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case reports  Ventilator-associated pneumonia

c a s e  r e p o r t s

Ventilator-associated pneumonia due


to Shewanella putrefaciens
Calvin Tucker, Genelyn Baroso, and Paul Tan

S
hewanella putrefaciens, also
known as Pseudomonas putre- Purpose. The first reported U.S. case of veolar lavage culture performed that day
faciens, is an aquatic, gram- ventilator-associated pneumonia evi- revealed the presence of S. putrefaciens.
dently caused by Shewanella putrefaciens According to the culture and susceptibil-
negative bacillus of the family Al-
is described. ity results, S. putrefaciens was resistant to
teromonadaceae. 1 S. putrefaciens Summary. A 39-year-old man with severe ampicillin–sulbactam and exhibited sensi-
is commonly found throughout head trauma was found face down and tivity to cefepime, piperacillin, piperacillin–
nature. Sources include marine unresponsive in a river after a watercraft ac- tazobactam, gentamicin, ciprofloxacin,
environments, soil sources, natural cident. After being resuscitated and trans- levofloxacin, and meropenem. The patient
energy reserves (oil and gas), and ferred to the intensive care unit, the patient received a 14-day course of cefepime, elim-
food products (i.e., beef, poultry, received treatment for a subarachnoid inating any further sign of the pathogen.
hemorrhage and spinal injuries. The patient Over the next two months, the patient’s
and dairy). S. putrefaciens is one
was also found to have decreased breath condition continued to improve, and he
of the main bacteria that causes sounds bilaterally. On hospital day 7, bron- was eventually discharged to a rehabilita-
seafood spoilage and is important choalveolar lavage was performed due to tion facility.
in the turnover of organic mate- acute febrile illness and thick pulmonary Conclusion. A 39-year-old man developed
rial. This species is also capable of secretions. The patient was treated em- ventilator-associated pneumonia evidently
reducing various metals, nitrates, pirically with i.v. vancomycin and cefepime. caused by S. putrefaciens. The pneumonia
thiosulfate, and trimethylamine- The culture results suggested pneumonia resolved after treatment with cefepime.
due to methicillin-sensitive Staphylococcus
N-oxide.2 S. putrefaciens is not a
aureus and colonization with Pseudomonas Index terms: Antiinfective agents;
common human pathogen, with aeruginosa. The vancomycin and cefepime Cefepime; Cephalosporins; Gram negative
most human isolates occurring as were replaced with nafcillin, after which bacterial infections; Pneumonia; Resis-
mixed flora obscuring any clinical the pneumonia resolved. The patient con- tance; Shewanella putrefaciens; United
significance.3-5 However, it has been tinued to be febrile, with leukocytosis on States; Ventilators
implicated in several illnesses, in- hospital day 14. A subsequent bronchoal- Am J Health-Syst Pharm. 2010; 67:1007-9
cluding bacteremia, otitis media,
and soft tissue infections.4-8 To our
knowledge, there has been only
one published report of ventilator-
associated pneumonia caused by Case report when he arrived at a local hospital.
S. putrefaciens.1 Isolation of this bac- A 39-year-old man with severe He had been intubated and had a
teria from the lower respiratory tract head trauma was found face down cervical collar with inline stabiliza-
has never been reported in the United in a river after a watercraft accident. tion in place. Mechanical ventilation
States. We describe such a case. He was unresponsive and cyanotic was started upon arrival to the hosp-

C alvin T ucker , P harm .D., is Pharmacy Practice Resident; 32209 (pharmdcet@gmail.com).


Genelyn Baroso, Pharm.D., is Transitional Care Practitioner; The authors have declared no potential conflicts of interest.
and Paul Tan, Pharm.D., FASHP, is Surgical Intensive Care Unit
Practitioner, Department of Pharmacy, Shands Medical Center— Copyright © 2010, American Society of Health-System Pharma-
Jacksonville, Jacksonville, FL. cists, Inc. All rights reserved. 1079-2082/10/0602-1007$06.00.
Address correspondence to Dr. Tucker at the Department of Phar- DOI 10.2146/ajhp090344
macy, Shands Medical Center, 655 West 8th Street, Jacksonville, FL

Am J Health-Syst Pharm—Vol 67 Jun 15, 2010 1007


case reports  Ventilator-associated pneumonia

tial. He was transferred to Shands replaced with nafcillin 2 g (as the Greater than 80% of the isolates
Jacksonville Hospital with a reported sodium salt) i.v. every 4 hours for from humans are attributable to
Glasgow coma scale score of 3t/15. 8 days; after which the pneumonia S. algae.2,5,7
Oxygen saturation was approxi- resolved. Identification systems used by
mately 80%, his blood pressure was The patient continued to be fe- most laboratories are unable to
109/68 mm Hg, and he was display- brile, with leukocytosis on hospital distinguish between S. putrefaciens
ing signs of hypotension and respira- day 14. His antibiotic therapy was and S. algae. There have been many
tory failure. He was resuscitated and, broadened, requiring cefepime (2 g instances of an isolate initially being
once stabilized, transferred to the [as the hydrochloride salt] i.v. every identified as S. putrefaciens but prov-
surgical intensive care unit. Cerebral 12 hours) to be resumed to cover ing to be S. algae after further test-
computed tomography revealed a possible P. aeruginosa pneumonia. A ing. The experience and familiarity
diffuse subarachnoid hemorrhage, subsequent BAL culture performed of the microbiology laboratory with
and radiograph of the cervical spine that day revealed the presence of Shewanella species can aid in the
revealed craniocervical dislocation. S. putrefaciens. According to the identification of S. putrefaciens
The patient was sedated and para- culture and susceptibility results, isolates. The microbiology staff at
lyzed, and seizure prophylaxis with S. putrefaciens was resistant to Shands Jacksonville Hospital has had
levetiracetam was initiated due to ampicillin–sulbactam and exhibited experience identifying S. putrefaciens,
traumatic brain injury. Auscultation susceptibility to cefepime, piperacil- providing some assurance that the
revealed that the lungs were clear lin, piperacillin–tazobactam, gen- identification of the pathogen was
and equal, with decreased breath tamicin, ciprofloxacin, levofloxacin, accurate.
sounds bilaterally. The patient had and meropenem. The cefepime Clinical syndromes attributable to
no known drug allergies and a already being used was considered S. putrefaciens and S. algae display no
medical history significant only for sufficient treatment for the S. putre- significant differences and are similar
hypertension. faciens infection. Subsequent blood to infections caused by species of the
During the next two weeks, the and BAL cultures obtained on days genus Vibrio.2,5,6 Clinical syndromes
patient remained in critical condi- 20 and 22 showed no sign of infec- commonly described in the literature
tion, with the primary concern being tion. During this period, the pa- are skin and soft tissue infections
his brain and spinal injuries. During tient’s respiratory function remained associated with damage to the skin
this period, the patient experienced stable, and the ventilator settings (e.g., trauma, cuts, scrapes, ulcers);
multiple complications, including remained unchanged. Over the next otitis media, mostly in children dur-
a pulmonary embolism requiring two months, the patient’s condition ing the summer when contact with
an inferior vena cava filter, acute continued to improve, and he was seawater is high; and bacteremia,
renal failure requiring hemodialysis, eventually transferred out of the in- which is usually benign.4,5 Neither
respiratory failure, anemia, chronic tensive care unit and discharged to a S. algae nor S. putrefaciens is com-
diarrhea, and recurrent bacterial rehabilitation facility. monly found in the lower respiratory
infections in the blood and lungs. tract. S. putrefaciens is well adapted to
Throughout this period, the patient’s Discussion the conditions of devitalized necrotic
ventilation remained stable, with a Human infections with Shewanel- tissue in which it has shown the abili-
pressure support ventilation setting la species are rare. Most cases have ty to multiply and chronically persist,
of 12 cm H2O, fraction of inspired occurred in geographic areas with usually in necrotic skin or leg ulcers.1
oxygen of 40%, and positive end- temperate to warm climates, such In rare cases, Shewanella species has
expiratory pressure of 5 cm H2O. as the United States, Australia, Asia, been known to cause osteomyelitis,
On hospital day 7, a bronchoal- South Africa, and southern Europe.5 usually due to trauma that results in
veolar lavage (BAL) was performed The clinical significance of these breaches of the skin, such as in frac-
due to acute febrile illness and thick organisms in humans has often tures.9 Respiratory colonization with
pulmonary secretions. The patient been obscured due to their frequent the possibility of infection has been
was treated empirically with i.v. van- occurrence as part of mixed flora identified in rare cases from isolates
comycin and cefepime. The culture in cultures.1,3-5 However, a number cultured from sputum and pleura
results suggested pneumonia due to of monomicrobial infections have and transthoracic needle aspiration
methicillin-sensitive Staphylococ- been reported, exhibiting the patho- cultures.1
cus aureus (>100,000 colonies/mL) genic capability of the Shewanella Ventilator-associated pneumonia
and colonization with Pseudomonas species.1,4,9 The only Shewanella spe- usually develops more than 48 hours
aeruginosa (20,000 colonies/mL). cies found in clinical specimens are after endotracheal intubation and
The vancomycin and cefepime were S. putrefaciens and Shewanella algae. mechanical ventilation.5 It is likely

1008 Am J Health-Syst Pharm—Vol 67 Jun 15, 2010


case reports  Ventilator-associated pneumonia

that S. putrefaciens was introduced to was susceptible and which eventually gene sequence analysis. Appl Environ
Microbiol. 1997; 63:2189-99.
our patient’s respiratory tract during eradicated it. In the previous case, it 3. Bulut C, Ertem GT, Gokcek C et al. A rare
his exposure to river water. Nosoco- took 38 days after the supposed ex- cause of wound infection: Shewanella
mial pneumonia is usually associ- posure for manifestation of a positive putrefaciens. Scand J Infect Dis. 2004;
ated with microbes common to the culture for S. putrefaciens.1 In that 36:692-4.
4. Yilmaz G, Aydin K, Bektas D et al. Cer-
hospital setting, such as S. aureus and case and in ours, the resolution of ebellar abscess and meningitis, caused
P. aeruginosa.10 Since the patient’s signs and symptoms of pneumonia by Shewanella putrefaciens and Klebsiella
pneumonia occurred two weeks after with antibiotic treatment is evidence pneumoniae, associated with chronic otitis
media. J Med Microbiol. 2007; 56:1558-60.
the initiation of mechanical ventila- of the pathogenicity of the isolates. It 5. Holt HM, Gahrn-Hansen B, Bruun B.
tion, it is reasonable to categorize it is fortunate that Shewanella was sus- Shewanella algae and Shewanella putrefa-
as a ventilator-associated pneumo- ceptible to common antibiotics. In ciens: clinical and microbiological char-
acteristics. Clin Microbiol Infect. 2005;
nia. Ventilator-associated pneumonia our patient, S. putrefaciens exhibited 11:347-52.
has only been attributed to S. putre- resistance to ampicillin–sulbactam. 6. Oh HS, Kum KA, Kim EC et al. Outbreak
faciens in one other case (in Antwerp, In one report, only 38% of skin and of Shewanella algae and Shewanella pu-
trefaciens infections caused by a shared
Belgium) in which the mode of ex- soft tissue isolates were susceptible to measuring cup in a general surgery unit
posure could not be established, and ampicillin.1 in Korea. Infect Control Hosp Epidemiol.
the infection became apparent after 2008; 29:742-8.
Conclusion 7. Pagani L, Lang A, Vedorelli C et al. Soft
several weeks of hospitalization.1 tissue infection and bacteremia caused by
S. putrefaciens is commonly found in A 39-year-old man developed Shewanella putrefaciens. J Clin Microbiol.
sputum as a part of mixed flora or ventilator-associated pneumonia evi- 2003; 41:2240-1.
8. Wang IK, Lee MH, Chen YM et al.
contamination, a circumstance that dently caused by S. putrefaciens. The Polymicrobial bacteremia caused by
obscures the clinical significance of pneumonia resolved after treatment Escherichia coli, Edwardsiella tarda, and
the organism’s presence. Rarely has with cefepime. Shewanella putrefaciens. Chang Gung Med
J. 2004; 27:701-5.
the bacterium been isolated from 9. Botelho-Nevers E, Gouriet F, Rovery C
the lower respiratory tract through References et al. First case of osteomyelitis due to
BAL. 1. Jorens PG, Goovaerts K, Ieven M. Shewanella algae. J Clin Microbiol. 2005;
It remains unclear why our pa- Shewanella putrefaciens isolated in a case 43:5388-90.
of ventilator-associated pneumonia. 10. American Thoracic Society and Infec-
tient’s S. putrefaciens infection be- Respiration. 2004; 71:199-201. tious Diseases Society of America. Guide-
came apparent two weeks after the 2. Vogel BF, Jorgensen K, Christensen H et lines for the management of adults with
likely introduction of the pathogen al. Differentiation of Shewanella putre- hospital-acquired, ventilator-associated,
faciens and Shewanella alga on the basis and healthcare-associated pneumonia.
and after several days of treatment of whole-cell protein, ribotyping, phe- Am J Respir Crit Care Med. 2005; 171:388-
with cefepime, to which the organism notypic characterization, and 16S rRNA 416.

Am J Health-Syst Pharm—Vol 67 Jun 15, 2010 1009


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