Vol. 17, No. 13
THE JOHNS HOPKINS MICROBIOLOGY NEWSLETTER
Monday, March 30, 1998
A. Provided by Marguerite Hawkins, Epidemiology and Disease Control Program, Division of Outbreak Investigation, Maryland Department of Health and Mental Hygiene
From March 19, 1998 through March 25, 1998, 4 outbreaks have been reported to the Maryland Department of Health and Mental Hygiene as follows: 2 presumed food-related gastroenterities, one pneumonia and one sepsis.
B. The Johns Hopkins Hospital: Information provided by Dr. Frank Holmes, Dept. of Pathology
A 47 year-old male, who is HIV-positive and an intravenous drug user, was admitted after developing seizures at home. His last CD4 count was 225. He was diagnosed with cryptococcal meningitis, Staphylococcus epidermidis endocarditis, and an aspiration pneumonia, requiring intubation. During his long hospitalization, he was placed on multiple antibiotics but continued to have persistent fevers. Blood cultures taken from his central venous line grew corynebacterium jeikeium. The organism was sensitive to vancomycin but resistant to penicillin, ampicillin, cefazolin, clindamycin, erythromycin, and oxacillin.
One of the most clinically important species of Corynebacterium to isolate and identify in the microbiology laboratory, other than C. diphtheriae, is C. jeikeium. In 1976, Hande et al. reported cases of severe sepsis in three hematologic patients with profound neutropenia and one patient with a ventricular CSF shunt, caused by a coryneform bacterium that was highly resistant to multiple antibiotics. Subsequently, additional cases were described in patients undergoing allogeneic bone marrow transplantation. In 1979, this pathogen was further characterized by the CDC in Atlanta and designated as group JK. Later this was changed to C. jeikeium. Other reports have documented that this organism can cause a wide variety of infections, including bacterial endocarditis (most commonly involving a prosthetic valve), cavitating or noncavitating pneumonia, CSF shunt infections, osteomyelitis, liver abscesses, peritonitis (usually in patients undergoing peritoneal dialysis), skin infections, and surgical wound infections.
Factors that predispose patients to infections with C. jeikeium include prolonged hospitalization, profound neutropenia, exposure to multiple antibiotics, and skin disruption, either surgically or by the presence of an indwelling catheter. Most patients with C. jeikeium are probably colonized before becoming infected. Although C. jeikeium is not usually found in the skin flora of healthy, nonhospitalized patients, it is commonly encountered in the skin flora of hospitalized patients, especially those treated with antibiotics. Body sites most commonly positive in cases of colonization are the groin, axilla, and rectum. The most important risk factor for infection in colonized patients is the presence of a device, such as a central venous catheter, ventricular CSF shunt, CAPD catheter, or prosthetic heart valve. These bacteria are also potential causes of serious nosocomial infections in immunocompromised hosts (for example, patients with hematologic or oncologic disorders receiving chemotherapy, bone marrow transplant recipients with central venous catheters, and patients with AIDS), although not all infected patients are immunocompromised.
Approximately one-fourth of patients with C. jeikeium infections have skin lesions, usually in those patients with severe neutropenia. The skin manifestations can take the form of either focal lesions in areas of skin disruption or, less commonly, papular eruptions over the trunk, extremities, or face in patients with C. jeikeium septicemia. Pulmonary lesions are reported in about one-third of patients. The mortality rate from the infection in neutropenic patients is high. Bone marrow recovery appears to be very important for a favorable outcome. However, other infected patients, such as those with infected CSF shunts and CAPD peritonitis, do not usually die and are easily treated with appropriate antibiotic therapy.
In gram-stained smears, C. jeikeium isolates are pleomorphic, non-spore-forming, gram-positive rods that vary from short coccobacilli to long bacillary forms. The organisms are non-motile. C. jeikeium is one of the lipid-requiring species of Corynebacterium. A negative test for nitrate reduction, a negative urease test, acid production from glucose, and, importantly, resistance to many antibiotics are additional key characteristics of this species.
Vancomycin is the treatment of choice. It is also advisable to replace any central venous line. The main reason why C. jeikeium is so important clinically is its resistance to multiple antibiotics. In most studies, the majority of C. jeikeium isolates were reported to be susceptible to vancomycin but resistant to most antibiotics that are commonly used to treat infections involving gram-positive bacteria.
Brown AE: Other corynebacteria and Rhodococcus. In Mandell GL, Bennett JE, Dolin R (eds): Principles and Practice of Infectious Diseases, vol 2 (4th ed.), pp 1872-1880. New York, Churchill Livingstone, 1995.
Hande KR, Witebsky FG, Brown MS, et al. Sepsis with a new species of Corynebacterium. Ann Intern Med 85: 423-426, 1976.
Van Der Lelie H, Leverstein-Van Hall M, Mertens M, et al. Corynebacterium CDC Group JK (Corynebacterium jeikeium) Sepsis in Haematological Patients: A Report of Three Cases and a Systematic Literature Review. Scand J Infect Dis 27: 581-584, 1995.