The Conundrum of the Gram-Positive Rod: Are We Missing Important Pathogens in Complicated Skin and Soft-Tissue Infections? A Case Report and Review of the Literature

Skin abscess caused by Trueperella bernardiae: Case report and literature review

We investigated a skin abscess caused by Trueperella bernardiae in a patient with comorbidities. Initial empirical therapy with Clindamycin did not yield a response, and follow-up culture revealed the presence of T. bernardiae through MALDI-TOF and NGS. Since no CLSI or FDA breakpoints have been published for this strain, resistant gene screening of the genetic sequence showed the presence of the erm(X) gene (with 95 % identity). This gene confers resistance to erythromycin, clindamycin, lincomycin, pristinamycin, quinupristin, and virginiamycin. Subsequent therapy with oral amoxicillin/clavulanate led to complete healing.

An Otogenic Variant of Lemierre's Syndrome Caused by Trueperella bernardiae: A Case Report and Literature Review

Upper airway infections caused by anaerobic bacteria, including pharyngitis and tonsillitis, are a common cause of septic thrombosis (Lemierre's syndrome). Although otitis media rarely progresses to systemic infection, an abscess surrounding the middle ear can affect the central nervous system. Trueperella bernardiae was originally considered a non-pathogenic aerobic bacterium but has subsequently been reported to cause bacteremia and brain abscesses. Here, we report a case of otitis media caused by T. bernardiae complicated by meningitis, subdural empyema, and septic pulmonary emboli in an immunocompetent patient.

Sepsis following acute pyelonephritis caused by Trueperella bernardiae: a case report and literature review

BACKGROUND

Trueperella bernardiae is a coryneform, gram-positive bacterium that is a commensal of the skin and upper respiratory tract. It is treated as a contaminant and rarely causes infections. Blood, urine, and abscesses have been previously reported as the most common sites of infection. Infections caused by T. bernardiae are rarely reported in bedridden very old patients with reduced activities of daily living (ADL). In this report, we describe a case of sepsis due to acute pyelonephritis caused by T. bernardiae in a very old patient with impaired ADL.

CASE PRESENTATION

A 94-year-old woman had a home visit from her local physician. She was bedridden and used diapers. On the day of admission, she presented with fever and dyspnea and was admitted with a diagnosis of sepsis associated with acute pyelonephritis. T. bernardiae was detected in blood and urine cultures; furthermore, multiple bacteria were detected in a urine culture. She was treated with ampicillin/sulbactam 3 g every 12 h on the day of admission. The fever was controlled, and inhaled oxygen 1 L/min via a nasal cannula was administered for dyspnea until hospitalization day 2. On hospitalization day 2, her fever resolved to 36 °C. Antimicrobials were de-escalated and changed to cephazolin and then to cephalexin on hospitalization days 9 and 16, respectively, and were continued until day 22. On hospitalization day 28, the urinary tract infection flared up; however, her fever resolved by hospitalization day 38 after the re-administration of antimicrobial agents. She was discharged on hospitalization day 60.

CONCLUSIONS

We encountered a rare case of sepsis following acute pyelonephritis caused by T. bernardiae infection. When bedridden, diaper-using, very old patients present with urinary tract infections caused by multiple bacteria, the presence of rare opportunistic organisms, such as T. bernardiae, should be considered.

Trueperella bernardiae bloodstream infection following onco-gynaecologic surgery and literature review

Trueperella bernardiae is a Gram-positive commensal bacillus of the human skin and oropharynx. It is known as an opportunistic human pathogen causing surgical wound, skin, and soft tissue, osteoarticular, and bloodstream infections (BSIs) with severe complications. We report a case of surgical wound related T. bernardiae BSI following onco-gynaecologic surgery together with a comprehensive literature review of T. bernardiae infections to alert clinicians about this emerging pathogen.

Trueperella bernardiae: first report of wound infection post laparoscopic surgery

We report the first case of wound infection caused by Trueperella bernardiae after laparoscopic surgery. The patient was treated with oral amoxicillin/clavulanate which was continued for 1 week after discharge with a successful clinical response. There are few cases described but none related to wound infection after laparoscopic surgery.

Prosthetic joint infection caused by Trueperella bernardiae

Trueperella bernardiae is a Gram-positive coryneform bacilli which role as human pathogen is unknown because it has been usually considered a contaminant. Furthermore its identification by biochemical test was difficult. We describe a prosthetic joint infection in a women who years ago underwent a total knee replacement with superinfection and necrosis of the patellar tendon as major complications. In the sample of synovial fluid collected grew a gram-positive bacilli which was identified by matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) as T. bernardiae. The patient was treated with ciprofloxacin and currently preserves the prosthesis without signs of infection.

Deep Spine Infection After Acupuncture in the Setting of Spinal Instrumentation

BACKGROUND

Acupuncture can be used to manage chronic pain. The most common complications related to acupuncture include pain, bruising, bleeding, or symptom exacerbation. Rarely, more serious adverse events occur, including infection, pneumothorax, septic arthritis, and peripheral nerve injury. To our knowledge, there are no reports of complications associated with acupuncture following spinal instrumentation.

PURPOSE

To report a case of deep infection as a rare complication of acupuncture following posterior spinal fusion for adolescent idiopathic scoliosis.

STUDY DESIGN

Case report.

METHODS

Case report.

RESULTS

A 15-year-old female presented 21 months after spinal arthrodesis for idiopathic scoliosis with a deep spine infection. The patient had recently been receiving a variation of acupuncture (dry needling therapy) in her medial periscapular region to manage chronic back and shoulder pain. She underwent serial irrigation and debridement with implant removal. Intraoperative cultures revealed pseudomonas and aerobic diptheroids. Two weeks later, the patient developed a periscapular abscess requiring additional operative debridement; cultures from this abscess were negative. After an 8-week course of antibiotics, the patient remains infection free with normalized inflammatory markers 2 years postoperatively.

CONCLUSIONS

Acupuncture is sometimes pursued as part of a multimodality pain management program for back pain, but it is not without risk and can lead to infection. Deep infection from acupuncture may contaminate existing spinal instrumentation and require operative debridement, implant removal, and long-term antibiotic therapy. Accordingly, there is an increased risk for deformity progression in this scenario related to the implant removal.

Draft Genome Sequence of Trueperella bernardiae LCDC 89-0504T, Isolated from a Human Blood Culture

We report here the draft genome sequence of Trueperella bernardiae LCDC 89-0504(T), an organism linked to mild to severe infections in humans and animals. The genome size is 2,028,874 bp, with a G+C content of 65.44%. Annotation of the genome revealed 5 rRNA sequences, 48 tRNA genes, and 1,762 coding sequences.

Necrotizing soft tissue infections: delayed surgical treatment is associated with increased number of surgical debridements and morbidity

BACKGROUND

Early surgical treatment is crucial in the management of necrotizing soft tissue infections (NSTI), a severe, potentially life threatening, rapidly progressive infection. The purpose of this study was to determine the influence of surgical procedure timing on the number of surgical debridements required.

METHODS

A retrospective study including 47 patients with the diagnosis of NSTI admitted to a large academic hospital from December 2004 to December 2010 was conducted. Demographics, basic laboratories on admission, medical comorbidities, site of infection, and intraoperative culture results were compared between patients with early (≤12 hour) and late (>12 hour) surgical treatment. The x-y plot for the study population and linear regression analyses were used to define the time cut point. Outcomes included the total number of debridements, mortality, hospital length of stay, and complications. Adjustment for confounding factors was done with binary regression logistic model for categorical outcomes and analysis of covariants for continuous outcomes.

RESULTS

Overall mortality was 17.0%. The average number of surgical debridements in patients with delay surgical treatment >12 hours from the time of emergency department admission was significantly higher than those who had an operation within 12 hours after admission (7.4 ± 2.5 vs. 2.3 ± 1.2; p < 0.001). Delayed surgical debridement was associated with significantly higher mortality, higher incidence of septic shock and renal failure, and more surgical debridements than patients with early surgical debridements. After adjusting for possible confounding factors, the average number of surgical debridements and the presence of septic shock and acute renal failure were still significantly higher in patients in whom surgery was delayed >12 hours.

CONCLUSION

In patients with NSTI, a delay of surgical treatment of >12 hours is associated with an increased number of surgical debridements and higher incidence of septic shock and acute renal failure.

Clinical impact of the use of 16S rRNA sequencing method for the identification of "difficult-to-identify" bacteria in immunocompromised hosts

Molecular method of 16S rRNA sequencing is reported to be helpful in the accurate identification of organisms with ambiguous phenotypic profiles. We analyzed the use of 16S rRNA sequencing method to identify clinically significant, "difficult-to-identify" bacteria recovered from clinical specimens, and evaluated its role in patient management and consequent clinical outcome. Among the 172 "difficult-to-identify" bacteria recovered over a 4-year period, 140 were gram-positive cocci or gram-negative bacilli; identification by 16S rRNA did not play a role in the management of patients infected with these bacteria. From 32 patients, 33 "difficult-to-identify" gram-positive bacilli were identified; the organisms were mycobacteria, Nocardia, Tsukamurella, Rhodococcus, and Gordonia. In 24 patients for whom clinical data were available, results from the 16S rRNA sequencing method led to treatment change in 14 immunocompromised patients (including 7 hematopoietic stem cell recipients and 1 liver transplant recipient). Therapy was modified in 9 patients, initiated in 3 patients, and discontinued in 2 patients. Most patients' therapy was switched to oral antibiotics with discontinuation of intravascular catheters, facilitating early hospital discharge. All 14 patients were alive 30 days after infection onset. The present study demonstrates the clinical application of 16S rRNA sequencing method to identify "difficult-to-identify" mycobacteria and other gram-positive bacilli in clinical specimens, particularly in immunocompromised hosts.

Actinobaculum schaalii causing Fournier's gangrene

Actinobaculum schaalii, which belongs to the group of Gram-positive rods, is difficult to culture. Using molecular genetics, Actinobaculum schaalii could be identified as a causing microorganism in a case of Fournier's gangrene.

Infected giant ophthalmic artery aneurysm remnant following craniotomy for surgical clip ligation. Case report

Postoperative intracranial infections, although found in only a minority of surgical cases, remain a recognized potential complication following elective craniotomy. In the treatment of intracranial aneurysms, specifically, reports of significant postoperative infections are rare. Significant postoperative infections are usually observed in association with foreign bodies, such as aneurysm clips, endovascular coils, or materials used for aneurysm wrapping. The authors present a case in which a patient underwent craniotomy for surgical clip ligation of a giant ophthalmic artery aneurysm without resection of the aneurysm mass; the patient then presented again approximately 4 months later with a first-time seizure. Following a second craniotomy for resection of the aneurysm mass, the aneurysm contents were noted on pathological examination to contain gram-positive rods, and the aneurysm wall was noted to contain inflammatory cells. Although cultures were not obtained, Propionibacterium acnes was detected using polymerase chain reaction. To the best of the authors' knowledge, this case represents the second reported case of an intraaneurysmal abscess and the first reported instance of a presumed secondary infection of a giant intracranial aneurysm remnant following surgical clip ligation.