Postoperative Chryseobacterium indologenes Bloodstream Infection Caused by Contamination ofDistillate Water • Author(s): Mehmet Refik Bayraktar , PhD; Elif Aktas , MD; Yasemin Ersoy , MD;Aysegul Cicek , MD; Riza Durmaz , PhDSource: Infection Control and Hospital Epidemiology, Vol. 28, No. 3 (March 2007), pp. 368-369Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/508839 .

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infection control and hospital epidemiology march 2007, vol. 28, no. 3

c o n c i s e c o m m u n i c a t i o n

Postoperative Chryseobacteriumindologenes Bloodstream InfectionCaused by Contaminationof Distillate Water

Mehmet Refik Bayraktar, PhD; Elif Aktas, MD;Yasemin Ersoy, MD; Aysegul Cicek, MD;Riza Durmaz, PhD

Chryseobacterium indologenes was isolated from blood samples froma 5-month-old infant with bloodstream infection. Environmentalsampling was performed. Molecular typing with arbitrarily primedpolymerase chain reaction demonstrated the cross-contamination ofcommercial distillate water. The infant was infected by this water asa result of medical assistance received during hospitalization.

Infect Control Hosp Epidemiol 2007; 28:368-369

Chryseobacterium indologenes is a nonfermentative, non-motile, indole- and oxidase-positive, and glucose-oxidizinggram-negative bacillus. It is widely distributed in nature (eg,in soil, water, plants, and foodstuffs), and it is an infrequenthuman pathogen rarely associated with bacteremia and men-ingitis in hospitalized patients.1 In the hospital environment,it was frequently recovered from wet surfaces and water sys-tems, as well as from numerous clinical human specimens.2

In this study, we aimed to perform an epidemiological in-vestigation to determine the source of infection after isolationof C. indologenes from a patient in a pediatric surgery ward.

methods

A 5-month-old male patient with Down syndrome underwentan operation for atrial septal defect and diaphragmatic hernia.The patient was followed-up in the intensive care unit, andhe received mechanical ventilation. He was given empirictreatment with ceftriaxone and amphotericin B because hehad a high fever and because there were frequent Candidainfections in the unit. On day 7 after the operation, the patientdeveloped signs of sepsis and lung infection. A tracheal as-piration sample and 3 blood samples were taken. Culture ofthe blood samples yielded C. indolegenes. The treatment waschanged to vancomycin and ofloxacin therapy. Unfortunately,the patient died on day 11 of treatment.

Specimens for culture were obtained with the aid of theinfection control staff of the hospital. Samples were takenfrom the feeding bottle that was used for the patient, thecommercial distillate water in the patient’s room, tap water,the nasogastric tube, water faucets, and various surfaces inthe patient’s hospital room.

The Bactec 9120 blood culture system (BD Becton Dick-

son) was used for culture of blood samples. The other clinicaland environmental samples were inoculated on 5% sheepblood or eosine methylene blue agar. The identification ofthe infectious agent was made with conventional biochemicaltests, as well as with API 20NE (bio-Merieux) and BD Phoenix(Phoenix) automated systems, which have identificationprobability values of 99.9% and 99%, respectively. Minimalinhibitory concentrations (MICs) of vancomycin and imi-penem were determined overnight with the E-test (AB Bio-disk; Dalvagen) by use of Muller Hinton agar with a 0.5-McFarland bacterial suspension, which has been proven tobe an alternative to the standard agar dilution method.3 In-terpretation of quantitative MIC results was in accordancewith Clinical and Laboratory Standards Institute criteria.4

The molecular epidemiological relatedness of the isolateswas evaluated by arbitrarily primed polymerase chain reaction(PCR). DNA isolation was performed following the protocolof Welsh and McClelland.5 Arbitrarily primed PCR was per-formed with M13 primer.6

results

All blood cultures yielded C. indologenes. C. indologenes wasalso isolated from the feeding bottle of the patient, hospitaltap water, commercial distillate water, the washbasin faucetin the patient’s room, the washbasin faucet in the pediatricsward, and the nasogastric tube. Samples from unopened com-mercial distillate water tanks did not yield any bacterial growth.

Although there is no standard method for determiningvancomycin resistance among gram-negative bacteria, MICvalues for vancomycin and imipenem were 164 mg/mL and0.5 mg/mL, respectively. The patterns from arbitrarily primedPCR of the isolates from the patient’s blood, the feedingbottle, and the commercial distillate water (used for preparingthe feeding solution) were identical, indicating epidemiolog-ical relatedness among these isolates (Figure).

discussion

Although C. indologenes is widely distributed in nature, it isa rare human pathogen. It has been isolated from clinicalspecimens but rarely from blood.1 It has been documentedto cause a variety of invasive infections, especially in hospi-talized patients with severe underlying diseases or indwellingdevices.7 Transmission via nosocomial tap water has beenreported.8 The highest prevalence of C. indologenes was re-ported among elderly individuals, and the antimicrobialsmost active against it were garenoxacin, gatifloxacin, and le-vofloxacin, whereas vancomycin showed poor potency.9 Nos-ocomial bacteremia is usually associated with high mortalityunless it is successfully treated. C. indologenes is usually re-sistant to imipenem because of constitutive production of b-lactmase, despite the susceptibility the isolate in our study

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postoperative c. indologenes bloodstream infection 369

figure. Genetic patterns of Chryseobacterium indolegenes isolatesobtained by typing with arbitrarily primed polymerase chain reac-tion. Lane 1, isolate from blood; lane 2, isolate from feeding bottle;lane 3, isolate from hospital tap water; lane 4, isolate from com-mercial distillate water; lane 5, isolate from washbasin faucet inpatient’s room; lane 6, isolate from washbasin faucet in pediatricward; lane 7, isolate from nasogastric tube; lane 8, marker.

showed in repeated E-tests.10 Vancomycin and b-lactam an-tibiotics are not satisfactory therapeutic choices for Chryseo-bacterium infections. The patient’s death was probably the re-sult of improper treatment with vancomycin and ceftriaxone.

In our study, identical genetic relatedness was documentedamong isolates from the patient’s blood, the feeding bottle,and the commercial distillate water. This indicates cross-in-fection. The findings suggest that contamination of the dis-tilled water could have occurred after the container wasopened, because the unopened distillate water did not harborthe organism. The organism was also isolated from manyenvironmental samples, including the nasogastric tube. Thenasogastric tube is routinely washed and irrigated with steriledistilled water, but it was mistakenly washed with tap waterby a new nurse in training. This may explain the identificationof an isolate from the tap water sample; however, the organ-ism was not isolated from aspirate samples from the patient.The tap water contamination may have been caused by dis-infection regimens (chlorination and UV treatment) used atwater depots of our university or addition of ozone to waterin the hospital water system. The relatively high frequency ofisolation of the organism and the documentation of cross-contamination suggest that the hospital staff should betteradhere to infection control measures. For this reason, mul-

tiple meetings with clinicians, nurses, and other healthcarepersonnel were held, and they were educated about imple-mentation of infection control measures, particularly handwashing and the use of hand antiseptics. Since then, no newinfections have been recorded.

In conclusion, a distillate water tank was shown to be thesource of C. indologenes that caused a blood stream infection.The spread of the organism was the result of limited educationof the hospital staff and incomplete adherence to infectioncontrol measures.

From the Department of Medical Microbiology (M.R.B., E.A., A.C., R.D.)and the Department of Infectious Diseases (Y.E.), Faculty of Medicine, InonuUniversity, Malatya, Turkey. (Present affiliation: Department of Medical Mi-crobiology, Faculty of Medicine, Zonguldak Karaelmas University, Zongul-dak, Turkey [E.A.].)

Address reprint requests to Mehmet Refik Bayraktar, PhD, Dept. of MedicalMicrobiology, Faculty of Medicine, Harran University, Sanliurfa, Turkey(mrtmehmet@yahoo.com).

Received July 8, 2005; accepted April 17, 2006; electronically publishedFebruary 7, 2007.

� 2007 by The Society for Healthcare Epidemiology of America. All rightsreserved. 0899-823X/2007/2803-0021$15.00. DOI: 10.1086/508839

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