Catheter Associated Blood Stream Infection Related to Chryseobacterium Indologenes in a Case with Acute Renal Failure

Chryseobacterium indologenes (C.indologenes) formerly Flavobacterium indologenes is not generally known as infectious agents and are rarely isolated in human infection [1]. C.indologenes is found primarily in soil and water. The organism can survive in chlorinated water supplies, frequently colonizing taps and be reservoirs for infections in the hospital. Colonization of patients through contaminated medical devices involving solutions such as respirators, intubation tubes, the intravenous catheter [2]. Previous studies have reported that C.indologenes can cause pneumonia, sepsis, and tracheobronchitis. C.indologenes is the primarily opportunistic pathogen in newborns and immunocompromised patients [3-6]. This report presents the case of a non-immunosuppressive patient developed C. indologenes related catheter-associated bloodstream infection, following acute renal failure treatment. Case Report

Chryseobacterium indologenes (C.indologenes) presence in soil, water, plants and can be detected in water systems, tap wetter and wet surfaces in the hospital environment because of its vitality in the chlorinated waters. C.indologenes is not involved in the human flora and rarely isolated as infectious agent. A 80 years old female patient, with known hypertension, who applied to hospital with complaint of nausea and vomiting was diagnosed as prerenal acute renal failure according to clinical and laboratory findings (TA: 75/ 50mmHg, urea: 85,06mg/dl, creatinine: 10.4mg/dl, pH: 7.22mmol/L, HC03: 16.3mmol/L, Na: 129mg/dl, K: 4.3mg/dl, Cl 93.1mg/dl,). Hemodialysis catheter was inserted due to hemodialysis requirement. It was seen that following hydration therapy, creatinine levels decreased. On the fifth day of hospitalization, the patient's fever was increased (38.5 °C) and the CRP value was 82.14mg/L. After the blood culture samples were taken, ceftriaxone and clindamycin were used as empirical treatment. The isolate was identified from blood samples as C. indologenes with both conventional methods (Gram strain, oxidase, indole, lactose, citrate, urease) and Microscan (Beckman Coulter, USA) automated system. Antibiotic susceptibilities were determined by both disk diffussion method and Microscan (Beckman Coulter, USA) automated system too. The isolate was found to be susceptible to ciprofloxacin, levofloxacin, piperacillin tazobactam, trimethoprim-sulfamethoxazole and resistant to cefotaxime, gentamicin, amikacin, tobramycin, ceftazidime, aztreonam, imipenem, meropenem, tetracycline, chloramphenicol. On the third day of antibiotic therapy, CRP (21.03 mg/L) started to decrease. During the follow-up, renal function was improved and fever control was provided. The patient was discharged on the 11 th day after the treatment with clindamycin and ciprofloxacin. As a result, it should be noted, C.indologenes can be found in the hospital environment, may cause infections with intravenous catheter applications. So avoided unnecessary applications and infection control measures should be taken in this regard. The patient was discharged on the 11 th day after the treatment.

Discussion
Opportunistic infections due to this organism, often arising from colonization of indwelling mechanical devices [8]. C. indologenes is of low pathogenicity. The production of biofilm on foreign materials may play an important role in the virulence of invasive infections caused by C. İndologenes [9,10]. Risc factors of C. indologenes were hospitalization, malignity and especially immunosuppression [1,3].
C. indologenes reported related tracheobronchitis in transplante patient who take anti-tuberculosis treatment for six months [4].
Ceylan, et al. [3] observed a case of fatal C. indologenes septicemia developed in a newborn with hydrocephalus. Christakis et al. [11] indicated non-catheter-related bacteremia caused by C. indologenes in a patient with a solid tumor. They highlihted, although the majority of C. indologenes infections are linked to the use of indwelling devices. In the literature, C. indologenes appears to cause infection in immunosuppressed patients [3,4,11]. However, it has been reported that it may be an infectious agent in immunocompetent individuals. McKewa, et al. [5] reported case of severe sepsis from a 53 year old man with no underlying medical conditions was admitted with the septic shock one week after returning from hiking. They indicated the organism has the potential to be highly pathogenic. In this report, C. indologenes infection occurred due to intravenous catheter use during the treatment of acute renal failure in an immunocompetent patient in hospital.
Antimicrobial susceptibility data of C. indologenes is limited since this pathogen has been barely isolated from clinical specimens. The SENTRY Antimicrobial Surveillance Program conducted by using results from North America, Latin America, Europe, and the Asia-Pacific region detected that the most active agents against C. indologenes are the quinolones and trimethoprimsulfamethoxazole, followed by piperacillin-tazobactam. In addition, aminoglycosides, chloramphenicol, linezolid, and glycopeptides are not appropriate for treating infections due to this organism [12]. Also, C. indologenes strains are the natural reservoir of chromosomally linked metallo-β-lactamases [13]. In this report in accordance with previous studies quinolones, piperacillin tazobactam and trimethoprim-sulfamethoxazole seem the most