Sphingobacterium multivorum: case report and literature review

Sphingobacterium multivorum: case report and literature review

Accepted Manuscript Sphingobacterium multivorum: a case report and literature review Dr. Fernando Barahona, Infectious Diseases Fellow, Dr. Jihad Slim...

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Accepted Manuscript Sphingobacterium multivorum: a case report and literature review Dr. Fernando Barahona, Infectious Diseases Fellow, Dr. Jihad Slim, Infectious Disease Fellowship Program Director PII:

S2052-2975(15)00036-0

DOI:

10.1016/j.nmni.2015.04.006

Reference:

NMNI 35

To appear in:

New Microbes and New Infections

Received Date: 5 October 2014 Revised Date:

23 February 2015

Accepted Date: 12 April 2015

Please cite this article as: Barahona F, Slim J, Sphingobacterium multivorum: a case report and literature review, New Microbes and New Infections (2015), doi: 10.1016/j.nmni.2015.04.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Category: Original Review Article

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Running title: Sphingobacterium multivorum: a review

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Sphingobacterium multivorum: a case report and literature review

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By

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Dr. Fernando Barahona

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Infectious Diseases Fellow

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Dr. Jihad Slim

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Infectious Disease Fellowship Program Director

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Infectious Diseases Department

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Saint Michael’s Medical Center

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Newark, New Jersey-USA

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Corresponding author: Fernando Barahona

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Phone: 1 973-877-2424

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Fax: 1 973-877-2493

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Infectious Diseases Department

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Saint Michael’s Medical Center

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111 Central Ave, Newark, New Jersey, zip code 07109 - USA

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SPHINGOBACTERIUM MULTIVORUM: A CASE REPORT AND LITERATURE

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REVIEW

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Abstract: This is the case of a 67-year-old African American female with multiple medical

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problems who presented with septic shock secondary to Sphingobacterium multivorum

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bacteremia. Sphingobacterium multivorum, a gram-negative bacillus, is ubiquitous in nature, and

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is rarely involved in human infections, however it is intrinsically resistant to many commonly

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employed antibiotics and can be a life threatening microorganism.

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Key words: gram negative bacilli, sphingophospholipids, septic shock, moist hospital

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environments, extended-spectrum β-lactamase, metallo-β-lactamase

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Case Report: 67-year-old African American female with past medical history of obesity (body

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mass index of 38), chronic active smoker, chronic obstructive pulmonary disease, obstructive

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sleep apnea on continuous positive airway pressure therapy, severe pulmonary hypertension,

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atrial fibrillation on anticoagulation, well controlled diabetes type II, hypertension, dyslipidemia,

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who was discharged to a rehabilitation facility from our institution four weeks prior after had

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been treated for hypercapnic hypoxic respiratory failure requiring mechanical ventilation

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presented with sudden onset of generalized weakness, lightheadedness, shortness of breath and

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dry cough after waking up the morning of admission. One day before admission patient was

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discharged from a rehabilitation center where she received physical therapy/hydrotherapy

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sessions. Patient was in distress but denied subjective fevers, chills, headache, photophobia,

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sputum production, nausea, vomiting, diarrhea, dysuria, vaginal discharge, recent travel, or

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exposure to pets. Patient’s medications included: simvastatin, metformin, glipizide, valsartan,

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labetalol, diltiazem, warfarin, fluticasone/salmeterol, and albuterol.

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Physical exam was remarkable for hypotension (64/36mmHg) which required epinephrine drip,

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tachypnea of 32 breaths/min, O2 sat of 78% on 2lts NC (91% on biphasic positive airway

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pressure), pulse 110/min, and temperature of 98.9ºF.

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Patient was alert and oriented to person, place and time, was in distress, and showed conjunctival

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pallor, dry mucous membranes, arrhythmic heart sounds with a 2/6 pansystolic tricuspid

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murmur, lungs with bilateral crackles at bases and wheezing, non-tender abdomen with ascetic

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wave, and 2+ edema in lower extremities with decreased peripheral pulses but not evidence of

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skin ulcers. Neurologic exam did not show meningeal signs neither focal deficits.

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Patient was empirically started on cefepime and vancomycin.

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Laboratory results showed a leukocyte count of 15.6/mL, neutrophils 85%, no bandemia, and

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platelets 877/mL. Patient also presented with acute kidney injury with a creatinine of 1.3mg/dL

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(baseline 0.6 mg/dL), and hyperglycemia 183mg/dL. Lactate level was 3mmol/L. INR was 3.

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Negative HIV test. Urinalysis was negative for blood, nitrates and leukocyte esterase. It has 5-10

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WBCs and many bacteria.

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Chest and abdominal CT showed a previously identified right pleural effusion with associated

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right-sided atelectasis, cardiomegaly, moderate ascites, and enlarged caliber hepatic veins.

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Transesophageal echocardiogram showed an ejection fraction of 60%, severe pulmonary

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hypertension, severe tricuspid regurgitation, mild mitral regurgitation and no signs of

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endocarditis. Cytology of peritoneal and the exudative pleural fluid were negative for malignant

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cells. Blood, urine, pleural and peritoneal fluid cultures were sent.

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On the second day of hospitalization patient no longer required vasopressors. Two sets of blood

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cultures were drawn and the two sets identified gram negative bacilli. Vancomycin was

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discontinued. On the fourth day of hospitalization the final identification of blood cultures

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showed

Sphingobacterium

multivorum

resistant

to

ceftazidime

and

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trimethoprim/sulfamethoxazole (TMP/SMX), and with intermediate susceptibility to meropenem

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and piperacillin/tazobactam (Figure 1). The method used for identification involved using a

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MacConkey agar, a breakpoint panel with biochemical and sensitivity sections for identification

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and susceptibility tests respectively and a MicroScan WalkAway plus-40® Microbiology

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System. Cefepime was switched to ciprofloxacin. Gram stain of urine was not reported but urine

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culture came negative as did peritoneal and pleural fluid cultures. Patient was clinically stable to

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be discharged with a total of ten days of ciprofloxacin. Repeated blood and urine cultures taken

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five days after admission came negative. Patient was followed up two and four weeks after

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discharged and was clinically stable.

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Discussion:

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Bacteria that belong to the genus Sphingobacterium are gram-negative, non-lactose fermentative

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microorganisms that are positive for catalase and oxidase tests and produce small, circular,

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convex, smooth, opaque colonies with light yellow pigment when incubated at 35° C in either

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carbon dioxide or ambient air for a minimum of 24 hours. Growth on McConkey agar is usually

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detectable within 24 hours of inoculation (1). An important feature of bacteria that belong to this

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genus is the presence of high concentrations of sphingophospholipids in their cell membrane (2).

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They are ubiquitous in nature, but are rarely involved in human infections. Sphingobacterium

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can be found in soil, on plants, foodstuffs, and in water sources (3). Sphingobacterium species

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have the ability to survive in moist hospital environments hence these organisms also have the

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potential to contaminate laboratory culture media and blood culture systems. Whenever these

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species are encountered, their clinical significance and the potential for contamination should be

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seriously considered (1).

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There are few reported cases of infections secondary to S. multivorum and usually occurred in

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severely comorbid patients (table 1) causing for instance necrotizing fasciitis and septic shock in

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a patient with rheumatoid arthritis treated with long-term intermediate-dose corticosteroids (0.25

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mg/kg of prednisone per day for more than 30 years) (3), bacteremia in immunocompromised

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hosts (4) (5) (6), sepsis in the setting of bacteremia in a hemodialyzed patient (7), peritonitis (8),

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chronic respiratory tract infection in patients with cystic fibrosis (9, 10) where however it was

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not associated with a deterioration of pulmonary function during the follow-up period (10) and

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respiratory infection in a patient with chronic obstructive pulmonary disease (11).

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In addition, the medical literature mentions a report of three cases of cystitis, one of which was

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complicated with bacteremia, within a period of ten days after transrectal ultrasound guided

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prostate biopsy where an infection hygiene evaluation identified and changed a step in the biopsy

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process in order to reduce the risk of inocula (12).

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Although we could not establish the source of the pathogen, we can speculate that it was present

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in the water or soil of the rehabilitation facility.

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Sphingobacterium species are intrinsically resistant to many commonly employed antibiotics and

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can grow in antiseptics and desinfectants (2) (13). S. multivorum can produce an extended-

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spectrum-β-lactamase and a metallo-β-lactamase conferring resistance to third generation

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cephalosporins and carbapenems respectively (14). In our review the three most common

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susceptible antibiotic therapies were TMP/SMX, quinolones and tetracycline however in our

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case there was resistance to TMP/SMX.

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Including our case, this review found a total of fourteen cases of S. multivorum infection: 9 males

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and 5 females. Out of the 11 cases where age was reported, 10 were adults and their mean age

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was 56 years. One patient died out of the fourteen reported cases.

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Here we present a case of septic shock secondary to Sphingobacterium multivorum bacteremia

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likely nosocomial in origin which, although rare, can cause life threatening infection.

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Bibliography:

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1.

States: Elsevier. 2007. Pages: 358-362.

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2.

Mandell G., Bennett J. and Dolin R. Principles and Practice of Infectious Diseases.

Seventh edition. Philadelphia, PA-United States: Elsevier. 2010. Pages: 3016-3017, 3027.

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Grimaldi D., Doloy A., Fichet J., et al. Necrotizing Fasciitis and Septic Shock related to

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Forbes B., Sahm D. and Weissfeld A. Diagnostic Microbiology-Twelfth Edition. United

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the uncommon Gram-Negative Pathogen Sphingobacterium multivorum. Journal of

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Clinical Microbiology. January 2012 vol. 50 no. 1 202-203.

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Freney J., Hansen W., Ploton C., et al. Septicemia caused by Sphingobacterium multivorum. Journal of Clinical Microbiology. June 1987 vol. 25 no. 6 1126-1128.

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Manfredi R, Nanetti A., Ferri M., et al. Flavobacterium spp. organisms as opportunistic bacterial pathogens during advanced HIV disease. The Journal of Infection. 1999

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September; 39(2):146-52.

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Areekul S., Vongsthongsri U., Mookto T., et al. Sphingobacterium multivorum septicemia: a case report. Journal of the medical association of Thailand. 1996 June;

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79(6):395-8. 7.

septicemia in a hemodialyzed patient. Journal of Clinical Microbiology. April 1984 vol.

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19 no. 4 568-569.

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Potvliege C., Dejaegher-Bauduin C., Hansen W., et al. Flavobacterium multivorum

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Dhawan V., Rajashekarajah K., Metzger W., et al. Spontaneous Bacterial Peritonitis Due to a Group IIk-2 Strain. Journal of Clinical Microbiology, May 1980, p. 492-495

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Lambiase A., Rossano F., Del Pezzo M., et al. Sphingobacterium respiratory tract

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infection in patients with cystic fibrosis. BioMed Central research notes. December 2009,

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2:262. 10.

Reina J., Borrell N., and Figuerola J. Sphingobacterium multivorum isolated from a

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patient with cystic fibrosis. European Journal of Clinical Microbiology and Infectious

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Diseases. 1992 January; 11 (1): 81-2.

Anales de Medicina Interna. Vol. 18, Nº 12, 2001: 655-656.

138 139

12.

Nielsen T., Pinholt M., Norgaard N., et al. Inoculation of Sphingobacterium multivorum in the prostate by prostate biopsy. Scandinavian Journal of Urology, 2014; 48: 116–118.

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Vella J., Rodríguez A. Respiratory infection caused by Sphingobacterium multivorum.

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Fass R., and Barnishan J. In vitro susceptibilities of nonfermentative gram-negative bacilli other than Pseudomonas aeruginosa to 32 antimicrobial agents. Reviews of

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Infectious Diseases. 1980 November-December; 2(6):841-53

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Blahová J., Králiková K., Krcmery V., et al. Hydrolysis of imipenem, meropenem, ceftazidime, and cefepime by multiresistant nosocomial strains of Sphingobacterium

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multivorum. European Journal of Clinical Microbiology and Infectious Diseases. 1997

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February; 16(2):178-80.

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Table 1. Summary of Sphingobacterium multivorum reports Comorbidities

Diagnosis

Susceptibility testing results

Treatment and outcome

References

60-year-old male presented with nausea, vomiting, and vague abdominal discomfort for 2 weeks (8).

Alcoholic liver disease, esophageal stricture due to prior suicidal attempt by ingesting liquid Drano (a strong alkaline corrosive)

Sepsis due to spontaneous bacterial peritonitis.

Resistant to ampicillin, amikacin, gentamicin, chloramphenicol and cephalosporins.

Hospital course complicated with aspiration pneumonia causing acute respiratory failure.

Susceptible to tetracycline, carbenicillin, and TMP/SMX*

Initially treated with ampicillin and gentamicin for 5 days with no improvement. Then treated with gentamicin and carbenicillin for 11 days.

Dhawan V., Rajashekarajah K., Metzger W., et al. Spontaneous Bacterial Peritonitis Due to a Group IIk-2 Strain. Journal of Clinical Microbiology, May 1980, p. 492-495.

Chronic renal insufficiency on hemodialysis through arteriovenous fistula, bilateral nephrectomy, history of infected arteriovenous fistula

Bacteremia

Resistant to penicillins, cephalosporins, tobramycin, amikacin, and colistin.

Immunoblastictype nonHodgkin's lymphoma treated with chemotherapy complicated with the development of bone marrow aplasia

Sepsis in the setting of bacteremia

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57-year-old male who presented with fever five days after starting chemotherapy (4).

Cystic fibrosis

47-year-old man presented with fever and chills for three months and ten kg weight loss

Diabetes type II Newly diagnosed HIV

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20 month old female diagnosed with cystic fibrosis at the age of 6 months presented with fever, cough productive of abundant mucous expectoration and respiratory difficulty for two days (10).

Fully recovery.

Sepsis in the setting of acute exacerbation of chronic bronchopathy

Bacteremia Meningitis Liver failure

*LOS: 21 days. Treated with ampicillin (MIC of 8ug/ml) for 10 days and one dose of tobramycin.

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Susceptible to erythromycin, tetracycline, chloramphenicol, vancomycin, gentamicin, sulfonamides and TMP/SMX MICs were as follows (mg/L): pefloxacin, 0.5; rifampin, 1; tetracycline, 2; erythromycin, 4; TMP/SMX, 5; chloramphenicol and ceftriaxone, 8; ceftazidime and cefotaxime 16; carbenicillin and azlocillin 64; piperacillin and cephalotin 128; gentamicin, tobramycin, vancomycin >16; ampicillin, aztreonam and amikacin, >32; and fosfomycin, >128 Resistant to aztreonam, gentamicin and TMP/SMX. Susceptible to carbenicillin, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, azlocillin, cefotaxime, ticarcillin, ciprofloxacin, imipenem, piperacillin, and amikacin

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43-year-old man presented with chills, fever and myalgias for one day (7).

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Patient characteristics

Resistant to ampicillin, gentamycin, amikacin, carbenicillin

Fully recovered. LOS: no data.

Treated with a combination of pefloxacin and TMP/SMX. Fully recovered. LOS: no data.

Treated with ceftazidime and amikacin Fully recovered. LOS: no data.

Treated initially with gentamycin and ampicillin. Then switched to

Potvliege C., Dejaegher-Bauduin C., Hansen W., et al. Flavobacterium multivorum septicemia in a hemodialyzed patient. Journal of Clinical Microbiology. April 1984 vol. 19 no. 4 568-569. Freney J., Hansen W., Ploton C., et al. Septicemia caused by Sphingobacterium multivorum. Journal of Clinical Microbiology. June 1987 vol. 25 no. 6 1126-1128.

Reina J., Borrell N., and Figuerola J. Sphingobacterium multivorum isolated from a patient with cystic fibrosis. European Journal of Clinical Microbiology and Infectious Diseases. 1992 January; 11 (1): 81-2. Areekul S., Vongsthongsri U., Mookto T., et al. Sphingobacterium

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Chronic lung infection

Report of three cases of infections after transrectal ultrasoundguided prostate biopsy (TRUS-Bx). All cases received oral prophylaxis with pivmecillinam and amoxicillin/clavulanic acid the night before and 2 h before TRUS-Bx. Case 1: 79 years old man was hospitalized with fever, chills and malaise

Susceptible to TMP/SMX, tetracyclines, quinolones, aminoglycosides, and beta-lactams. Resistant to β-lactams, carbapenems and aminoglycosides.

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Susceptible to TMP/SMX and quinolones

Morbid obesity (BMI 33.5 kg/m2), coronary artery disease, diabetes type II and rheumatoid arthritis treated with long-term intermediate-dose corticosteroids

Case 1: end stage renal disease secondary to glomerulonephriti s on hemodialysis, benign prostatic hyperplasia, prostate cancer Case 2: benign prostatic hyperplasia

Patient died on the 6th day of hospitalization

Treated initially with ceftazidime and then switched to cefuroxime. Fully recovered. LOS: no data.

The authors don’t specify which therapy was used but mentioned that no subsequent decline in lung function was registered. LOS: no data.

Septic shock, encephalopathy, acute kidney injury requiring hemodialysis and respiratory failure in the setting of necrotizing fasciitis

Resistance to penicillins, cephalosporins, carbapenems, and aminoglycosides.

Treated with amoxicillinclavulanate for 10 days.

Susceptible to amoxicillin-clavulanate, ticarcillin-clavulanate, quinolones, and TMP/SMX

The patient was discharged to a rehabilitation unit after 7 weeks; she did not suffer from physical sequelae.

Case 1: cystitis and bacteremia

Case 1 and 2 had the same antibiogram: Resistant to ampicillin, cefuroxime, piperacillin / tazobactam, mecillinam and gentamicin.

Case 1: initially started on piperacillin / tazobactam and ciprofloxacin. He was discharged after 6 days with oral ciprofloxacin.

Case 2: Cystitis Case 3: Cystitis

multivorum septicemia: a case report. Journal of the medical association of Thailand. 1996 June; 79(6):395-8.

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Cystic fibrosis, pancreatic insufficiency

Resistance to ceftazidime and aztreonam. Intermediate to tobramycin, and ticarcillin.

ceftriaxone and TMP/SMX.

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Sepsis secondary to respiratory infection (authors don’t specify if pneumonia was present)

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Chronic obstructive pulmonary disease (COPD), history of several hospitalizations due to bronchial infections with Pseudomona sp

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Sputum samples were obtained from January 2006 to June 2008 from 332 cystic fibrosis patients. S. multivorum was isolated from three patients: two females and one male. Among these, one patient was identified as chronically infected by S. multivorum. All patients were co-infected by at least one other Gram negative pathogen (9). 64-year-old female who presented with leg pain and fever 24 hours after her dog scratched her right leg Patient was confused, her skin was mottled from legs to abdominal wall and her right leg was erythematous, edematous and tender to palpation (3).

Sensitive to TMP/SMX, chloramphenicol, tetracycline, cefotaxime, ceftazidime and ceftriaxone.

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for 1 month. He was found to have a positive HIV test and cultures from the blood and sputum yielded S. multivorum. Patient developed meningitis with negative CSF cultures (6). 74-year-old male presented with 4 days history of chills, subjective fevers, cough productive of purulent sputum and chest pain, found to have fever, tachypnea and neutrophilia (11)

Susceptible to ciprofloxacin and TMP/SMX An antibiogram was not performed in case 3.

Case 2: did not receive antibiotic treatment

Vella J., Rodríguez A. Respiratory infection caused by Sphingobacterium multivorum. Anales de Medicina Interna. Vol. 18, Nº 12, 2001: 655-656.

Lambiase A., Rossano F., Del Pezzo M., et al. Sphingobacterium respiratory tract infection in patients with cystic fibrosis. BioMed Central research notes. December 2009, 2:262.

Grimaldi D., Doloy A., Fichet J., et al. Necrotizing Fasciitis and Septic Shock related to the uncommon GramNegative Pathogen Sphingobacterium multivorum. Journal of Clinical Microbiology. January 2012 vol. 50 no. 1 202-203. Nielsen T., Pinholt M., Norgaard N., et al. Inoculation of Sphingobacterium multivorum in the prostate by prostate biopsy. Scandinavian Journal of Urology, 2014; 48: 116–118.

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Case 3: empiric treatment with trimethoprim for 10 days

Case 3: benign prostatic hyperplasia

Septic shock and acute kidney injury in the setting of bacteremia

Resistance to ceftazidime and TMP/SMX

Initially treated with cefepime (4 days) and vancomycin (2 days). Then switched to ciprofloxacin for a total of 10 days.

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Obesity (BMI of 38kg/m2), chronic active smoker, COPD, obstructive sleep apnea, severe pulmonary hypertension, atrial fibrillation, diabetes type II, hypertension, dyslipidemia.

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All patients recovered.

Intermediate to meropenem and Piperacillin/tazobactam

Susceptible to amikacin, cefepime, cefotaxime, ceftriaxone, ciprofloxacin, gentamicin, imipenem, tetracycline

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three days after TRUSBx. Case 2: 59 years old man complained of dysuria and frequent voiding 2 weeks after TRUS-Bx. Case 3: 69 years old man was followed in an active surveillance program for low-risk prostate cancer consulted the emergency room 3 days after the TRUS-Bx with dysuria and hematuria (11). 67-year-old African American female who was discharged to a rehabilitation facility from our institution four weeks prior after had being treated for hypercapnic hypoxic respiratory failure requiring mechanical ventilation presented with sudden onset of generalized weakness, lightheadedness, shortness of breath and dry cough the morning of admission.

Barahona F., and Slim J. Sphingobacterium multivorum: a case report and literature review. Newark, NJ, USA. October, 2014.

Fully recovered. LOS: 10 days, 4 of which patient was in ICU*.

*TMP/SMX: trimethoprim-sulfamethoxazole, COPD: chronic obstructive pulmonary disease,

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LOS: length of stay, ICU: intensive care unit.

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Blood culture/susceptibility testing result Sphingobacterium multivorum Antibiotic MIC Amikacin <16 Blood susceptible Cefepime <8 Blood susceptible Cefotaxime 8 Blood susceptible Ceftazidime >16 Blood resistant Ceftriaxone <8 Blood susceptible Ciprofloxacin <1 Blood susceptible Gentamicin <4 Blood susceptible Imipenem <4 Blood susceptible Meropenem 8 Blood intermediate Piperacillin/tazobactam 64 Blood intermediate Tetracycline <4 Blood susceptible Trimethoprim/sulfamethoxazole >2/38 Blood resistant Figure 1.

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