A case of urinary tract infection caused by Raoultella planticola after a urodynamic study

brazjinfectdis2017;21(2):196–198

w w w . e l s e v ie r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Case

report

A

case

of

urinary

tract

infection

caused

by

Raoultella

planticola

after

a

urodynamic

study

Murat

Tu ˘gcu

_,

_Caglar

_Ruhi

_,

_Ali

_M.

_Gokce

_,

_Melih

_Kara

_,

_Sebahat

_Aksaray

a_{HaydarpasaNumuneTrainingandResearchHospital,DepartmentofNephrology,Istanbul,Turkey} b_{HaydarpasaNumuneTrainingandResearchHospital,DepartmentofUrology,Istanbul,Turkey} c_{HaydarpasaNumuneTrainingandResearchHospital,DepartmentofGeneralSurgery,Istanbul,Turkey} d_{HaydarpasaNumuneTrainingandResearchHospital,DepartmentofMicrobiology,Istanbul,Turkey}

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Articlehistory:

Received17June2016 Accepted28September2016 Availableonline21November2016

Keywords:

Urinarytractinfection

Raoultellaplanticola

Urodynamicstudy Contamination

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Herewereportthecaseofapatientwhodevelopedurinarytractinfectionaftera urody-namicstudy.ThecausativeagentwasRaoultellaplanticola,arareopportunisticpathogen thatusuallyinvadesimmunocompromisedpatients.Whileaurinarytractinfectionwith

R.planticolahasbeenpreviouslydescribed,thisisthefirstreportinwhichanR.planticola

infectiondevelopedafteraurodynamicstudy.Wepostulatethatthemechanismofinfection wasdirectinvasionoftheurinarytractfromcontaminatedurodynamicstudyequipment. Here,wediscusstheroleplayedbyisotonicsolutionsinfacilitatingbacterialreproduction. ©2017SociedadeBrasileiradeInfectologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/ by-nc-nd/4.0/).

Introduction

Both lower urinary tract and pelvic floor function can be efficiently evaluated by a urodynamic study (US),1 _{but it}

isaninvasiveprocedurethat involvesurethral catheteriza-tion. A urinary tract infection (UTI) is the most frequent complication.2_{InpatientsundergoingaUS,however,infection}

duetocontaminationoftheequipmentusedinthe evalua-tionisunusual.Hereinwepresentacaseofhospital-acquired UTI resulting from infection with Raoultella planticola in a patientwhounderwentaUSpriortokidneytransplantation.

R.planticolaisaGram-negativebacteriumthatusuallyinvades immunocompromisedpatientsandsometimescausesserious infections.Toourknowledge,thisisthefirst caseofaUTI causedbyR.planticolathatoccurredsubsequenttoaUS.

∗ _{Correspondingauthor.}

E-mailaddress:drmrttgc@hotmail.com(M.Tu ˘gcu).

Case

presentation

A57-year-oldmalewhohadbeenonperitonealdialysisfor the pasttwoyears becauseofend-stagerenal disease sec-ondary to diabetes mellitus wasadmitted toour clinicfor alivekidney transplant. Theresultsofthebasic investiga-tions usedtodeterminetransplanteligibilitydidnotreveal anyobstaclestotransplantation.However,urodynamic test-ing (voidingpressure-flowanalysis)wasperformedbecause he complained of problems in initiating urination; these wereattributedtobenignprostatichypertrophy,identifiedon ultrasonography(USG).OnedayaftertheUS,thepatient com-plained ofdysuria,and then,threedaysafter, offever and chills. Onphysical examination,his generalcondition was moderateandhehadabloodpressureof140/70mmHg,aheart

http://dx.doi.org/10.1016/j.bjid.2016.09.014

1413-8670/©2017SociedadeBrasileiradeInfectologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

brazj infect dis.2017;21(2):196–198

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rate of 110beats/min,a respiratory rate of 17breaths/min, andhisbody temperature was37.8◦C.Theonlysignificant physicalfindingwassuprapubictenderness.Hiswhiteblood cell count was 17,400cells/␮L (absolute neutrophil count, 14,880cells/␮L),andurinalysisshowedahighnumberofwhite bloodcellsanderythrocytes.Hisbiochemicaltestresultswere asfollows:plasmacreatinine10.3mg/dL,bloodureanitrogen 86mg/dL,sodium133mEq/dL,potassium4.7mEq/dL,and C-reactiveprotein(CRP)75mg/L(referencerange,0–5mg/L).The peritonealfluidcell countwas 10/mm3_{. A chestX-raywas}

unremarkable.USGofthepelvisidentifiedonlybladderwall thickness. Twoperipheral bloodcultures, aperitoneal fluid cultureand aurinary culturewere taken.The patientwas treatedwithempiricalbroad-spectrumintravenousantibiotic therapy(ceftriaxone,1gq12h)fortheUTIafterthefirst eval-uation.TheurineculturerevealedR.planticola,buthisblood culturesandperitonealfluidcultureturnedoutnegative.

Wesuspectedthattheinfectionwassecondarytobacterial invasionfromcontaminatedUSequipmentbecauseR. planti-colaisararecausativebacteriaforUTIandthereforesetup culturesfromsamplingsofthedifferentpartsofthedevice. BoththeculturefromtheUSpumptubeandtheisotonic solu-tionwerepositiveforR.planticola;moreover,thestrainwas identicaltothatisolatedfromthepatient’surine.Duringthe seconddayofantibiotictreatment,thepatient’sclinical con-ditionimprovedsignificantly.HisserumCRPleveldecreased to5mg/L;onday7oftreatment,hisWBCwas8700/mm3_.

Cef-triaxonetherapywasthereforestopped.Hewastransplanted withalivekidneyonemonthlater.

Diagnosis

Aurinespecimenwassenttothemicrobiologydepartmentfor culture.Gram-negativerodsand polymorphonuclear leuko-cytes were seen in the Gram-stained sample. The urine samplewascultivatedonEMBandsheepbloodagarwitha 10-␮Lstandard loopastheinoculant.Gram-negativebacilli grewonbothculturemediatoadensityof>100,000CFU/mL. Theisolate was analyzed bymatrix-assisted laser desorp-tion/ionization time-of-flight mass spectrometry using the VITEK MS (bioMérieux, Marcy l’Étoile, France) system and identified as R. planticola. Antimicrobial susceptibility test-ing was performed using the VITEK-2 compact system. Thebacterium was resistant to ampicillin and fosfomycin and susceptible to amoxicillin/clavulanic acid, ceftriaxone, ciprofloxacin, gentamicin, ceftazidime, cefuroxime axetil, trimethoprim/sulfamethoxazole,andnitrofurantoin(Table1). Theculture from the US pump tube and isotonicsolution revealedthesamestrainofR.planticolaasisolatedfromthe patient’surine.Theresultswereinterpretedaccordingtothe guidelinesoftheEuropeanCommitteeonAntimicrobial Sus-ceptibilityTesting.

Discussion

R. planticola is a Gram-negative, non-motile, encapsulated bacterium previously referred to as Klebsiella planticola but reclassifiedasanewgenusin2001.3_{AlthoughR.planticolais}

Table1–InvitrosusceptibilityresultsforRaoultella planticola(urine,USpump,andisotonicsolution).

Antimicrobialagent MIC(mg/L)a

Ampicillin ≥32 Amoxicillin/clavulanicacid ≤2 Ceftriaxone ≤0.25 Ciprofloxacin ≤0.25 Gentamicin ≤1 Nitrofurantoin ≤16 Ceftazidime 0.25 Cefuroxime 2 Trimethoprim/sulfamethoxazole ≤20 MIC,minimuminhibitoryconcentration.

a _{DeterminedusingtheVITEK-2system(bioMérieux,Marcyl’Étoile,}

France).

mainlyanaquaticandsoilbacterium,it hasbeenclinically isolatedfromhumansputum,stool,wounds,andurine.4,5_To

date,several humaninfectionswithR.planticolahave been reported. Riskfactorsfortheseinfectionsinclude immuno-suppression,comorbidities,andinvasiveprocedures.6,7

R. planticolamay also cause UTIs.8,9 _{In our patient,}

dia-betesandchronicrenalfailurewerethemajorcomorbidities, whichledtoanimmunosuppressedstate.Anadditionalrisk factorwastheinvasiveprocedureheunderwent,US,which requiresurethralcatheterization.Themostcommon compli-cationafteraUSisUTI10_{;however,inthesecasesthemost}

frequently isolated causative agent is Escherichia coli, with pathogenssuchasKlebsiellaspeciesormembersofthe Entero-bacteriaceaeencounteredonlyrarely.11,12 _{Toourknowledge,}

thisisthefirstcaseofanR.planticolainfectionthatdeveloped subsequenttoaUS.

Inourunit,asterileisotonicsolutionisusedforaUS,and thepumptubeisreplacedevery threedays. Therewereno previousincidencesofUTIduetocontaminationofthetest device.However,aftertheurineculturerevealedR.planticola,

theinfectionwasregardedascontaminationinitsorigin.This wasconfirmedbythefindingthattheUSpumptubeand iso-tonicsolutionwerecontaminatedwiththesamestrainofR. platicolaisolatedfromthepatient.Bacterialcontaminationof USequipmentwaspreviouslyreported.13_{Inourinvestigation}

ofthesourceofthecontamination,weestablishedthatthe isotonicsolutionhadbeenopenedforuseinanotherpatientin thepreviousweekandshouldhavebeendiscardedthereafter; instead,itwasmistakenlyusedinourpatient.Isotonic solu-tionsmaybecontaminatedbycontactwithanotherinfected patientor bybacterialtransmissionfromtheenvironment, includingviasurfacecontact,invasiveprocedures,andasa bioaerosolthroughtheair.14

Microorganisms suchasR.planticola thatare commonly foundinaquaticenvironmentsmaybeabletorapidly mul-tiplyintheisotonicsolutionsusedinUSdevices.Aprevious casereportdescribedthedevelopmentofcholangitiscaused byR.planticolainapatientwhohadundergoneanendoscopic retrogradecholangiopancreatographicprocedure,whichalso involved the use of anisotonicsolution. Thecause of the infection inthat patientwas attributedtoaninadequately sterilized,reusableendoscopyline.7

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R.planticolaisgenerallysensitivetocephalosporins, amino-glycosides,fluoroquinolones,andcarbapenems,butextensive resistancehasalsobeendescribedforthisbacterium.15_The

isolate from our patient was resistant to ampicillin and fosfomycin, and susceptible to amoxicillin/clavulanic acid, ceftriaxone,ciprofloxacin,gentamicin,ceftazidime, cefurox-imeaxetil,trimethoprim/sulfamethoxazole,and nitrofuran-toin.Treatmentwitha1-weekcourseofceftriaxone(2g/day) resultedinfullrecoveryandabolishmentoftheinfection.

Inconclusion,wepresentthecaseofapatientwho under-wentaninvasiveurinary tractprocedure andsubsequently developedaUTI,withR.planticolaidentifiedasthecausative agent.Thepatient’sclinicalpresentationwasconsistentwith aUTI,determinedtobenosocomial,associatedwiththeuse ofacontaminatedisotonicsolution.Thepatientsufferedfrom diabetesandchronicrenalfailure,bothofwhichmay have beencontributingfactorsinthepathogenesisoftheinfection. Ourresultsemphasizetheneedforthestrictimplementation ofmeasurestoensurethatUSdevices,especiallytheisotonic solution,areproperlysterilizedpriortotheiruse.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1. BradleyCS,SmithKE,KrederKJ.Urodynamicevaluationof thebladderandpelvicfloor.GastroenterolClinNAm. 2008;37:539–52.

2. YipSK,FungK,PangMW,LeungP,ChanD,SahotaD.Astudy offemaleurinarytractinfectioncausedbyurodynamic investigation.AmJObstetGynecol.2004;190:1234–40.

3. DrancourtM,BolletC,CartaA,etal.Phylogeneticanalysesof

KlebsiellaspeciesdelineateKlebsiellaandRaoultellagen.nov.,

withdescriptionofRaoultellaornithinolyticacomb.nov.,

Raoultellaterrigenacomb.nov.andRaoultellaplanticolacomb. nov.IntJSysEvolMicrobiol.2001;51:925–32.

4.FreneyJ,GaviniF,AlexandreH,etal.Nosocomialinfection andcolonizationbyKlebsiellatrevisanii.JClinMicrobiol. 1986;23:948–50.

5.BoattiniM,AlmeidaA,CardosoC,etal.Infectionsontherise:

Raoultellaspp.,clinicalandmicrobiologicalfindingsfroma retrospectivestudy,2010–2014.InfectDis.2016;48:87–91.

6.PodschunR,AcktunH,OkparaJ,etal.IsolationofKlebsiella planticolafromnewbornsinaneonatalward.JClinMicrobiol. 1998;36:2331–2.

7.YokotaK,GomiH,MiuraY,etal.Cholangitiswithsepticshock causedbyRaoultellaplanticola.JMedMicrobiol.2012;61:446–9.

8.GangcuangcoLMA,SaulZK.AnovelcaseofRaoultella planticolaurinarytractinfectioninafemale:commenton ‘Nosocomialpneumoniacausedbycarbapenem-resistant

Raoultellaplanticola:acasereportandliteraturereview’. Infection.2015;43:621–2.

9.OlsonDSJr,AsareK,LyonsM,etal.AnovelcaseofRaoultella planticolaurinarytractinfection.Infection.2013;41:259–61.

10.AlmallahYZ,RennieCD,StoneJ,etal.Urinarytractinfection andpatientsatisfactionafterflexiblecystoscopyand urodynamicevaluation.Urology.2000;56:37–9.

11.BombieriL,DanceDAB,RienhardtGW,etal.Urinarytract infectionafterurodynamicstudiesinwomen:incidenceand naturalhistory.BJUInt.1999;83:392–5.

12.OkorochaI,CummingG,GouldI.Femaleurodynamicsand lowerurinarytractinfection.BJUInt.2002;89:863–7.

13.CannKJ,JohnstoneD,SkeneAI.AnoutbreakofSerratia marcescensinfectionfollowingurodynamicstudies.JHosp Infect.1987;9:291–3.

14.HeidelbergJF,ShahamatM,LevinM,etal.Effectof

aerosolizationonculturabilityandviabilityofGram-negative bacteria.ApplEnvironMicrobiol.1997;63:3585–8.

15.CastanheiraM,DeshpandeLM,DiPersioJR,KangJ,Weinstein MP,JonesRN.FirstdescriptionsofblaKPCinRaoultellaspp.(R.

planticolaandR.ornithinolytica):reportfromtheSENTRY AntimicrobialSurveillanceProgram.JClinMicrobiol. 2009;47:4129–30.