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-
faciens, is an aquatic, gram-
negative bacillus of the family Al-
teromonadaceae. 1 S. putrefaciens
is commonly found throughout
nature. Sources include marine
environments, soil sources, natural
energy reserves (oil and gas), and
food products (i.e., beef, poultry,
and dairy). S. putrefaciens is one
of the main bacteria that causes
seafood spoilage and is important
in the turnover of organic mate-
rial. This species is also capable of
reducing various metals, nitrates,
thiosulfate, and trimethylamine-
N-oxide.2 S. putrefaciens is not a
common human pathogen, with
most human isolates occurring as
mixed flora obscuring any clinical
significance.3-5 However, it has been
implicated in several illnesses, in-
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
S. putrefaciens.1 Isolation of this bac-
teria from the lower respiratory tract
has never been reported in the United
States. We describe such a case.
Purpose. The first reported U.S. case of
ventilator-associated pneumonia evi-
dently caused by Shewanella putrefaciens
is described.
Summary. A 39-year-old man with severe
head trauma was found face down and
unresponsive in a river after a watercraft ac-
cident. After being resuscitated and trans-
ferred to the intensive care unit, the patient
received treatment for a subarachnoid
hemorrhage and spinal injuries. The patient
was also found to have decreased breath
sounds bilaterally. On hospital day 7, bron-
choalveolar lavage was performed due to
acute febrile illness and thick pulmonary
secretions. The patient was treated em-
pirically with i.v. vancomycin and cefepime.
The culture results suggested pneumonia
due to methicillin-sensitive Staphylococcus
aureus and colonization with Pseudomonas
aeruginosa. The vancomycin and cefepime
were replaced with nafcillin, after which
the pneumonia resolved. The patient con-
tinued to be febrile, with leukocytosis on
hospital day 14. A subsequent bronchoal-
Case report
A 39-year-old man with severe
head trauma was found face down
in a river after a watercraft accident.
He was unresponsive and cyanotic
veolar lavage culture performed that day
revealed the presence of S. putrefaciens.
According to the culture and susceptibil-
ity results, S. putrefaciens was resistant to
ampicillin–sulbactam and exhibited sensi-
tivity to cefepime, piperacillin, piperacillin–
tazobactam, gentamicin, ciprofloxacin,
levofloxacin, and meropenem. The patient
received a 14-day course of cefepime, elim-
inating any further sign of the pathogen.
Over the next two months, the patient’s
condition continued to improve, and he
was eventually discharged to a rehabilita-
tion facility.
Conclusion. A 39-year-old man developed
ventilator-associated pneumonia evidently
caused by S. putrefaciens. The pneumonia
resolved after treatment with cefepime.
Index terms: Antiinfective agents;
Cefepime; Cephalosporins; Gram negative
bacterial infections; Pneumonia; Resis-
tance; Shewanella putrefaciens; United
States; Ventilators
Am J Health-Syst Pharm. 2010; 67:1007-9
when he arrived at a local hospital.
He had been intubated and had a
cervical collar with inline stabiliza-
tion in place. Mechanical ventilation
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;
and Paul Tan, Pharm.D., FASHP, is Surgical Intensive Care Unit
Practitioner, Department of Pharmacy, Shands Medical Center—
Jacksonville, Jacksonville, FL.
Address correspondence to Dr. Tucker at the Department of Phar-
macy, Shands Medical Center, 655 West 8th Street, Jacksonville, FL
The authors have declared no potential conflicts of interest.
Copyright © 2010, American Society of Health-System Pharma-
cists, Inc. All rights reserved. 1079-2082/10/0602-1007$06.00.
DOI 10.2146/ajhp090344

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

 case reports  Ventilator-associated pneumonia
tial. He was transferred to Shands
Jacksonville Hospital with a reported
Glasgow coma scale score of 3t/15.
Oxygen saturation was approxi-
mately 80%, his blood pressure was
109/68 mm Hg, and he was display-
ing signs of hypotension and respira-
tory failure. He was resuscitated and,
once stabilized, transferred to the
surgical intensive care unit. Cerebral
computed tomography revealed a
diffuse subarachnoid hemorrhage,
and radiograph of the cervical spine
revealed craniocervical dislocation.
The patient was sedated and para-
lyzed, and seizure prophylaxis with
levetiracetam was initiated due to
traumatic brain injury. Auscultation
revealed that the lungs were clear
and equal, with decreased breath
sounds bilaterally. The patient had
no known drug allergies and a
medical history significant only for
hypertension.
During the next two weeks, the
patient remained in critical condi-
tion, with the primary concern being
his brain and spinal injuries. During
this period, the patient experienced
multiple complications, including
a pulmonary embolism requiring
an inferior vena cava filter, acute
renal failure requiring hemodialysis,
respiratory failure, anemia, chronic
diarrhea, and recurrent bacterial
infections in the blood and lungs.
Throughout this period, the patient’s
ventilation remained stable, with a
pressure support ventilation setting
of 12 cm H2O, fraction of inspired
oxygen of 40%, and positive end-
expiratory pressure of 5 cm H2O.
On hospital day 7, a bronchoal-
veolar lavage (BAL) was performed
due to acute febrile illness and thick
pulmonary secretions. The patient
was treated empirically with i.v. van-
comycin and cefepime. The culture
results suggested pneumonia due to
methicillin-sensitive Staphylococ-
cus aureus (>100,000 colonies/mL)
and colonization with Pseudomonas
aeruginosa (20,000 colonies/mL).
The vancomycin and cefepime were
1008 Am J Health-Syst Pharm—Vol 67 Jun 15, 2010
replaced with nafcillin 2 g (as the
sodium salt) i.v. every 4 hours for
8 days; after which the pneumonia
resolved.
The patient continued to be fe-
brile, with leukocytosis on hospital
day 14. His antibiotic therapy was
broadened, requiring cefepime (2 g
[as the hydrochloride salt] i.v. every
12 hours) to be resumed to cover
possible P. aeruginosa pneumonia. A
subsequent BAL culture performed
that day revealed the presence of
S. putrefaciens. According to the
culture and susceptibility results,
S. putrefaciens was resistant to
ampicillin–sulbactam and exhibited
susceptibility to cefepime, piperacil-
lin, piperacillin–tazobactam, gen-
tamicin, ciprofloxacin, levofloxacin,
and meropenem. The cefepime
already being used was considered
sufficient treatment for the S. putre-
faciens infection. Subsequent blood
and BAL cultures obtained on days
20 and 22 showed no sign of infec-
tion. During this period, the pa-
tient’s respiratory function remained
stable, and the ventilator settings
remained unchanged. Over the next
two months, the patient’s condition
continued to improve, and he was
eventually transferred out of the in-
tensive care unit and discharged to a
rehabilitation facility.
Discussion
Human infections with Shewanel-
la species are rare. Most cases have
occurred in geographic areas with
temperate to warm climates, such
as the United States, Australia, Asia,
South Africa, and southern Europe.5
The clinical significance of these
organisms in humans has often
been obscured due to their frequent
occurrence as part of mixed flora
in cultures.1,3-5 However, a number
of monomicrobial infections have
been reported, exhibiting the patho-
genic capability of the Shewanella
species.1,4,9 The only Shewanella spe-
cies found in clinical specimens are
S. putrefaciens and Shewanella algae.
Greater than 80% of the isolates
from humans are attributable to
S. algae.2,5,7
Identification systems used by
most laboratories are unable to
distinguish between S. putrefaciens
and S. algae. There have been many
instances of an isolate initially being
identified as S. putrefaciens but prov-
ing to be S. algae after further test-
ing. The experience and familiarity
of the microbiology laboratory with
Shewanella species can aid in the
identification of S. putrefaciens
isolates. The microbiology staff at
Shands Jacksonville Hospital has had
experience identifying S. putrefaciens,
providing some assurance that the
identification of the pathogen was
accurate.
Clinical syndromes attributable to
S. putrefaciens and S. algae display no
significant differences and are similar
to infections caused by species of the
genus Vibrio.2,5,6 Clinical syndromes
commonly described in the literature
are skin and soft tissue infections
associated with damage to the skin
(e.g., trauma, cuts, scrapes, ulcers);
otitis media, mostly in children dur-
ing the summer when contact with
seawater is high; and bacteremia,
which is usually benign.4,5 Neither
S. algae nor S. putrefaciens is com-
monly found in the lower respiratory
tract. S. putrefaciens is well adapted to
the conditions of devitalized necrotic
tissue in which it has shown the abili-
ty to multiply and chronically persist,
usually in necrotic skin or leg ulcers.1
In rare cases, Shewanella species has
been known to cause osteomyelitis,
usually due to trauma that results in
breaches of the skin, such as in frac-
tures.9 Respiratory colonization with
the possibility of infection has been
identified in rare cases from isolates
cultured from sputum and pleura
and transthoracic needle aspiration
cultures.1
Ventilator-associated pneumonia
usually develops more than 48 hours
after endotracheal intubation and
mechanical ventilation.5 It is likely

that S. putrefaciens was introduced to
our patient’s respiratory tract during
his exposure to river water. Nosoco-
mial pneumonia is usually associ-
ated with microbes common to the
hospital setting, such as S. aureus and
P. aeruginosa.10 Since the patient’s
pneumonia occurred two weeks after
the initiation of mechanical ventila-
tion, it is reasonable to categorize it
as a ventilator-associated pneumo-
nia. Ventilator-associated pneumonia
has only been attributed to S. putre-
faciens in one other case (in Antwerp,
Belgium) in which the mode of ex-
posure could not be established, and
the infection became apparent after
several weeks of hospitalization.1
S. putrefaciens is commonly found in
sputum as a part of mixed flora or
contamination, a circumstance that
obscures the clinical significance of
the organism’s presence. Rarely has
the bacterium been isolated from
the lower respiratory tract through
BAL.
It remains unclear why our pa-
tient’s S. putrefaciens infection be-
came apparent two weeks after the
likely introduction of the pathogen
and after several days of treatment
with cefepime, to which the organism
case reports  Ventilator-associated pneumonia
was susceptible and which eventually
eradicated it. In the previous case, it
took 38 days after the supposed ex-
posure for manifestation of a positive
culture for S. putrefaciens.1 In that
case and in ours, the resolution of
signs and symptoms of pneumonia
with antibiotic treatment is evidence
of the pathogenicity of the isolates. It
is fortunate that Shewanella was sus-
ceptible to common antibiotics. In
our patient, S. putrefaciens exhibited
resistance to ampicillin–sulbactam.
In one report, only 38% of skin and
soft tissue isolates were susceptible to
ampicillin.1
Conclusion
A 39-year-old man developed
ventilator-associated pneumonia evi-
dently caused by S. putrefaciens. The
pneumonia resolved after treatment
with cefepime.
References
1. Jorens PG, Goovaerts K, Ieven M.
Shewanella putrefaciens isolated in a case
of ventilator-associated pneumonia.
Respiration. 2004; 71:199-201.
2. Vogel BF, Jorgensen K, Christensen H et
al. Differentiation of Shewanella putre-
faciens and Shewanella alga on the basis
of whole-cell protein, ribotyping, phe-
notypic characterization, and 16S rRNA
Am J Health-Syst Pharm—Vol 67 Jun 15, 2010
gene sequence analysis. Appl Environ
Microbiol. 1997; 63:2189-99.
3. Bulut C, Ertem GT, Gokcek C et al. A rare
cause of wound infection: Shewanella
putrefaciens. Scand J Infect Dis. 2004;
36:692-4.
4. Yilmaz G, Aydin K, Bektas D et al. Cer-
ebellar abscess and meningitis, caused
by Shewanella putrefaciens and Klebsiella
pneumoniae, associated with chronic otitis
media. J Med Microbiol. 2007; 56:1558-60.
5. Holt HM, Gahrn-Hansen B, Bruun B.
Shewanella algae and Shewanella putrefa-
ciens: clinical and microbiological char-
acteristics. Clin Microbiol Infect. 2005;
11:347-52.
6. Oh HS, Kum KA, Kim EC et al. Outbreak
of Shewanella algae and Shewanella pu-
trefaciens infections caused by a shared
measuring cup in a general surgery unit
in Korea. Infect Control Hosp Epidemiol.
2008; 29:742-8.
7. Pagani L, Lang A, Vedorelli C et al. Soft
tissue infection and bacteremia caused by
Shewanella putrefaciens. J Clin Microbiol.
2003; 41:2240-1.
8. Wang IK, Lee MH, Chen YM et al.
Polymicrobial bacteremia caused by
Escherichia coli, Edwardsiella tarda, and
Shewanella putrefaciens. Chang Gung Med
J. 2004; 27:701-5.
9. Botelho-Nevers E, Gouriet F, Rovery C
et al. First case of osteomyelitis due to
Shewanella algae. J Clin Microbiol. 2005;
43:5388-90.
10. American Thoracic Society and Infec-
tious Diseases Society of America. Guide-
lines for the management of adults with
hospital-acquired, ventilator-associated,
and healthcare-associated pneumonia.
Am J Respir Crit Care Med. 2005; 171:388-
416.
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