Gram-positive Cocci In Pairs Research Articles

Identifying organisms directly from BacT/Alert FAN plus blood culture bottles using Vitek MS in a state-wide laboratory network

Identifying organisms directly from positive blood culture bottles using matrix-assisted laser desorption-ionisation time-of-flight mass spectrometry (MALDI-TOF MS) has many advantages to patients, clinical services, and laboratories. However, few published methods have demonstrated good performance using the current BioMérieux culture bottles and MALDI-TOF system: BacT/Alert FAN plus and Vitek MS. The effect of transporting bottles on test performance has not been assessed for any direct-from-bottle MS method. In this study, 802 positive blood culture bottles were analysed including 234 requiring inter-laboratory transport, using a method involving protein extraction with formic acid and acetonitrile. Correct identification rates were high for Staphylococcus aureus (58/58 of new diagnostic samples), Enterococcus faecalis (27/27), Gram-negative bacilli (160/176, 90.1%), and coagulase-negative Staphylococcus species (108/132, 81.8%). Three false identifications were made, none with clinical significance. For Gram-positive cocci in pairs or chains, more correct identifications were made from bottles analysed immediately compared to transported bottles (67% vs 44%, p=0.016), and longer transport time was associated with slightly lower probability of correct identification (OR 0.984 per additional hour, p=0.040). Transportation was not associated with a difference for other organism types. This technique is a vastly more cost-effective alternative to molecular techniques for rapid identification of bacteraemia isolates, and performance is minimally affected by inter-laboratory transport of bottles at ambient temperature.

Performance evaluation of machine-assisted interpretation of Gram stains from positive blood cultures.

Manual microscopy of Gram stains from positive blood cultures (PBCs) is crucial for diagnosing bloodstream infections but remains labor intensive, time consuming, and subjective. This study aimed to evaluate a scan and analysis system that combines fully automated digital microscopy with deep convolutional neural networks (CNNs) to assist the interpretation of Gram stains from PBCs for routine laboratory use. The CNN was trained to classify images of Gram stains based on staining and morphology into seven different classes: background/false-positive, Gram-positive cocci in clusters (GPCCL), Gram-positive cocci in pairs (GPCP), Gram-positive cocci in chains (GPCC), rod-shaped bacilli (RSB), yeasts, and polymicrobial specimens. A total of 1,555 Gram-stained slides of PBCs were scanned, pre-classified, and reviewed by medical professionals. The results of assisted Gram stain interpretation were compared to those of manual microscopy and cultural species identification by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). The comparison of assisted Gram stain interpretation and manual microscopy yielded positive/negative percent agreement values of 95.8%/98.0% (GPCCL), 87.6%/99.3% (GPCP/GPCC), 97.4%/97.8% (RSB), 83.3%/99.3% (yeasts), and 87.0%/98.5% (negative/false positive). The assisted Gram stain interpretation, when compared to MALDI-TOF MS species identification, also yielded similar results. During the analytical performance study, assisted interpretation showed excellent reproducibility and repeatability. Any microorganism in PBCs should be detectable at the determined limit of detection of 105 CFU/mL. Although the CNN-based interpretation of Gram stains from PBCs is not yet ready for clinical implementation, it has potential for future integration and advancement.

Implementation of a pharmacy-driven rapid bacteremia response program.

This report describes a comprehensive pharmacy-driven rapid bacteremia response program. This novel program positioned the pharmacy department at a large, community health system to receive and respond to critical microbiologic diagnostic testing results, 24/7/365. The program empowered pharmacists to provide centralized, comprehensive care including assessing blood culture Gram stain results, adjusting antibiotic therapy per protocol, ordering repeat blood cultures, analyzing and interpreting rapid molecular diagnostic test results, placing orders for contact isolation, and communicating antibiotic recommendations to the treatment team. In the first year after program implementation, 2,282 blood culture Gram stains and 2,046 rapid diagnostic test results were called in to the pharmacy department. The program reduced the median time to effective therapy in patients who did not already have active antimicrobial orders from over 10 hours to less than 1 hour. Based on the Gram stain results, antibiotics were started per protocol in 34.2% of patients. Based on the rapid molecular diagnostic test results, adjustments were made to antibiotic regimens in 55.7% of cases after discussion with a provider. Of these adjustments, 39.9% were for escalation of antibiotics and 37.7% were for de-escalation of antibiotics. By expanding the scope of pharmacy practice, barriers to optimizing clinical care were overcome.

Hearing Loss from S. Suis Meningitis In A Middle-Aged Couple

Hearing Loss from S. Suis Meningitis In A Middle-Aged Couple

COTTON SWAB TODAY, BRAIN ABSCESS TOMORROW

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Brain abscess usually occurs as a result of predisposing factors such as HIV or other immunosuppressive state, systemic infection, or disruption in the protective barrier surrounding the brain, including trauma, operative procedures, mastoiditis, sinusitis or dental procedure. We report a very unique case of subdural empyema and abscess with associated mastoiditis and sinus thrombosis in the setting of a retained cotton swab. CASE PRESENTATION: Patient is a 47-year-old male with a past medical history of hypertension who presented with left arm weakness and numbness and left-sided facial droop. Computed Tomography (CT) of the brain showed an ill-defined hypodense 3.4 cm posterior right parietal lobe mass. Magnetic Resonance Imaging (MRI) was significant for an acute/subacute 2.8 x 3.1x 2 cm subdural empyema with extra-axial mass with smooth ring enhancement with associated thrombosis of the right transverse and sigmoid sinuses with right mastoiditis and medial erosion of air cells. A chronic left occipital abscess was also visualized on MRI with contrast. The patient was started on ceftriaxone, flagyl and vancomycin for empiric coverage and was managed in the ICU for septic shock. A decision was made not to anticoagulate due to the high risk of bleeding with an infectious etiology. HIV testing was negative. The patient was taken for right craniectomy with empyema evacuation and tympanomastoidectomy. During the surgical procedure, a posterior canal incision was made to the mastoid cortex and a cotton swab was found and retracted; it was attached to granulation tissue coming through the ear drum. Pathology confirmed cotton material representing a cotton swab. Gram stain showed gram positive cocci in pairs and surgical culture grew Anaerococcus species. DISCUSSION: The most common organism occurring in cases of contiguous spread of middle ear, mastoid, or sinus infection are streptococcus species, however, staphlococcal and polymicrobial abscesses caused by anaerobes, gram negative bacilli, and uncultured bacteria have been reported. Anaerococcus are gram positive strictly anaerobic bacteria that can occur in pairs, tetrads, or short chains. While many species are found as part of the normal flora of skin, oral cavity or gut, specimens isolated from abscesses have been reported. This is the first case to our knowledge of subdural empyema and abscess associated sinus thrombosis in the setting of retained cotton swab and isolation of Anaerococcus species. CONCLUSIONS: Warnings against the using cottons swabs in the ear canal exist due to the risk of foreign body, worsening cerumen impaction, and tympanic membrane rupture. Our case highlights the risk of cotton swab use in the ear. Physicians should be aware that resulting complications can include subdural empyema and abscess associated with transverse and sigmoid sinus thrombosis. REFERENCE #1: Brouwer MC, Tunkel AR, McKhann GM 2nd, van de Beek D. Brain abscess. N Engl J Med. 2014 Jul 31;371(5):447-56. doi: 10.1056/NEJMra1301635. PMID: 25075836. REFERENCE #2: Masalma MA, Lonjon M, Richet H, Dufour H, Roche P-H, Drancourt M, et al. Metagenomic Analysis of Brain Abscesses Identifies Specific Bacterial Associations. Clinical Infectious Diseases. 2011;54(2):202–10. REFERENCE #3: Murphy EC, Frick I-M. Gram-positive anaerobic cocci – commensals and opportunistic pathogens. FEMS Microbiology Reviews. 2013;37(4):520–53. DISCLOSURES: No relevant relationships by Benjamin Carmel, source=Web Response No relevant relationships by Mauricio Danckers, source=Web Response No relevant relationships by Davide Fox, source=Web Response No relevant relationships by Daniel Heller, source=Web Response No relevant relationships by Vijay Srinivasan, source=Web Response

Streptococcus oralis MitraClip endocarditis following a dental procedure: a case report

BackgroundTranscatheter edge-to-edge mitral valve repair using the MitraClip device is increasingly used for high surgical risk patients with severe mitral regurgitation (MR). Previous guidelines for infective endocarditis prophylaxis prior to dental procedures focused on high-risk patients, but without explicit recommendation for MitraClip recipients. We believe this could be the first reported case to identify Streptococcus oralis as the causative organism.Case presentationAn 87-year-old male with severe MR treated with two MitraClip devices three months prior to index admission, presented with worsening malaise and intermittent chills on a background of multiple comorbid conditions. The patient had dental work a month prior to presentation, including a root canal procedure, without antibiotic prophylaxis. Vitals were significant for fever and hypotension. On physical examination, there was a holosystolic murmur at the apex radiating to the axilla, bilateral pitting edema in the lower extremities, and elevated jugular venous pulsation. A transthoracic echocardiogram showed severe MR with a possible echodensity on the mitral valve, prompting a transesophageal echocardiogram, which demonstrated a pedunculated, mobile mass on the posterior leaflet of the mitral valve. Five blood cultures grew gram positive cocci in pairs and chains, later identified as Streptococcus oralis, with minimum inhibitory concentration to penicillin 0.06 mg/L. Initial empiric antibiotics were switched to ceftriaxone 2 gr daily and subsequent blood cultures remained negative. However, the patient developed pulmonary edema and worsening hemodynamic instability requiring vasopressors. As surgical risk for re-operation was considered prohibitive, the decision was made to continue medical management and comfort-directed care. The patient died a week later.ConclusionsDespite low incidence, infective endocarditis should be included in the differential among MitraClip recipients. The explicit inclusion of this growing patient population in the group requiring prophylaxis prior to dental procedures in the 2020 ACC/AHA valvular heart disease guidelines is an important step forward.

The BinaxNOW pneumococcal antigen test: An adjunct for diagnosis of pneumococcal bacteraemia

BackgroundCulture remains the diagnostic standard for Streptococcus pneumoniae bacteraemia but is limited by time to identification, prior antibiotics and bacterial autolysis. Culture-independent methods for detecting S. pneumoniae include PCR and antigen tests. We evaluated an antigen test on blood culture broth for the rapid detection of S. pneumoniae bacteraemia.MethodWe collected 212 signal-positive blood cultures, with gram-positive cocci in pairs, chains or with uncertain morphology. The BinaxNOW S. pneumoniae urinary antigen test, Gram stain, culture and lytA PCR were performed on all samples. Diagnostic accuracy of the antigen test and Gram stain with gram-positive cocci in pairs were compared with culture, polymerase chain reaction (PCR) and the composite of culture and PCR.ResultsStreptococcus pneumoniae was isolated in 26% of samples, 66% cultured other gram-positive organisms and 8% of samples had no growth. Sensitivity and negative predictive values of the antigen test were 100%, specificity and positive predictive values were 87% – 88% and 76% – 81%, but increased to 93% – 96% and 96% – 98% when applied to subsets with gram-positive cocci in pairs, or history compatible with respiratory illness or meningitis. Sensitivity (69% – 75%) and specificity (81%) of Gram stain (gram-positive cocci in pairs) were lower than the antigen test even when applied to the same subsets.ConclusionAccurate and rapid diagnosis of S. pneumoniae bacteraemia is challenging. Specificity of this antigen test is limited by cross-reactivity with other gram-positive organisms, but could be improved if Gram stain morphology and clinical history are available. The antigen test is a useful adjunct for rapid diagnosis of S. pneumoniae bacteraemia.

HYPHOPICHIA BURTONII: A NOVEL PATHOGEN IN SECONDARY PERITONITIS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: We present a case of secondary peritonitis (SP) due to intestinal infarction from bowel ischemia in a patient with decompensated alcoholic cirrhosis. Differing from spontaneous bacterial peritonitis (SBP) based on presence of a surgically treatable abdominal infectious source, SP is less common than SBP and carries a 3-fold higher risk of in-hospital death (1). CASE PRESENTATION: A 63 year-old man with decompensated alcoholic cirrhosis and a ventral hernia presented to an outside hospital with altered mental status and gastrointestinal bleeding. On hospital day (HD) 1, he underwent esophagogastroduodenoscopy with variceal banding and was treated empirically with piperacillin/tazobactam. On HD 3, paracentesis showed: WBC 4,046 mm3, 96% PMNs, culture positive for Klebsiella pneumoniae and Enterobacter cloacae resistant to piperacillin/tazobactam; he was transitioned to meropenem. He underwent 8.3L paracentesis on HD 7, and was transferred to our hospital on HD 9 for liver transplant evaluation. On arrival, he had stable vitals, West Haven grade III encephalopathy, a ventral hernia, and large ascites without tenderness to palpation. Pertinent labs: WBC 25,600 mm3, Na 156, BUN 78, and Cr 2.07 and MELD-Na of 24. On HD 10, repeat 4.0L paracentesis revealed: WBC 11,385 mm3, 95% PMNs, with cultures growing Candida guilliermondii. Micafungin was initiated and meropenem continued. On HD 13, due to worsening mental status and septic shock, he was transferred to the ICU and intubated. Pertinent labs: WBC 26,800 mm3, Na 140, BUN 98, and Cr 4.09. Repeat paracentesis yielded 2.2L of frank pus, with WBC 18,975 mm3 (no differential), microscopy showed mixed microbiota with budding yeast and gram positive cocci in pairs and chains. Micafungin was continued and daptomycin initiated. CT scan demonstrated ischemic and perforated bowel within the hernia. Despite aggressive measures, he died on HD 14. Among the peritoneal microbiota isolated, Hyphopichia burtonii predominated, speciating 6 days after death. DISCUSSION: To our knowledge, this case of SP due to intestinal infarction represents the first report of Hyphopichia burtonii as a human pathogen. The mixed microbiota on HD 13 raised concerned for SP, prompting a CT scan which revealed intestinal infarction. Notably, our patient exhibited every key sign of SP: polymicrobial peritonitis, a poor response to antibiotics, uptrending PMNs on serial paracenteses, and abnormal imaging findings (2). Hyphopichia burtonii is a species of yeast known as a bread and dairy mold, and part of flora of cured meat. Hyphopichia burtonii has only been reported as the cause of cutaneous mycosis in a bat (3). CONCLUSIONS: We present a case of secondary peritonitis involving Hyphopichia burtonii, a yeast not previously known to be a human pathogen. Reference #1: Lu MLR, et al. Infected ascites: Distinguishing secondary peritonitis from spontaneous bacterial peritonitis in a cirrhotic patient with classic symptoms. IDCases. 2017;8:29-31. Published 2017 Feb 28. doi:10.1016/j.idcr.2017.02.010 Reference #2: Soriano G, et al. Secondary bacterial peritonitis in cirrhosis: a retrospective study of clinical and analytical characteristics, diagnosis and management. J Hepatol. 2010;52(1):39-44. doi:10.1016/j.jhep.2009.10.012 Reference #3: Simpson, V. R., et al (2013). Cutaneous mycosis in a Barbastelle bat (Barbastella barbastellus) caused by Hyphopichia burtonii. Journal of Veterinary Diagnostic Investigation, 25(4), 551–554. https://doi.org/10.1177/1040638713493780 DISCLOSURES: No relevant relationships by Shira Abeles, source=Web Response No relevant relationships by Amy Bellinghausen, source=Web Response No relevant relationships by Erica Feldman, source=Web Response No relevant relationships by Biren Kamdar, source=Web Response No relevant relationships by Irine Vodkin, source=Web Response

S3027 Breast Milk Fistula: An Unusual Complication of Therapy for Gastroparesis

INTRODUCTION: We report an unusual medication related complication that developed in a patient being treated for chronic idiopathic gastroparesis. CASE DESCRIPTION/METHODS: The patient, a 40-year-old female, has a long history of idiopathic gastroparesis. Symptoms have been present for many years and in the past resulted in weight loss and numerous hospital visits. Gastric emptying scans have been markedly abnormal and on endoscopic examination residual old food was always present in the stomach. She had been evaluated for a possible gastric pacemaker and she has had pyloric Botox injections, pyloric dilation and has been treated with metoclopramide and more recently with domperidone for the last few years. She had also had a Nissen fundoplication for chronic reflux associated with gastric stasis. Her condition has remained stable for many months and she has gained weight and not required hospital visits. She presented to a breast surgeon with a recurrent chronic right breast abscess with overlying necrotic skin. Breast exam revealed no nipple discharge at that time, and she went to surgery for exploration, drainage and debridement. One week post procedure she complained of malodorous drainage from the incision and serous drainage was noted on the dressing. Wound culture was obtained and grew rare Streptococcus anginosis. The patient was started on Bactrim and a wick and plain packing was placed. Eleven days later she presented to the emergency room with complaints of malodorous drainage and right breast pain. Ultrasound revealed 3.1 × 0.7 × 3.5 cm complex fluid collection. Culture grew rare gram-positive cocci in pairs. She was treated with clindamycin and discharged home. She was reevaluated by the surgeon and new left nipple drainage was noted. Wound healing remained impaired. This raised the question of a milk fistula. The patient was instructed to stop taking domperidone. Over the next weeks the wound closed and there was no further drainage. She subsequently resumed her domperidone. DISCUSSION: Galactorrhea can be an uncommon side effect of domperidone. In this case it led to an unusual complication of breast wound milk fistula delaying healing of an abscess.

Primary Peritonitis Due to Streptococcus pyogenes

Introduction Primary peritonitis (PP) is peritonitis occurring in patients without underlying causes such as perforated viscus, preexisting ascites, or nephrosis. We report 2 cases of primary Streptococcus pyogenes peritonitis and review the literature on this subject since January 1, 2000. Case Reports Patient 1 was a 45-year-old woman who presented to hospital with fever, diarrhea, and abdominal pain. Examination revealed fever, hypotension, epigastric tenderness, and guarding. Computed tomography (CT) scan was negative for signs of perforated viscus. Workup included blood cultures, parenteral antibiotics, and surgical consult. She underwent emergent operative intervention, which revealed generalized peritonitis, cloudy peritoneal fluid, and no evidence of perforated viscus. Blood cultures revealed S. pyogenes. She underwent an unremarkable recovery on parenteral ceftriaxone followed by oral ampicillin. Patient 2 was a 47-year-old woman who presented to hospital with fever, chills, anorexia, nausea, vomiting, and abdominal pain. Physical examination showed fever, hypotension, tachycardia, and diffuse abdominal tenderness but no rebound tenderness. Abdominal CT scan revealed fluid but no free air. Paracentesis revealed purulent fluid, which on Gram-stained smear showed gram-positive cocci in pairs and chains. Blood and peritoneal fluid cultures were positive for S. pyogenes. Exploratory laparotomy by surgical consultant showed purulent fluid and fibrinous exudate with multiple interloop abscesses and no perforated viscus. Postoperatively, she received parenteral penicillin G, transient hemodialysis, and ventilator support with eventual full recovery. Review of Literature We reviewed the medical literature from January 1, 2000, to December 31, 2016, and found 36 patients with diagnosis of S. pyogenes PP. Despite most of these case reports stating that the occurrence of S. pyogenes PP is “rare,” it seems that it is more common than previously thought. All but 3 patients underwent surgical intervention. All 38 patients presented with physical findings of an acute abdomen. There was no evidence of free air on CT scanning or ultrasound of the 33 patients who underwent one of these imaging techniques. Septic shock was common, and all but 1 patient survived. Conclusions Streptococcus pyogenes PP is more common than previously reported, is associated with physical findings of acute abdomen, is usually accompanied by circulatory shock, and is almost always clinically responsive to treatment with operative and antimicrobial agent interventions.

Eight Years of Antimicrobial Stewardship Program (ASP) at a Large Academic Medical Center: Antibiotic Utilization, Hospital-onset Clostridium difficile infection (HO-CDI) and Resistance Trends

BackgroundAntibiotic (ABX) use and outcome measures (rate of HO-CDI, local antimicrobial resistance) are recommended ASP metrics. These metrics can be used for internal benchmarking to assess ASP performance within an institution over time.MethodsAn adult ASP at our 750-bed academic medical center was implemented in 2008. ASP interventions include prospective audit and feedback, prior authorization with fluoroquinolone (FLQ) restriction as an ASP target and implementation of facility-specific guidelines for common infections. Newer ASP initiatives were Cepheid/Xpert for blood cultures with Gram-positive cocci in pairs and clusters with daily real-time ASP interventions (11/2014), oral vancomycin secondary prophylaxis for patients with prior CDI (4/2014) and optimization of β-lactam (BL) dosing (piperacillin-tazobactam [PTZ] extended infusion hospital-wide 4/2013; cefepime [CEF] 4/2015 and meropenem 7/2015 protocols). ABX use is measured in days of therapy per 1000 patient-days (DOT/1000 PD) and length of therapy/admission when ABX were administered (LOT/ADM). NHSN definition is used for HO-CDI. For resistance trends the first unique isolate/patient/year regardless of source or susceptibility profile was included. Statistical analysis of trends during 8-years period 2009–2016 was performed by Poisson (SAS).ResultsMajor shifts in ABX use include decrease in FLQ use (-17%, P < 0.01) with compensatory increase in ceftriaxone (CTX, +12%, P < 0.01), antipseudomonal BL (+3%, P < 0.01) and no change in carbapenem (+0.6%, P=0.5) as well as an increase in nafcillin and oxacillin (+7%, P < 0.01) use. There was a decrease in aggregate LOT/ADM (-4%, P < 0.01) with no change in DOT/1000 PD. We observed a decrease in HO-CDI rate (-17%, P < 0.01). Major resistance trends include reduction in Enterobacteriaceae spp. and Pseudomonas aeruginosa isolates nonsusceptible (NS) to FLQ (-4%, P < 0.01; -10%, P < 0.01, respectively) with increase in Enterobacteriaceae spp. NS to ceftriaxone, (+3%, P < 0.01). A decrease in P. aeruginosa NS to PTZ (-11%, P < 0.01) and no change for CEF was reported. There was no difference in Enterobacteriaceae spp. NS to PTZ or CEF.ConclusionOverall, reported trends aligned with ASP initiatives. Increased CTX NS is of concern and warrants an ASP-led strategy to decrease CTX use.Disclosures All authors: No reported disclosures.

STREPTOCOCCUS PYOGENES AS THE CAUSE OF VULVOVAGINITIS IN ADULT WOMEN

According to the literature data, Streptococcus pyogenes is the most common cause of infectious vulvovaginitis in prepubertal girls, but it is rarely described in adult women. In this paper we report the prevalence of S. pyogenes vulvovaginitis in adult women in the municipality of Nis, Serbia, in a five-year period. The total of 42.259 women with symptoms of vulvovaginal infection were enrolled in the study and their swabs from the vagina and cervix were examined using the standard microbiological procedures: direct microscopy of Gram stained preparations and sample culture. Women with positive S. pyogenes findings were later contacted to give anamnestic data and for post-treatment control examinations. S. pyogenes was isolated from the samples of 2 patients: in July 2012 in a 20-year-old woman with the anamnesis of a previously diagnosed tonsillopharyngitis, and in May 2015 in a 32-year-old breast-feeding woman. These patients had the signs and symptoms of acute inflammation: vaginal and vulvar pain, dyspareunia, burning sensation, pruritus, and a profuse, watery, yellow vaginal discharge. Gram staining revealed abundant segmented WBCs and gram-positive cocci in pairs and chains. After the administered penicillin therapy, the control microbiological examinations of the vaginal and cervical swabs were done, as well as the throat swab culture for the presence of S.pyogenes, and all the results were negative. Streptococcal vulvovaginitis in adult women was diagnosed in only two examinees in our study and was associated with a predisposing factors: personal history of a respiratory infection and lactational vaginal atrophy.

Bacteraemia Caused by Kytococcus schroeteri in a Pneumonia Patient

The genus Kytococcus are pigmented, non-encapsulated, non-motile, aerobic, catalase-positive, Gram-positive cocci in pairs or tetrads. We report a case of Kytococcus schroeteri isolated from a blood specimen of a patient with pneumonia. The isolate was Gram-variable and difficult to identify using conventional biochemical tests.

First case of pregnant women bacteraemia and probable early-onset neonatal infection due to Aerococcus urinae.

First case of pregnant women bacteraemia and probable early-onset neonatal infection due to Aerococcus urinae.

Growth of Streptococcus pneumoniae on Macconkey Agar: Possibility of Impossible?

Dear Editor Streptococcus pneumoniae (S. pneumoniae) is Gram-positive lanceolate-shaped diplococci which is a significant human pathogenic bacterium causing pneumonia, meningitis and various other infections. It is a fastidious organism and grows well in 5% carbondioxide (CO2) and media containing blood (blood agar, chocolate gar) as growth requires a source of catalase (e.g. blood) to neutralize the large amount of hydrogen peroxide (H2O2) produced by the bacteria [1]. Hence, it does not grow on MacConkey agar (MA) due to the absence of blood as well as due to the presence of high concentration of bile in the medium which is inhibitory to the growth of S. pneumoniae. However, to the best of our knowledge, we are reporting the first and unusual case of S. pneumoniae growth on MA. We received cerebrospinal fluid from a 21-year-old male patient who was admitted with fever, headache, vomiting and clinically had signs of meningitis. Gram stain revealed few pus cells. Biochemical parameters showed decreased glucose, moderately increased protein. Culture revealed pure growth of tiny opaque lactose-fermenting colonies on MA and alpha-haemolytic colonies on blood agar (BA) and chocolate agar (CA). Colony smear from all the three plates showed lanceolate-shaped Gram positive cocci in pairs and short chains. Identification and antibiotic sensitivity testing was done by Vitek-2 compact (BioMerieux) using GPC identification card (GP 21 342) and Streptococcal AST card (AST-ST01) respectively. The organism was identified as Streptococcus pneumoniae which was sensitive to all the antibiotics tested except benzylpenicillin. However, the growth of the isolate on MA created a dilemma and hence the same was sent for identification by MALDI-TOF method. The later identified the isolate as Streptococcus pneumoniae with score value of 2.114. Several studies have highlighted evolving clinical problems with S. pneumoniae. Increasing resistance to antimicrobial agents, and failure of traditional optochin(ethylhydrocupreine) sensitivity had been a growing concern [2]. Dias CA et al., reported the characteristics of four optochin-resistant (Opt(r)) Streptococcus pneumoniae isolates from Brazil. All four Opt(r) isolates presented mutations in the nucleotide sequence coding for the c subunit of F(0)F(1) ATPase [3]. Clinical isolate with intermediate sensitivity to penicillin was first reported in 1967. Since then, penicillin non-susceptible S. pneumoniae has been reported with increasing frequency in many countries.The resistance to penicillin arises from mosaic mutation of penicillin binding protein (PBP) genes due to interspecies recombination of homologous genes [4]. Growth of S. pneumoniae on MA may be a beginning of the changing trend of the organism’s fastidious growth requirements. One of the possible explanations for the same may be some mutation causing alteration in hydrogen peroxide producing capacity of S. pneumoniae and hence bypassing the need for catalase in the media used.Some strains of S. pneumoniae with such mutations have been used in experimental studies to create an environment with low concentration of H2O2 [5,6]. Pericone et al., used loss-of-function mutations of spxB gene in P62 and P878 strains of S. pneumoniae to study the effect of low H2O2 on rate of spontaneous gene mutation. The lower spxB expression resulting in under-expression of pyruvate oxidase results in the lower production of hydrogen peroxide. A spxB-defective pneumococcal mutant produces opaque colony and opaque variants show increased virulence for non-nasopharyngeal infections [5]. In our case also the colony morphology was opaque on MA, and the infection site was meninges. So, these findings provides an assumption that the spx-B mutation can be occurring in the clinical isolates like in our case thus leading to diminished production of hydrogen peroxide and hence not requiring catalase in the growth medium. Due to unavailability of molecular methods at our institution the genetic analysis could not be performed in this case. However, it is advisable that in future if any such scenario is encountered by any institution the genetic analysis could be of great help.

Development of a Treatment Algorithm for Streptococci and Enterococci from Positive Blood Cultures Identified with the Verigene Gram-Positive Blood Culture Assay

Seventy-eight blood cultures with a Gram stain result of Gram-positive cocci in pairs and/or chains were evaluated with the Nanosphere Verigene Gram-positive blood culture (BC-GP) assay. The overall concordance of the assay with culture was 89.7% (70/78 cultures), allowing for the development of a targeted treatment algorithm.

Isolation and characterization of Streptococcus gallolyticus subsp. pasteurianus causing meningitis in ducklings

Increased mortality was observed in a group of 10-day-old ducklings in China in 2010. The dead ducklings were characterized by meningitis, suggesting microbial infection as the cause of disease. Laboratory investigation led to the isolation of a bacterial strain designated as AL101002 from the brain of dead ducklings. Subsequent experimental infections with this strain resulted in marked symptoms in the ducklings similar to those observed in nature outbreaks. Gram-staining revealed Gram-positive cocci in pairs or short chains. Phenotypical analysis revealed the microorganism as Streptococcus pasteurianus. DNA sequencing revealed that the isolate was Streptococcus gallolyticus subsp. pasteurianus. Experimental infection with AL101002 resulted in the death of ducklings with meningitis. To the best of our knowledge, this is the first report of the isolation of S. gallolyticus subsp. pasteurianus with high virulence in ducklings.

Enterovirus Meningitis With Marked Pleocytosis

In neonates and young infants, it can be difficult to distinguish bacterial from aseptic meningitis, especially in the setting of marked CSF (cere-brospinal fluid) pleocytosis. This case series and review of the literature explores the role of early CSF EV-PCR (enterovirus-polymerase chain reaction) in these patients' diagnostic workup, management, and overall hospital stay. Patient 1 was a 30-day-old female who presented with a fever of 102°F and increased irritability for 1 day. She was admitted to the hospital for an evaluation including complete blood cell count (CBC), blood culture, urine culture, urinalysis, and lumbar puncture (LP). Ampicillin, gentamicin, and acyclovir were initiated. Admission laboratory data included peripheral white blood cell (WBC) count of 9200 cells/μL and a normal urinalysis. Cerebrospinal fluid (CSF) was remarkable for pleocytosis of 1005 cells/μL with 53% lymphocytes, 0 red blood cells (RBCs), protein of 92.8 mg/dL, and glucose of 44 mg/dL (Table 1). Gram-stain of the CSF revealed Gram-positive cocci in pairs; however, no bacteria were cultured. Results of the urine culture were negative. The blood culture grew coagulase-negative Staphylococcus, which was believed to be a contaminant. The patient continued to be febrile despite 72 hours of antibiotic therapy. Therefore, a repeat LP was performed, revealing 80 WBC/μL with 63% lymphocytes, 700 RBC/μL, protein of 138 mg/dL, and glucose of 38 mg/dL. Enterovirus-polymerase chain reaction (EV-PCR) performed on the repeat CSF was positive. Herpes simplex virus polymerase chain reaction (PCR) was negative. Antibiotic therapy was discontinued, and the patient was discharged from the hospital. View this table: TABLE 1 Summary of Patient Laboratory Data Patient 2 was a 7-day-old female who presented with fever of 104°F for 1 day and jaundice. She was transferred from a referring hospital after undergoing an evaluation that included CBC, blood culture, urine culture, urinalysis, and LP. Ampicillin, gentamicin, and acyclovir were begun before patient …

Pericardial Abscess: A Rare Complication of Pyogenic Liver Abscess

Massive pericardial effusion from rupture of a hepatic abscess is rare. We report an unusual case of a pericardial abscess caused by a poorly treated hepatic abscess. This is the case of a 60-year old male with exertional dyspnea, intermittent low back pain, occasional low-grade fever; and progressive malaise, anorexia and weight loss. One month prior to admission, an abdominal ultrasound showed a left hepatic abscess. The patient was treated with metronidazole, but had poor compliance. A later two dimensional echocardiogram with doppler showed a massive pericardial effusion with no signs of tamponade. The patient was then referred to the Philippine Heart Center. On physical examination, heart sounds were muffled. Hematology revealed leukocytosis. Electrocardiography showed sinus tachycardia, isolated premature ventricular depolarization, and low-voltage chest leads. Subxiphoid tube pericardiostomy drained one liter of purulent non-foul smelling pericardial fluid. Cytology and chemistry showed an inflammatory process. Gram staining showed pus cells and gram-positive cocci in pairs. The patient was given intravenous (IV) metronidazole 500 mg every 8 hours, and IV ampicillin 1.5 mg every 8 hours. Computerized tomography of the upper abdomen revealed a large abscess at the lateral segment of the left lobe of the liver; hepatic cortical cysts; and minimal pericardial effusion. On the 20th hospital day, the subxiphoid catheter was removed and the patient was discharged. Home medications included oral metronidazole and ampicillin-sulbactam for 2 weeks. The hepatic catheter was then subsequently removed after another 2 weeks.

Neonatal meningitis caused by Streptococcus gallolyticus subsp. pasteurianus

We encountered a case of neonatal meningitis caused by Streptococcus gallolyticus subsp. pasteurianus. The patient was an 8-day-old boy. Gram staining of the cerebrospinal fluid (CSF) revealed gram-positive cocci in pairs or in short chains. In culture, γ-streptococcus-like colonies grew. The result of 16S rRNA sequence analysis identified S. gallolyticus subsp. pasteurianus. From these results, bacterial meningitis was diagnosed and, as a result of antimicrobial susceptibility testing, single-dose ampicillin therapy was given. Because inflammatory deterioration and spread was suspected from the CSF test results, this therapy was added by panipenem/betamipron. In response to his recovery, antibiotic treatment was stopped and the boy was discharged. This bacterium was classified as S. gallolyticus subsp. pasteurianus in the latest report in 2003. Since this change, there have only been a few cases of neonatal meningitis caused by this bacterium. Here we report this rare case.