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Myroides injenensis Bacteremia and Severe Cellulitis

Myroides injenensis Bacteremia and Severe Cellulitis Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Manuscript title: Myroides injenensis bacteremia and severe cellulitis. Authors: 1. Stephanie LaVergne, Division of Infectious Diseases, University of California, San Diego, La Jolla, USA 2. Thaidra Gaufin, Division of Infectious Diseases, University of California, San Diego, La Jolla, USA 3. Douglas Richman, VA San Diego Healthcare System and Division of Infectious Diseases, University of California, San Diego, La Jolla, USA Corresponding author: Stephanie LaVergne Address: Division of Infectious Diseases and Global Public Health University of California, San Diego 9500 Gilman Drive, La Jolla, California 92093-0711 Email: slavergne@ucsd.edu Phone: (225) 931-2494 Alternate corresponding author: Thaidra Gaufin Address: Division of Infectious Diseases and Global Public Health University of California, San Diego 9500 Gilman Drive, La Jolla, California 92093-0711 Email: tgaufin@ucsd.edu Phone: 559-871-7396 Published by Oxford University Press on behalf of Infectious Diseases Society of America 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Keywords: Myroides, cellulitis. multi-drug resistance Conflicts of Interest: none to declare. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 ABSTRACT: Myroides spp. are environmental bacterial organisms that rarely cause disease in humans. Myroides spp. infections are infrequently reported in the literature, and Myroides injenensis infections are quite uncommon. Myroides spp. usually infect immunocompromised hosts, and can have highly resistant antibiotic susceptibility patterns. Here we report a case of Myroides injenensis bacteremia and severe cellulitis in a patient with cirrhosis, and review the literature of other Myroides spp. infections. INTRODUCTION Myroides spp. are found in the environment in soil and water (1). They were previously described as not highly pathogenic; however, these bacteria can cause significant morbidity and mortality, as detailed in Table 1. They are aerobic, yellow-pigmented, non-lactose fermenting, oxidase positive Gram negative rods (1,2). On nutrient agar, the colonies are yellow and have a fruity odor (1,2). Organisms from the genus Myroides spp. were initially isolated from human intestine in 1923 (2). They were initially classified in the genus Flavobacterium; however, after unique characteristics of the bacteria were recognized (such as halo-tolerance, lack of gliding motility, abundant growth at 37°C, and differences in fatty acid composition), they were reclassified in a new genus, Myroides, in 1996, and further differentiated into Myroides odoratus and Myroides odoratimimus (2). In 2012 and 2014, a new Myroides sp., injenensis, was isolated from clinical specimens and sequenced (3,4). The isolate had a high level of antibacterial resistance (3). Six additional Myroides spp. not yet associated with human infections have been Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 identified: M. profundi, M. marinus, M. phaeus, M. pelagicus, M. guanonsis, and M. xuanwensis (4). Myroides spp. rarely cause disease, and when they are implicated in infections, they usually occur in immunocompromised hosts (5). Over the past several years, an increase in cases have been reported. Many reported cases are low grade infections; however, reports of aggressive infections, such as our case and those reviewed here, have become more frequent (1,6,7). Most cases described in the literature are skin and soft tissue infections, although a variety of clinical presentations are summarized in Table 1, including tricuspid valve endocarditis, ventriculitis, and urinary tract infections (UTI) among others. Clinicians should be aware of this increasingly recognized and potentially multi-drug resistant organism. CASE REPORT A 74-year-old male plumber was admitted to the inpatient medicine service at the San Diego VA Medical Center for rapidly worsening erythema and pain in his legs. The erythema and pain were noted by the patient only about 24 hours before admission; however, he had experienced leg swelling and skin weeping for about 1 year. He had no fevers or chills. One day before the start of his symptoms, he waded in a house flooded with sewage to assist with his client’s plumbing. He remained in his wet pants and boots for the rest of the work day. Later that day and the following morning, he had worsening pain and erythema in his legs, and presented to the hospital. Regarding his past medical history, he had received a diagnosis of Crohn’s disease, but had not sought medical care or been on medication for several decades. He used alcohol heavily, consuming 2 liters of wine a day for 50 years and had a 75 pack-year smoking history. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 His temperature on admission was 36.4°C, blood pressure of 111/55 mmHg, heart rate of 100 beats per minute, respiratory rate of 20 breaths per minute, and his oxygen saturation was 96% on room air. On physical examination, bilateral leg erythema was present from his feet to his knees, with a hemorrhagic violaceous component. He had scattered bullae with clear weeping fluid that progressed to severe desquamation and necrosis (Fig. 1). Initial laboratory data were most notable for WBC 7,600/µL (normal 4,000-10,800), 91% segmented neutrophils, 3% bands, platelets 22,000/µL (normal 140,000-400,000), fibrinogen 539 mg/dL (normal 197-403), d-dimer 10.36 µg/mL fibrinogen equivalent units (normal <0.48), INR 1.7 (normal 0.9-1.2), PT 19.1 seconds (normal 11.8-14), lactic acid 5.1 mMol/L (normal 0.7-2.1), ESR 40 mm/hr (normal 0- 15), CRP 26.19 mg/dL (normal <0.8), creatinine 3.39 mg/dL (normal 0.6-1.3), glucose 27 mg/dL (normal 70-100), total bilirubin 4.1 mg/dL (normal 0.4-1.2), direct bilirubin 2.3 mg/dL (normal <0.2), AST 70 IU/L (normal 10-35), and ALT 30 IU/L (normal 10-40). He had an elevated calculated DIC Score of 7, suggestive of disseminated intravascular coagulopathy (DIC). Blood cultures were obtained on admission before the initiation of vancomycin and piperacillin- tazobactam by the admitting team for broad spectrum coverage in the setting of sepsis. Vancomycin dosing was 15 mg/kg given once daily and piperacillin-tazobactam was dosed 2.25 g IV every 6 hours. Both medications were adjusted for the patient’s poor creatinine clearance. After 14 hours of culture, 4 of 4 blood cultures grew a non-lactose fermenting Gram negative rod in the aerobic bottles only. Susceptibility testing was performed with Kirby-Bauer methods for disk diffusion, and MICs were obtained by E-test using Clinical and Laboratory Standards Institute guidelines. The isolate was resistant to aztreonam, ceftazidime (MIC = 32 µg/mL), trimethoprim/sulfamethoxazole, amikacin (MIC >=64 µg/mL), gentamicin (>=16 µg/mL), and Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 tobramycin (>=16 µg/mL), and was sensitive to ampicillin/sulbactam and piperacillin/tazobactam (MIC <=4 µg/mL), ciprofloxacin (MIC<=0.25 µg/mL), levofloxacin (MIC <=0.12 µg/mL), and meropenem, with intermediate sensitivity to cefepime. Myroides sp. was identified using Bruker matrix assisted laser desorption and ionization time-of-flight (MALDI-TOF) technology. The isolate was sent to the University of Washington for 16S ribosomal RNA sequencing and further identification, and was speciated as Myroides injenensis. A wound aspirate was cultured, and grew a non-lactose fermenting Gram negative rod, with the same susceptibility pattern as the Myroides injenensis blood isolate by E-test, and was presumed to be Myroides injenensis as well. Within 24 hours of antibiotic therapy and IV fluid resuscitation, sepsis resolved, vital signs improved to normal parameters, and his lactic acidosis resolved. His creatinine improved to 0.9 mg/dL, platelets improved to 147, AST and ALT normalized, and his total bilirubin improved to 1.8 mg/dL at the time of discharge. His INR improved but remained elevated at 1.4, thought to be due chronic decompensated alcoholic cirrhosis. A liver ultrasound was done and showed evidence of cirrhosis. His blood glucose levels normalized with sepsis treatment, and his hypoglycemia was thought to be due to abnormal gluconeogenesis from cirrhosis and baseline liver dysfunction. Myroides injenensis susceptibility data were available 72 hours after his admission, and his antibiotics were narrowed to ampicillin-sulbactam 3g IV q 6 hours. He was treated for 4 weeks with ampicillin-sulbactam and improvement; an extended course of IV antibiotics was chosen because of the deep extent of his skin and soft tissue infection. Topical antibiotic ointment was not used. He developed dry gangrene of two toes and subcutaneous tissue (Figure Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 2), but he had no signs of osteomyelitis by radiograph. He had appreciable peripheral pulses by Doppler, and the gangrene was thought not to be due to arterial insufficiency, and likely the consequence of DIC. He was offered operative debridement with staged reconstruction, but declined, and was discharged to a skilled nursing facility to finish his course of IV antibiotics after a 2-week inpatient hospitalization. He has been treated with aggressive wound care as an outpatient. The chronic leg edema and skin weeping he presented with were attributed to chronic decompensated liver cirrhosis. DISCUSSION: Myroides spp. infections have become increasingly recognized in the literature. We searched for cases on PubMed by using the keywords “Myroides” + “infection”, and included cases in our review that identified the type of Myroides spp. infection. We excluded cases that reported Myroides spp. colonization without evidence of an active infection, and manuscripts that were not available in English. Of the 60 cases we included, 29 were reported in the last decade. Three of the 60 cases were in hosts with no known underlying chronic disease or immunosuppression. Most of the cases reported were isolated infections, but hospital outbreaks have been described (20). Myroides spp. are strong producers of biofilm (33). We reviewed 10 cases that were suggestive of biofilm formation as a cause of pathogenesis, such as a line associated infection, recurrent UTI with a long-term urinary catheter, UTIs associated with nephrolithiasis, and chronic wound infections (3, 14, 20, 29, 33). Myroides spp. grow well in high concentrations of glucose, and in our review we found that diabetes was a comorbidity in several cases (5, 11, 17, Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 21, 22, 27, 29. 33, 34). Cirrhosis may be another risk factor for infection. Besides our patient, there are 4 reports of cirrhotic patients with Myroides spp. infection (Table 1) (7,12,21,27). Many Myroides spp. cases in the literature occurred in immunocompromised patients, such as those on chemotherapy (3,5,14), immunosuppression for transplantation (29), or chronic steroid use (13,28) as detailed in Table 1. Myroides spp. can cause serious infections with rapid progression of disease. They usually have resistance to multiple antibiotics (1,7,8). Myroides spp. have variable susceptibility to beta-lactams and carbapenems. Our patient’s isolate was unusually sensitive to amoxicillin- clavulanic acid, and there have been no other reported cases of Myroides injenensis clinical infection with the same susceptibility pattern. Myroides injenensis has been reported as a highly resistant strain (4). The mechanisms of resistance to antibiotics in Myroides spp. are unknown. Gunzer et al evaluated the MIC of a collection of Myroides odoratimimus and Myroides odoratus strains. All strains were resistant to ceftazidime, cefepime, and aztreonam (31). Most were susceptible to meropenem and moxifloxacin, but fewer exhibited susceptibility to levofloxacin and ciprofloxacin (31). One strain of M. odoratimimus was found to have Amp-C Beta lactamase (31). Metallo-β-lactamases, TUS-1 and MUS-1, have been found in Myroides odoratimimus and Myroides odoratus (9,31). The significance of metallo-β-lactamases in Myroides spp. is unclear. Metallo-β-lactamases are active against carbapenems and not active against aztreonam, which is the opposite of what is generally observed with susceptibility testing of Myroides spp. isolates (9,31). More research needs to be done on determining the mechanisms of resistance in Myroides spp. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Our patient was at risk for Myroides spp. infection because of his alcoholic cirrhosis, as well as his occupational exposure as a plumber and contact with sewage. An infection with Myroides spp. should be considered in patients with severe skin and soft tissue infections with the appropriate risk factors, such as underlying immunosuppression and environmental exposure to soil and water. Given the variability in susceptibility testing of different Myroides species, extended susceptibility testing should be performed. SUMMARY: In conclusion, we have found that Myroides spp. infections have become increasingly recognized over the past decade. Consideration for this pathogen should be given in patients with immunocompromised state, and in patients with exposure to contaminated water. Although our patient had a sensitive strain of Myroides spp., many isolates can be multi-drug resistant. Expanded susceptibility testing should be performed on isolates from infected patients, and treatment with broad spectrum antibiotics should be considered for initial management. We encourage other clinicians to report identified cases, and further research on this emerged pathogen is needed. REFERENCES: 1. Holmes B, et al. Flavobacterium odoratum: a species resistant to a wide range of antimicrobial agents. Journal of Clinical Pathology. 1979 Jan; 32 (1): 73-77. 2. Bendetti, P. et al. Septic shock, pneumonia, and soft tissue infection due to Myroides odoratimimus: report of a case and review of Myroides infections. Infection. April 2011;39(2):161-165. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 3. Kim D-S, et al. Genome sequence of Myroides injenensis M09-0166, isolated from clinical specimens. Journal of Bacteriology. 2012 May;194(10):2748-2749. 4. Paek J et al. Myroides injenensis sp. nov., a new member isolated from human urine. Antione van Leeuwenhoek. 2015 Jan; 107(1):201-207. 5. Beharrysingh, R. Myroides bacteria: A case report and concise review. ID Cases. 2017 Feb;8, 34-36. 6. Ferrer C, et al. Right-sided bacterial endocarditis due to Flavobacterium odoratum in a patient on chronic hemodialysis. American Journal of Nephrology. 1995;15(1):82-4. 7. Crum-Cianflone NF, Matson RW, and Ballon-Landa G. Fatal case of necrotizing fasciitis due to Myroides odoratus. Infection (2014) 42:931-935. 8. Bachmeyer C, et al. Cellulitis due to Myroides odoratimimus in a patient with alcoholic cirrhosis. Clinical and Experimental Dermatology. 2008; 33(1):97-98. 9. Mammeri H et al. Chromosome-encoded B lactamases TUS-1 and MUS-1 from Myroides odoratus and Myroides odoratimimus (Formerly Flavobacterium odoratum) New members of the lineage of molecular subclass B1 Metalloenzymes. Antimicrobial Agents and Chemotherapy. 2002;46(11):3561-3567. 10. Macfarlane, DE. Flavobacterium odoratum ventriculitis treated with intraventricular cefotaxime. Journal of Infection. 1985; 11(3):233-238. 11. Prieur D. Bacteremia due to Flavobacterium odoratum. Medecine et Maladies Infectieuses. 1988;18(10):466-467. 12. Hsueh PR, Wu JJ, Hsiue TR, Hsieh WC. Bacteremic necrotizing fasciitis due to Flavobacterium odoratum. Clinical Infectious Diseases. 1995 Nov;21(5):1337-8. PubMed PMID:8589173. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 13. Bachman KH (1), Sewell DL, Strausbaugh LJ. Recurrent cellulitis and bacteremia caused by Flavobacterium odoratum. Clinical Infectious Diseases. 1996 Jun;22(6):1112-3. PMID: 8783727 14. Spanik S, Trupl J, Krcmery V. Nosocomial catheter-associated Flavobacterium odoratum bacteraemia in cancer patients. Journal of Medical Microbiology. 1998; 47:183. 15. Yağci A, Cerikçioğlu N, Kaufmann ME, Malnick H, Söyletir G, Babacan F, Pitt L. Molecular typing of Myroides odoratimimus (Flavobacterium odoratum) urinary tract infections in a Turkish hospital. European Journal of Clinical Microbiology and Infectious Diseases. 2000 Sep;19(9):731-2. 16. Green BT et al. Myroides odoratus cellulitis and bacteremia: case report and review. Scandinavian Journal of Infectious Diseases. 2001;33(12):932-4. 17. Motwani B, et al. Myroides odoratum cellulitis and bacteremia: A case report. Infectious Disease in Clinical Practice. 2004; 12(6):343-344. 18. Thomas M et al. Oerskovia turbata and Myroides species: rare isolates from a case of acalculous cholecystitis. Indian Journal of Medical Microbiology. 2007;25(3):297-8. 19. Maraki S, Sarchianaki E, Barbagadakis S. Myroides odoratimimus soft tissue infection in an immunocompetent child following a pig bite: case report and literature review. Brazilian Journal of Infectious Diseases. 2012; 16:390–2. 20. Ktari S., Mnif B., Koubaa M. Nosocomial outbreak of Myroides odoratimimus urinary tract infection in a Tunisian hospital. Journal of Hospital Infection. 2012;80(1):77–81. 21. Deepa R., Venkatesh K.G., Parveen J.D., Banu S.T., Jayalakshmi G. Myroides odoratus and Chryseobacterium indologenes: two rare isolates in the immunocompromised. Indian Journal of Medical Microbiology. 2014;32(3):327–330. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 22. Endicott-Yazdani T.R., Dhiman N., Benavides R., Spak C.W. Myroides odoratimimus bacteremia in a diabetic patient. Baylor University Medical Center Proceedings. 2015;28(3):342– 23. Prateek S., Gupta P., Mittal G., Singh A.K. Fatal case of pericardial effusion due to Myroides odoratus: a rare case report. Journal of Clinical and Diagnostic Research. 2015;9(11):DD01–2. 24. Ali M.J., Joseph J., Sharma S., Naik M.N. Canaliculitis with isolation of Myroides species. Ophthalmic Plastic and Reconstructive Surgery. 2015. 25. Lahmer T., Beitz A., Ehmer U., Schmid R. Septic shock due to Myroides odoratus in a medical intensive care unit patient with severe necrotising pancreatitis. Anaesthesia and Intensive Care. 2016;44(2):298–299. 26. Belloir L., Billy P.A., Hentgen C., Fille A., Barrans A. Myroides odoratimimus bacteremia. Medecine et Maladies Infectieuses. 2016;46(7):396–397. 27. Jover-Sáenz A., Pérez-Villar F., Barcenilla-Gaite F. Severe sepsis caused by infected prosthesis joint due to Myroides odoratimimus. Medicina Clinica. 2016;147(6):276–277 28. Willems P., Muller J., Verhaegen J., Saegeman V., Desmet S. How to treat a fulminant erysipelas and sepsis caused by Myroides odoratimimus: case report and literature review. Acta Clinica Belgica. 2016:1–5. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 29. Licker et al. Extensively drug-resistant Myroides odoratimimus – a case series of urinary tract infections in immunocompromised patients. Infection and Drug Resistance. 2018; 11:743-749. 30. Ahamed I, Annapandian VM, Muralidhara KD. Myroides odoratimimus urinary tract infection. Saudi Journal of Kidney Diseases and Transplantation. Sept 2018;29(5):1220-1222. 31. Gunzer F et al. Whole-genome sequencing of a large collection of Myroides odoratimimus and Myroides odoratus isolates and antimicrobial susceptibility studies. Emerging Microbes & Infections. 2018;7(1):1-8. 32. Sato K, Fujii T, Okamoto R, Inoue M, Mitsuhashi S. Biochemical properties of beta-lactamase produced by Flavobacterium odoratum. Antimicrobial Agents and Chemotherapy. 1985;27(4):612-4. 33. Lorenzin G et al. Myroides odoratimimus urinary tract infection in an immunocompromised patient: an emerging multidrug-resistant micro-organism. Antimicrobial Resistance & Infection Control. 2018; 7:96. 34. Pompilio A, et al. Infection of recurrent calcaneal ulcer caused by a biofilm-producer Myroides odoratimimus strain. Folia Microbiologica. March 2018;63(2):203-207. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Reference Species Type of infection Host factors Year # of infections published in paper Holmes (1) odoratum (1)stump infection ischemic lower limb 1979 5 (2)indwelling disease catheter infection (2)syringomyelia (3)foot gangrene, (3)frostbite (4)bladder cellulitis carcinoma (5)chronic (4&5)recurrent renal impairment UTI Macfarlane (10) odoratum ventriculitis hydrocephalus, 6 1985 1 week old Prieur (11) odoratum blood heart failure, diabetes 1988 1 Hsueh (12) odoratum bacteremia, HBV cirrhosis 1995 1 necrotizing fasciitis Ferrer (6) odoratum TV endocarditis chronic hemodialysis 1995 1 Bachman (13) odoratum cellulitis and chronic steroid use 1996 1 bacteremia Spanik (14) odoratum central line 1 solid cancer, 3 heme 1998 4 associated cancer bacteremia Yağci (15) odoratimimus UTI urinary neoplasm or 2000 13 stones Green (16) odoratus cellulitis and immunocompetent, 2001 1 Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 bacteremia heart disease Motwani (17) odoratum cellulitis, diabetes, wound 2004 1 bacteremia, shock Thomas (18) Myroides spp acalculous COPD 2007 1 cholecystitis Bachmeyer (8) odoratimimus cellulitis, chronic alcohol use, 2008 1 bacteremia trauma Bendetti (2) odoratimimus shock, pneumonia, immunocompetent 2011 1 cellulitis Maraki (19) odoratimimus cellulitis, pig bite in 2012 1 osteolytic lesions immunocompetent child Ktari (20) odoratimimus UTI recent GU 2012 7 instrumentation, nephrolithiasis Kim (3) injenensis UTI cervical cancer and 2012 1 percutaneous nephrostomy tube Crum-Cianflone odoratus necrotizing cirrhosis 2014 1 (7) fasciitis Deepa (21) odoratus pneumonia liver disease, diabetes 2014 2 Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 + pulmonary TB Endicott- odoratus bacteremia foot ulcer, diabetes 2015 1 Yazdani (22) Prateek (23) odoratus pericardial CKD on hemodialysis 2015 1 effusion Ali (24) Myroides spp canaliculitis immunocompetent, no 2015 1 trauma Lahmer (25) odoratus necrotizing alcohol abuse 2016 1 pancreatitis Belloir (26) odoratimimus bacteremia CKD 2016 1 Jover-sáenz (27) odoratimimus prosthetic joint HCV cirrhosis, 2016 1 infection diabetes Willems (28) odoratimimus erysipelas and chronic steroid use, 2016 1 sepsis traumatic skin erosion Beharrysingh Myroides spp bacteremia and diabetes, Merkel cell 2017 1 (5) cellulitis carcinoma on carboplatin/etoposide Pompilio (34) odoratimimus calcaneal ulcer diabetes 2017 1 Licker (29) odoratimimus UTI papillary urothelial 2018 4 carcinoma, TURP, diabetes, kidney Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 transplant on immunosuppression Ahmed (30) odoratimimus UTI ESRD 2018 1 Lorenzin (33) odoratimimus UTI ESRD, CMML, 2018 1 Diabetes Current case injenensis cellulitis alcoholic cirrhosis 2019 1 Table 1. Reports of infections caused by Myroides spp. Host factors are underlying conditions and immunocompromising factors thought to contribute to risk of Myroides spp. infection. Ref This 33 30 29 28 25 23 21 20 19 17 13 12 8 7 5 2 case Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Species Inj Os Os Os Os Ods Ods Ods Os Os Om Om Om Os Ods M.spp Os Test ET& MD ND Vitek Vitek ND MD MD MB ND ND DD DD ND MD ND ND DD &ET Antibiotic Tested Ampicillin 16 >16 16 R Ampicillin/ S 4 >16/8 4 16 R clavulaunate Piperacillin 32 R >256 Pipericillin/ <4 64 >64/4 R R >64/4 <16/4 >256 64 S R >64/4 I S tazobactam Temocillin R >32 Cefuroxime >64 >256 R R Cefotaxime >64 >32 >256 32 R R Ceftriaxone >32 >256 I R >32 R Ceftazidime 32 >64 R >64 R >16 >16 >256 32 R R R R Cefepime I >16 R 16 >16 >16 48 16 16 R R Cefoxitin >64 R R Imipenem >8 >16 R R >8 <4 R >16 S S I S Meropenem S 4 R 4 R >8 <4 2 S S Ciprofloxacin <0.25 R >2 R S >2 <1 R 0.5 1 S >2 I R Levofloxacin <0.12 R 0.5 >4 <2 0.5 <0.5 Ofloxacin S Nitrofurantoin R 128 Colistin R >4 R >16 >2 R Gentamicin >16 R >8 R >16 >8 >8 >256 8 R R >8 R R Tobramycin >16 R >8 R >16 <4 8 >8 R R Amikacin >64 R >32 R >64 >32 <16 >256 >64 R R >32 R R Trim/Sulf 160 1/19 >8/152 R >320 S >2/38 <2/38 20 S >2/38 S R Tigecycline 1 R Clindamycin 0.5 Rifampin 2 R S Aztreonam >64 >16 R >16 >16 32 S >8 R Chloram R 8 S Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Vancomycin R >16 Cephalothin R Cefmetazole R Cefmenoxine R Cefoperazone R Cefazolin >32 R R Cefotetan 64 Ticarcillin R >256 Tetracycline 32 32 8 Cotrimoxazole 0.5/9.5 Cefoperazone/ >16 sulbactam Ceftazidime/ >32 Avibactam Fosfomycin R Table 2. Antibiotic resistant patterns for Myroides spp. Cases were selected by availability of data in the report. Holmes et al (1) not included because not all isolates analyzed were infectious, and isolate susceptibility patterns were not identified by isolate in the manuscript. Abbreviations: Ref= reference. Test= susceptibility testing method. Om= F. odoratum Os= M. odoratimimus Ods= M. odoratus. Inj= M. injenensis M.spp.=Myroides species, not further identified. MD=broth microdilution DD=disc diffusion. ET=E test ND=not defined. Trim/Sulf=Trimethoprim/sulfamethoxazole. Chloram= Chloramphenicol Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Image 1. Leg on day 2 of hospitalization. Image 2. Leg 4 weeks after initial presentation. Accepted Manuscript http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Open Forum Infectious Diseases Oxford University Press

Myroides injenensis Bacteremia and Severe Cellulitis

LaVergne, Stephanie; Gaufin, Thaidra; Richman, Douglas
Open Forum Infectious Diseases , Volume 6 (7): 1 – Jun 17, 2019
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Abstract

Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Manuscript title: Myroides injenensis bacteremia and severe cellulitis. Authors: 1. Stephanie LaVergne, Division of Infectious Diseases, University of California, San Diego, La Jolla, USA 2. Thaidra Gaufin, Division of Infectious Diseases, University of California, San Diego, La Jolla, USA 3. Douglas Richman, VA San Diego Healthcare System and Division of Infectious Diseases, University of California, San Diego, La Jolla, USA Corresponding author: Stephanie LaVergne Address: Division of Infectious Diseases and Global Public Health University of California, San Diego 9500 Gilman Drive, La Jolla, California 92093-0711 Email: slavergne@ucsd.edu Phone: (225) 931-2494 Alternate corresponding author: Thaidra Gaufin Address: Division of Infectious Diseases and Global Public Health University of California, San Diego 9500 Gilman Drive, La Jolla, California 92093-0711 Email: tgaufin@ucsd.edu Phone: 559-871-7396 Published by Oxford University Press on behalf of Infectious Diseases Society of America 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Keywords: Myroides, cellulitis. multi-drug resistance Conflicts of Interest: none to declare. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 ABSTRACT: Myroides spp. are environmental bacterial organisms that rarely cause disease in humans. Myroides spp. infections are infrequently reported in the literature, and Myroides injenensis infections are quite uncommon. Myroides spp. usually infect immunocompromised hosts, and can have highly resistant antibiotic susceptibility patterns. Here we report a case of Myroides injenensis bacteremia and severe cellulitis in a patient with cirrhosis, and review the literature of other Myroides spp. infections. INTRODUCTION Myroides spp. are found in the environment in soil and water (1). They were previously described as not highly pathogenic; however, these bacteria can cause significant morbidity and mortality, as detailed in Table 1. They are aerobic, yellow-pigmented, non-lactose fermenting, oxidase positive Gram negative rods (1,2). On nutrient agar, the colonies are yellow and have a fruity odor (1,2). Organisms from the genus Myroides spp. were initially isolated from human intestine in 1923 (2). They were initially classified in the genus Flavobacterium; however, after unique characteristics of the bacteria were recognized (such as halo-tolerance, lack of gliding motility, abundant growth at 37°C, and differences in fatty acid composition), they were reclassified in a new genus, Myroides, in 1996, and further differentiated into Myroides odoratus and Myroides odoratimimus (2). In 2012 and 2014, a new Myroides sp., injenensis, was isolated from clinical specimens and sequenced (3,4). The isolate had a high level of antibacterial resistance (3). Six additional Myroides spp. not yet associated with human infections have been Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 identified: M. profundi, M. marinus, M. phaeus, M. pelagicus, M. guanonsis, and M. xuanwensis (4). Myroides spp. rarely cause disease, and when they are implicated in infections, they usually occur in immunocompromised hosts (5). Over the past several years, an increase in cases have been reported. Many reported cases are low grade infections; however, reports of aggressive infections, such as our case and those reviewed here, have become more frequent (1,6,7). Most cases described in the literature are skin and soft tissue infections, although a variety of clinical presentations are summarized in Table 1, including tricuspid valve endocarditis, ventriculitis, and urinary tract infections (UTI) among others. Clinicians should be aware of this increasingly recognized and potentially multi-drug resistant organism. CASE REPORT A 74-year-old male plumber was admitted to the inpatient medicine service at the San Diego VA Medical Center for rapidly worsening erythema and pain in his legs. The erythema and pain were noted by the patient only about 24 hours before admission; however, he had experienced leg swelling and skin weeping for about 1 year. He had no fevers or chills. One day before the start of his symptoms, he waded in a house flooded with sewage to assist with his client’s plumbing. He remained in his wet pants and boots for the rest of the work day. Later that day and the following morning, he had worsening pain and erythema in his legs, and presented to the hospital. Regarding his past medical history, he had received a diagnosis of Crohn’s disease, but had not sought medical care or been on medication for several decades. He used alcohol heavily, consuming 2 liters of wine a day for 50 years and had a 75 pack-year smoking history. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 His temperature on admission was 36.4°C, blood pressure of 111/55 mmHg, heart rate of 100 beats per minute, respiratory rate of 20 breaths per minute, and his oxygen saturation was 96% on room air. On physical examination, bilateral leg erythema was present from his feet to his knees, with a hemorrhagic violaceous component. He had scattered bullae with clear weeping fluid that progressed to severe desquamation and necrosis (Fig. 1). Initial laboratory data were most notable for WBC 7,600/µL (normal 4,000-10,800), 91% segmented neutrophils, 3% bands, platelets 22,000/µL (normal 140,000-400,000), fibrinogen 539 mg/dL (normal 197-403), d-dimer 10.36 µg/mL fibrinogen equivalent units (normal <0.48), INR 1.7 (normal 0.9-1.2), PT 19.1 seconds (normal 11.8-14), lactic acid 5.1 mMol/L (normal 0.7-2.1), ESR 40 mm/hr (normal 0- 15), CRP 26.19 mg/dL (normal <0.8), creatinine 3.39 mg/dL (normal 0.6-1.3), glucose 27 mg/dL (normal 70-100), total bilirubin 4.1 mg/dL (normal 0.4-1.2), direct bilirubin 2.3 mg/dL (normal <0.2), AST 70 IU/L (normal 10-35), and ALT 30 IU/L (normal 10-40). He had an elevated calculated DIC Score of 7, suggestive of disseminated intravascular coagulopathy (DIC). Blood cultures were obtained on admission before the initiation of vancomycin and piperacillin- tazobactam by the admitting team for broad spectrum coverage in the setting of sepsis. Vancomycin dosing was 15 mg/kg given once daily and piperacillin-tazobactam was dosed 2.25 g IV every 6 hours. Both medications were adjusted for the patient’s poor creatinine clearance. After 14 hours of culture, 4 of 4 blood cultures grew a non-lactose fermenting Gram negative rod in the aerobic bottles only. Susceptibility testing was performed with Kirby-Bauer methods for disk diffusion, and MICs were obtained by E-test using Clinical and Laboratory Standards Institute guidelines. The isolate was resistant to aztreonam, ceftazidime (MIC = 32 µg/mL), trimethoprim/sulfamethoxazole, amikacin (MIC >=64 µg/mL), gentamicin (>=16 µg/mL), and Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 tobramycin (>=16 µg/mL), and was sensitive to ampicillin/sulbactam and piperacillin/tazobactam (MIC <=4 µg/mL), ciprofloxacin (MIC<=0.25 µg/mL), levofloxacin (MIC <=0.12 µg/mL), and meropenem, with intermediate sensitivity to cefepime. Myroides sp. was identified using Bruker matrix assisted laser desorption and ionization time-of-flight (MALDI-TOF) technology. The isolate was sent to the University of Washington for 16S ribosomal RNA sequencing and further identification, and was speciated as Myroides injenensis. A wound aspirate was cultured, and grew a non-lactose fermenting Gram negative rod, with the same susceptibility pattern as the Myroides injenensis blood isolate by E-test, and was presumed to be Myroides injenensis as well. Within 24 hours of antibiotic therapy and IV fluid resuscitation, sepsis resolved, vital signs improved to normal parameters, and his lactic acidosis resolved. His creatinine improved to 0.9 mg/dL, platelets improved to 147, AST and ALT normalized, and his total bilirubin improved to 1.8 mg/dL at the time of discharge. His INR improved but remained elevated at 1.4, thought to be due chronic decompensated alcoholic cirrhosis. A liver ultrasound was done and showed evidence of cirrhosis. His blood glucose levels normalized with sepsis treatment, and his hypoglycemia was thought to be due to abnormal gluconeogenesis from cirrhosis and baseline liver dysfunction. Myroides injenensis susceptibility data were available 72 hours after his admission, and his antibiotics were narrowed to ampicillin-sulbactam 3g IV q 6 hours. He was treated for 4 weeks with ampicillin-sulbactam and improvement; an extended course of IV antibiotics was chosen because of the deep extent of his skin and soft tissue infection. Topical antibiotic ointment was not used. He developed dry gangrene of two toes and subcutaneous tissue (Figure Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 2), but he had no signs of osteomyelitis by radiograph. He had appreciable peripheral pulses by Doppler, and the gangrene was thought not to be due to arterial insufficiency, and likely the consequence of DIC. He was offered operative debridement with staged reconstruction, but declined, and was discharged to a skilled nursing facility to finish his course of IV antibiotics after a 2-week inpatient hospitalization. He has been treated with aggressive wound care as an outpatient. The chronic leg edema and skin weeping he presented with were attributed to chronic decompensated liver cirrhosis. DISCUSSION: Myroides spp. infections have become increasingly recognized in the literature. We searched for cases on PubMed by using the keywords “Myroides” + “infection”, and included cases in our review that identified the type of Myroides spp. infection. We excluded cases that reported Myroides spp. colonization without evidence of an active infection, and manuscripts that were not available in English. Of the 60 cases we included, 29 were reported in the last decade. Three of the 60 cases were in hosts with no known underlying chronic disease or immunosuppression. Most of the cases reported were isolated infections, but hospital outbreaks have been described (20). Myroides spp. are strong producers of biofilm (33). We reviewed 10 cases that were suggestive of biofilm formation as a cause of pathogenesis, such as a line associated infection, recurrent UTI with a long-term urinary catheter, UTIs associated with nephrolithiasis, and chronic wound infections (3, 14, 20, 29, 33). Myroides spp. grow well in high concentrations of glucose, and in our review we found that diabetes was a comorbidity in several cases (5, 11, 17, Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 21, 22, 27, 29. 33, 34). Cirrhosis may be another risk factor for infection. Besides our patient, there are 4 reports of cirrhotic patients with Myroides spp. infection (Table 1) (7,12,21,27). Many Myroides spp. cases in the literature occurred in immunocompromised patients, such as those on chemotherapy (3,5,14), immunosuppression for transplantation (29), or chronic steroid use (13,28) as detailed in Table 1. Myroides spp. can cause serious infections with rapid progression of disease. They usually have resistance to multiple antibiotics (1,7,8). Myroides spp. have variable susceptibility to beta-lactams and carbapenems. Our patient’s isolate was unusually sensitive to amoxicillin- clavulanic acid, and there have been no other reported cases of Myroides injenensis clinical infection with the same susceptibility pattern. Myroides injenensis has been reported as a highly resistant strain (4). The mechanisms of resistance to antibiotics in Myroides spp. are unknown. Gunzer et al evaluated the MIC of a collection of Myroides odoratimimus and Myroides odoratus strains. All strains were resistant to ceftazidime, cefepime, and aztreonam (31). Most were susceptible to meropenem and moxifloxacin, but fewer exhibited susceptibility to levofloxacin and ciprofloxacin (31). One strain of M. odoratimimus was found to have Amp-C Beta lactamase (31). Metallo-β-lactamases, TUS-1 and MUS-1, have been found in Myroides odoratimimus and Myroides odoratus (9,31). The significance of metallo-β-lactamases in Myroides spp. is unclear. Metallo-β-lactamases are active against carbapenems and not active against aztreonam, which is the opposite of what is generally observed with susceptibility testing of Myroides spp. isolates (9,31). More research needs to be done on determining the mechanisms of resistance in Myroides spp. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Our patient was at risk for Myroides spp. infection because of his alcoholic cirrhosis, as well as his occupational exposure as a plumber and contact with sewage. An infection with Myroides spp. should be considered in patients with severe skin and soft tissue infections with the appropriate risk factors, such as underlying immunosuppression and environmental exposure to soil and water. Given the variability in susceptibility testing of different Myroides species, extended susceptibility testing should be performed. SUMMARY: In conclusion, we have found that Myroides spp. infections have become increasingly recognized over the past decade. Consideration for this pathogen should be given in patients with immunocompromised state, and in patients with exposure to contaminated water. Although our patient had a sensitive strain of Myroides spp., many isolates can be multi-drug resistant. Expanded susceptibility testing should be performed on isolates from infected patients, and treatment with broad spectrum antibiotics should be considered for initial management. We encourage other clinicians to report identified cases, and further research on this emerged pathogen is needed. REFERENCES: 1. Holmes B, et al. Flavobacterium odoratum: a species resistant to a wide range of antimicrobial agents. Journal of Clinical Pathology. 1979 Jan; 32 (1): 73-77. 2. Bendetti, P. et al. Septic shock, pneumonia, and soft tissue infection due to Myroides odoratimimus: report of a case and review of Myroides infections. Infection. April 2011;39(2):161-165. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 3. Kim D-S, et al. Genome sequence of Myroides injenensis M09-0166, isolated from clinical specimens. Journal of Bacteriology. 2012 May;194(10):2748-2749. 4. Paek J et al. Myroides injenensis sp. nov., a new member isolated from human urine. Antione van Leeuwenhoek. 2015 Jan; 107(1):201-207. 5. Beharrysingh, R. Myroides bacteria: A case report and concise review. ID Cases. 2017 Feb;8, 34-36. 6. Ferrer C, et al. Right-sided bacterial endocarditis due to Flavobacterium odoratum in a patient on chronic hemodialysis. American Journal of Nephrology. 1995;15(1):82-4. 7. Crum-Cianflone NF, Matson RW, and Ballon-Landa G. Fatal case of necrotizing fasciitis due to Myroides odoratus. Infection (2014) 42:931-935. 8. Bachmeyer C, et al. Cellulitis due to Myroides odoratimimus in a patient with alcoholic cirrhosis. 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Oerskovia turbata and Myroides species: rare isolates from a case of acalculous cholecystitis. Indian Journal of Medical Microbiology. 2007;25(3):297-8. 19. Maraki S, Sarchianaki E, Barbagadakis S. Myroides odoratimimus soft tissue infection in an immunocompetent child following a pig bite: case report and literature review. Brazilian Journal of Infectious Diseases. 2012; 16:390–2. 20. Ktari S., Mnif B., Koubaa M. Nosocomial outbreak of Myroides odoratimimus urinary tract infection in a Tunisian hospital. Journal of Hospital Infection. 2012;80(1):77–81. 21. Deepa R., Venkatesh K.G., Parveen J.D., Banu S.T., Jayalakshmi G. Myroides odoratus and Chryseobacterium indologenes: two rare isolates in the immunocompromised. Indian Journal of Medical Microbiology. 2014;32(3):327–330. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 22. 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Severe sepsis caused by infected prosthesis joint due to Myroides odoratimimus. Medicina Clinica. 2016;147(6):276–277 28. Willems P., Muller J., Verhaegen J., Saegeman V., Desmet S. How to treat a fulminant erysipelas and sepsis caused by Myroides odoratimimus: case report and literature review. Acta Clinica Belgica. 2016:1–5. Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 29. Licker et al. Extensively drug-resistant Myroides odoratimimus – a case series of urinary tract infections in immunocompromised patients. Infection and Drug Resistance. 2018; 11:743-749. 30. Ahamed I, Annapandian VM, Muralidhara KD. Myroides odoratimimus urinary tract infection. Saudi Journal of Kidney Diseases and Transplantation. Sept 2018;29(5):1220-1222. 31. Gunzer F et al. 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Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Reference Species Type of infection Host factors Year # of infections published in paper Holmes (1) odoratum (1)stump infection ischemic lower limb 1979 5 (2)indwelling disease catheter infection (2)syringomyelia (3)foot gangrene, (3)frostbite (4)bladder cellulitis carcinoma (5)chronic (4&5)recurrent renal impairment UTI Macfarlane (10) odoratum ventriculitis hydrocephalus, 6 1985 1 week old Prieur (11) odoratum blood heart failure, diabetes 1988 1 Hsueh (12) odoratum bacteremia, HBV cirrhosis 1995 1 necrotizing fasciitis Ferrer (6) odoratum TV endocarditis chronic hemodialysis 1995 1 Bachman (13) odoratum cellulitis and chronic steroid use 1996 1 bacteremia Spanik (14) odoratum central line 1 solid cancer, 3 heme 1998 4 associated cancer bacteremia Yağci (15) odoratimimus UTI urinary neoplasm or 2000 13 stones Green (16) odoratus cellulitis and immunocompetent, 2001 1 Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 bacteremia heart disease Motwani (17) odoratum cellulitis, diabetes, wound 2004 1 bacteremia, shock Thomas (18) Myroides spp acalculous COPD 2007 1 cholecystitis Bachmeyer (8) odoratimimus cellulitis, chronic alcohol use, 2008 1 bacteremia trauma Bendetti (2) odoratimimus shock, pneumonia, immunocompetent 2011 1 cellulitis Maraki (19) odoratimimus cellulitis, pig bite in 2012 1 osteolytic lesions immunocompetent child Ktari (20) odoratimimus UTI recent GU 2012 7 instrumentation, nephrolithiasis Kim (3) injenensis UTI cervical cancer and 2012 1 percutaneous nephrostomy tube Crum-Cianflone odoratus necrotizing cirrhosis 2014 1 (7) fasciitis Deepa (21) odoratus pneumonia liver disease, diabetes 2014 2 Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 + pulmonary TB Endicott- odoratus bacteremia foot ulcer, diabetes 2015 1 Yazdani (22) Prateek (23) odoratus pericardial CKD on hemodialysis 2015 1 effusion Ali (24) Myroides spp canaliculitis immunocompetent, no 2015 1 trauma Lahmer (25) odoratus necrotizing alcohol abuse 2016 1 pancreatitis Belloir (26) odoratimimus bacteremia CKD 2016 1 Jover-sáenz (27) odoratimimus prosthetic joint HCV cirrhosis, 2016 1 infection diabetes Willems (28) odoratimimus erysipelas and chronic steroid use, 2016 1 sepsis traumatic skin erosion Beharrysingh Myroides spp bacteremia and diabetes, Merkel cell 2017 1 (5) cellulitis carcinoma on carboplatin/etoposide Pompilio (34) odoratimimus calcaneal ulcer diabetes 2017 1 Licker (29) odoratimimus UTI papillary urothelial 2018 4 carcinoma, TURP, diabetes, kidney Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 transplant on immunosuppression Ahmed (30) odoratimimus UTI ESRD 2018 1 Lorenzin (33) odoratimimus UTI ESRD, CMML, 2018 1 Diabetes Current case injenensis cellulitis alcoholic cirrhosis 2019 1 Table 1. Reports of infections caused by Myroides spp. Host factors are underlying conditions and immunocompromising factors thought to contribute to risk of Myroides spp. infection. Ref This 33 30 29 28 25 23 21 20 19 17 13 12 8 7 5 2 case Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Species Inj Os Os Os Os Ods Ods Ods Os Os Om Om Om Os Ods M.spp Os Test ET& MD ND Vitek Vitek ND MD MD MB ND ND DD DD ND MD ND ND DD &ET Antibiotic Tested Ampicillin 16 >16 16 R Ampicillin/ S 4 >16/8 4 16 R clavulaunate Piperacillin 32 R >256 Pipericillin/ <4 64 >64/4 R R >64/4 <16/4 >256 64 S R >64/4 I S tazobactam Temocillin R >32 Cefuroxime >64 >256 R R Cefotaxime >64 >32 >256 32 R R Ceftriaxone >32 >256 I R >32 R Ceftazidime 32 >64 R >64 R >16 >16 >256 32 R R R R Cefepime I >16 R 16 >16 >16 48 16 16 R R Cefoxitin >64 R R Imipenem >8 >16 R R >8 <4 R >16 S S I S Meropenem S 4 R 4 R >8 <4 2 S S Ciprofloxacin <0.25 R >2 R S >2 <1 R 0.5 1 S >2 I R Levofloxacin <0.12 R 0.5 >4 <2 0.5 <0.5 Ofloxacin S Nitrofurantoin R 128 Colistin R >4 R >16 >2 R Gentamicin >16 R >8 R >16 >8 >8 >256 8 R R >8 R R Tobramycin >16 R >8 R >16 <4 8 >8 R R Amikacin >64 R >32 R >64 >32 <16 >256 >64 R R >32 R R Trim/Sulf 160 1/19 >8/152 R >320 S >2/38 <2/38 20 S >2/38 S R Tigecycline 1 R Clindamycin 0.5 Rifampin 2 R S Aztreonam >64 >16 R >16 >16 32 S >8 R Chloram R 8 S Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Vancomycin R >16 Cephalothin R Cefmetazole R Cefmenoxine R Cefoperazone R Cefazolin >32 R R Cefotetan 64 Ticarcillin R >256 Tetracycline 32 32 8 Cotrimoxazole 0.5/9.5 Cefoperazone/ >16 sulbactam Ceftazidime/ >32 Avibactam Fosfomycin R Table 2. Antibiotic resistant patterns for Myroides spp. Cases were selected by availability of data in the report. Holmes et al (1) not included because not all isolates analyzed were infectious, and isolate susceptibility patterns were not identified by isolate in the manuscript. Abbreviations: Ref= reference. Test= susceptibility testing method. Om= F. odoratum Os= M. odoratimimus Ods= M. odoratus. Inj= M. injenensis M.spp.=Myroides species, not further identified. MD=broth microdilution DD=disc diffusion. ET=E test ND=not defined. Trim/Sulf=Trimethoprim/sulfamethoxazole. Chloram= Chloramphenicol Accepted Manuscript Downloaded from https://academic.oup.com/ofid/advance-article-abstract/doi/10.1093/ofid/ofz282/5520232 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Image 1. Leg on day 2 of hospitalization. Image 2. Leg 4 weeks after initial presentation. Accepted Manuscript

Journal

Open Forum Infectious Diseases – Oxford University Press

Published: Jun 17, 2019

Keywords: cellulitis; multidrug resistance; Myroides

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