campus of the University of Mississippi (Ole Miss). Located in Jackson, Mississippi (USA), it houses the Schools of Medicine, Dentistry, Nursing, Health Related Professions, and Graduate Studies in the Health , Jackson, MS.
Reprint requests to Tami Brooks, MD, Department of Pediatrics, University of Mississippi Medical Center, 2500 N. State Street,-Jackson, MS 39211.
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