J Infect Chemother xxx (2014) 1e3
Contents lists available at ScienceDirect
Journal of Infection and Chemotherapy journal homepage: http://www.elsevier.com/locate/jic
Case report
Catheter-related bacteremia caused by Kocuria salsicia: The first case Kyung Mok Sohn a, *, Jin-Yang Baek b, So Hyun Kim b, Shinhye Cheon a, Yeon-Sook Kim a a b
Division of Infectious Diseases, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea Asia Pacific Foundation for Infectious Diseases (APFID), Seoul, South Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Received 28 August 2014 Received in revised form 30 October 2014 Accepted 4 November 2014 Available online xxx
We report the first case of catheter-related bacteremia caused by Kocuria salsicia in a patient with short bowel syndrome. The pathogen was initially identified as Kocuria varians by a Vitek 2-based assessment, but its 16S rRNA gene sequence showed 100% similarity to K. salsicia. The patient was successfully treated with vancomycin and removal of the catheter. © 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Keywords: Kocuria Bacteremia Catheter-related infections Vancomycin
1. Introduction Kocuria species are coagulase-negative, gram-positive cocci that belong to the family Micrococcaceae. They can be found in a variety of animals and soil. In humans, they are normal microflora of the skin and mucous membranes [1,2]. These microorganisms are usually considered to be contaminants, but they can cause major infections, mostly in immunocompromised hosts or patients with serious underlying conditions [3]. Eighteen Kocuria species have been described thus far [2]. Among these, only five Kocuria species (Kocuria kristinae, Kocuria varians, Kocuria rhizophila, Kocuria rosea, Kocuria marinia) have been documented to cause infections in humans. To our knowledge, there have been no reports of Kocuria salsicia being isolated from clinical specimens. Here, we present the first case of catheter-related bacteremia associated with K. salsicia. 2. Case report A 67-year-old female was referred to our hospital with a fourday history of fever and vomiting. She had been diagnosed with multiple cerebral infarctions two years earlier, but was not compliant with medications. Five months prior to the current
* Corresponding author. Division of Infectious Diseases, Chungnam National University Hospital, Chungnam National University School of Medicine, 282 Munhwa-ro, Jung-gu, Daejeon 301-721, South Korea. Tel.: þ82 42 280 7126; fax: þ82 42 280 8125. E-mail address: [email protected] (K.M. Sohn).
admission, she required a massive small bowel resection due to acute mesenteric ischemia. This surgery resulted in short bowel syndrome and a Hickman-type central venous catheter was implanted for nutritional support. On admission, the patient was alert and well-oriented. However, she was unable to leave her bed due to general weakness and sequelae of cerebral infarction. Her body temperature was 39.5 C, blood pressure was 140/95 mmHg, and heart rate was 125 beats per minute. On the second hospital day blood cultures from the date of admission grew gram-positive cocci. Blood cultures were repeated and empirical intravenous vancomycin was started. We removed the central venous catheter and cultured the tip since the time to positivity between the peripheral and central blood cultures was greater than two hours. Additional blood cultures and the tip culture grew gram-positive cocci in tetrads or clusters. Colonies were lemon-yellow in color, opaque and circular with entire margins on sheep blood agar rieux (Fig. 1). Isolates were identified by the Vitek 2 system (bioMe Inc., Durham, NC, USA) as Kocuria varians. However, the colony color was not consistent with that of K. varians. The 16S rRNA gene sequence (1417 bp) was compared using BLAST searches in the GenBank and EzTaxon public databases. The sequence was 100% identical to that of K. salsicia (GenBank accession number GQ352404). The second closest match was K. rhizophila with 98.9% homology (accession number Y16264). The repeated isolation of K. salsicia from different blood and catheter tip cultures suggests that K. salsicia was the cause of the patient's catheter-related blood rieux Inc.), stream infection. According to the Vitek system (bioMe the isolates were susceptible to vancomycin, ciprofloxacin,
http://dx.doi.org/10.1016/j.jiac.2014.11.005 1341-321X/© 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Sohn KM, et al., Catheter-related bacteremia caused by Kocuria salsicia: The first case, J Infect Chemother (2014), http://dx.doi.org/10.1016/j.jiac.2014.11.005
2
K.M. Sohn et al. / J Infect Chemother xxx (2014) 1e3
Fig. 1. Growth of Kocuria salsicia on a blood agar plate after 48 h of incubation, showing non-hemolytic, lemon-yellow colonies.
tetracycline, gentamicin, rifampicin, erythromycin, trimethoprim/ sulfamethoxazole, and clindamycin, but were resistant to oxacillin, mupirocin, and nitrofurantoin (Table 1). We did not perform further susceptibility testing because breakpoints for Kocuria have not been established. The patient's fever rapidly resolved after catheter removal. She received a total of two weeks of intravenous vancomycin, and repeated blood cultures were sterile. We implanted a Hickman-type catheter after completion of antibiotic therapy for management of her short bowel syndrome. The patient was transferred to a long-term care facility in her usual condition. 3. Discussion Kocuria species had been included in the genus Micrococcus, but were reclassified in 1995 into the genus Kocuria based on phylogenetic analysis and chemotaxonomic characteristics [2]. They are catalase-positive, non-motile, mesophilic, non-hemolytic cocci and appear in tetrads, clusters or pairs. Kocuria salsicia was first described in 2010, isolated from salt-fermented Korean seafood (flatfish) called gajami-sikhae [4]. On the agar surface, colonies of isolates from our case appeared lemon-yellow pigmentation, which
Table 1 Antimicrobial susceptibility profiles of Kocuria salsicia. Antibiotics
MIC (mg/mL)
Susceptibilitya
Ciprofloxacin Clindamycin Cotrimoxazole Erythromycin Fusidic acid Gentamicin Arbekacin Linezolid Mupirocin Nitrofurantoin Oxacillin Penicillin Rifampicin Teicoplanin Tetracycline Tigecycline Vancomycin
1 0.25 10 0.25 2 0.5 1 2 512 256 4 0.5 0.5 2 1 0.12 1
S S S S S S S S R R R R S S S S S
MIC, minimum inhibitory concentration; S, susceptible; R, resistant. a Because breakpoints for Kocuria have not been established, this result was referred to criteria for Staphylococcus.
is compatible with the characteristics of K. salsicia [3]. The closest species to K. salsicia is K. rhizophila, as shown in the present case. Infections in animals or humans have not yet been described. Twenty-five cases of bacteremia caused by Kocuria species have been reported in the literature [1,5e19]. Seventeen of these 25 patients (68%) were infected with K. kristinae, and the remaining patients with K. rosea (4), K. rhizophila (2), K. varians (1), or Kocuria marina (1). In contrast, according to a review of Kocuria-species peritonitis, K. varians was the most frequent pathogen (41.7%, 5 of 12 episodes) [20]. Because infections due to Kocuria species are rare, they may be misidentified or considered culture contaminants. However, a number of severe infections with Kocuria species have been reported, including central venous catheter-related bacteremia, endocarditis, cholecystitis, brain abscess, peritonitis in peritoneal dialysis patients, synovitis, bursitis, septic arthritis, and urinary tract infection [2,20]. Although most patients infected with Kocuria have serious underlying diseases or are immunocompromised, Kocuria can cause severe infections in immunocompetent hosts [9]. Kocuria bacteremia has frequently been observed in central venous-catheter-related infections in patients receiving total parenteral nutrition (TPN), as in our case. This indicates that TPN may be a potential risk factor for infection with Kocuria [9]. We could not find the source of K. salsicia infection. The patient had no history of eating fermented seafood like gajami-sikhae. rieux) results, the strain in In the API Staph and API ZYM (bioMe this case was positive for alkaline phosphatase, esterase lipase C8, urease and nitrate reduction, but negative for leucine arylamidase, valine arylamidase, cystine arylamidase, trypsin, acid phophatase, a-galactosidase, b-glucuronidase, a-glucosidase, b-glucosidase and arginine dihydrolase activities. It was positive for the assimilation of glucose, fructose, mannose, and maltose, but could not utilize mannitol and N-acetyl-glucosamine. These phenotypic characteristics were compatible with those of K. salsicia described by Yun et al. [4]. However, because the enzymatic activities, carbon source utilization, and nitrate reduction are heterogeneous in the different strains [3], we had to conduct genomic investigation for correct identification. Commercial identification systems can misidentify coagulasenegative staphylococci as Kocuria species or vice versa [2]. Although the recent Vitek 2 GP card introduced a supplementary database for the identification of K. kristinae and showed improved accuracy, commercial systems do not include all Kocuria species in their databases [2,3,10]. Because different species of Kocuria exhibit heterogeneous biochemical and carbon assimilation test results, phenotypic identification may not differentiate all Kocuria species [3]. Furthermore, because commercial identification systems can also misidentify within the Kocuria genus as in this report, precise identification of Kocuria to the species level requires genomic methods [19]. Matrix-assisted laser desorption/ionization time-offlight mass spectrometry (MALDI-TOF) correctly identified K. kristinae and K. rhizophila [15,12]. This method needs further evaluation for the identification of all classified Kocuria species. Most cases of catheter-associated bloodstream infection due to Kocuria resolved after catheter removal [1,6,9e11,14,19]. In one study, Kocuria rosea did not produce biofilm [2]. Although the ability of other Kocuria species to produce biofilm is unknown, recurrent bacteremia related to catheter use might imply biofilm formation [1,20]. In addition, glycopeptide therapy does not change the clinical course of bacteremia until the catheter is removed [1,5]. Therefore, catheter removal is likely necessary when Kocuria species involvement is suspected [9,10]. There are no treatment guidelines or susceptibility criteria for Kocuria. As a result, many studies referred to criteria for Staphylococcus. According to a review of in vitro susceptibilities of Kocuria species, there is no evidence of resistance to glycopeptides, fusidic
Please cite this article in press as: Sohn KM, et al., Catheter-related bacteremia caused by Kocuria salsicia: The first case, J Infect Chemother (2014), http://dx.doi.org/10.1016/j.jiac.2014.11.005
K.M. Sohn et al. / J Infect Chemother xxx (2014) 1e3
acid, rifampicin or linezolid, and variable susceptibility to betalactams, quinolones, and trimethoprim/sulfamethoxazole is observed [3]. Based on interpretative criteria for staphylococci, K. kristinae showed resistance to penicillin and oxacillin, but sensitivity to ampicillin and amoxicillin/clavulanate [10]. In contrast, Dunn et al. reported that K. kristinae was susceptible to all antibiotics tested [9]. Our strain (K. salsicia) was resistant to oxacillin (MIC 4 mg/L). Accordingly, we treated this isolate as panbeta-lactam-resistant to avoid clinical failure. This report is the first case of K. salsicia causing bacteremia related to central venous catheter use. Although infections caused by Kocuria species are believed to be rare, results from automated identification systems should be interpreted with caution and may require molecular methods such as 16S rRNA gene sequencing analysis for accurate identification of Kocuria species. Clinicians should not underestimate the importance of Kocuria, especially when the patient has an implanted medical device. Conflict of interest No conflicts of interest. References [1] Basaglia G, Carretto E, Barbarini D, Moras L, Scalone S, Marone P, et al. Catheter-related bacteremia due to Kocuria kristinae in a patient with ovarian cancer. J Clin Microbiol 2002;40:311e3. [2] Purty S, Saranathan R, Prashanth K, Narayanan K, Asir J, Devi CS, et al. The expanding spectrum of human infections caused by Kocuria species: a case report and literature review. Emerg Microbes Infect 2013;2. e71. [3] Savini V, Catavitello C, Masciarelli G, Astolfi D, Balbinot A, Bianco A, et al. Drug sensitivity and clinical impact of members of the genus Kocuria. J Med Microbiol 2010;59:1395e402. [4] Yun JH, Roh SW, Jung MJ, Kim MS, Park EJ, Shin KS, et al. Kocuria salsicia sp. nov., isolated from salt-fermented seafood. Int J Syst Evol Microbiol 2011;61: 286e9. [5] Altuntas F, Yildiz O, Eser B, Gundogan K, Sumerkan B, Cetin M. Catheterrelated bacteremia due to Kocuria rosea in a patient undergoing peripheral blood stem cell transplantation. BMC Infect Dis 2004;4:62.
3
[6] Becker K, Rutsch F, Uekotter A, Kipp F, Konig J, Marquardt T, et al. Kocuria rhizophila adds to the emerging spectrum of micrococcal species involved in human infections. J Clin Microbiol 2008;46:3537e9. [7] Martinaud C, Gisserot O, Gaillard T, Brisou P, de Jaureguiberry JP. Bacteremia caused by Kocuria kristinae in a patient with acute leukaemia. Med Mal Infect 2008;38:334e5. [8] Shivaprakasha S, Radhakrishnan K, Kamath P, Jayaprakash C, Shailaja T, Karim P. Prosthetic valve endocarditis due to Kocuria varians. Internet J Microbiol 2009;6:14. [9] Dunn R, Bares S, David MZ. Central venous catheter-related bacteremia caused by Kocuria kristinae: case report and review of the literature. Ann Clin Microbiol Antimicrob 2011;10:31. [10] Lai CC, Wang JY, Lin SH, Tan CK, Wang CY, Liao CH, et al. Catheter-related bacteraemia and infective endocarditis caused by Kocuria species. Clin Microbiol Infect 2011;17:190e2. [11] Corti M, Villafane MF, Soto I, Palmieri O, Callejo R. Bacteremia by Kocuria rosea in an AIDS patient. Rev Chil Infectol 2012;29:355e6. [12] Moissenet D, Becker K, Merens A, Ferroni A, Dubern B, Vu-Thien H. Persistent bloodstream infection with Kocuria rhizophila related to a damaged central catheter. J Clin Microbiol 2012;50:1495e8. [13] Karadag Oncel E, Boyraz MS, Kara A. Black tongue associated with Kocuria (Micrococcus) kristinae bacteremia in a 4-month-old infant. Eur J Pediatr 2012;171:593. [14] Chen HM, Chi H, Chiu NC, Huang FY. Kocuria kristinae: a true pathogen in pediatric patients. J Microbiol Immunol Infect 2013. http://dx.doi.org/ 10.1016/j.jmii.2013.07.001. [15] Citro R, Prota C, Greco L, Mirra M, Masullo A, Silverio A, et al. Kocuria kristinae endocarditis related to diabetic foot infection. J Med Microbiol 2013;62: 932e4. [16] Kiraz A, Durmaz S, Baykan A, Perçin D. Endocarditis and bacteremia due to Kocuria rosea following heart valve replacement. Eur J Basic Med Sci 2013;3: 93e5. [17] Seyman D, Kizilates F, Oztoprak N, Ayoglu RU, Arslan S. Kocuria kristinae: a rare cause of infective endocarditis involving 2 native valves. Infect Dis Clin Pract 2013;21:407e9. [18] Srinivasa KH, Agrawal N, Agarwal A, Manjunath CN. Dancing vegetations: Kocuria rosea endocarditis. BMJ Case Rep 2013. http://dx.doi.org/10.1136/bcr2013-010339. [19] Lee MN, Huh HJ, Kim B, Kang CI, Kim K, Ki CS, et al. A case of catheter-related Kocuria marina bloodstream infection in a patient with multiple myeloma. Lab Med Online 2014;4:51e4. [20] Dotis J, Printza N, Stabouli S, Papachristou F. Kocuria species peritonitis: although rare, we have to care. Perit Dial Int 2014. http://dx.doi.org/10.3747/ pdi.2013.00138.
Please cite this article in press as: Sohn KM, et al., Catheter-related bacteremia caused by Kocuria salsicia: The first case, J Infect Chemother (2014), http://dx.doi.org/10.1016/j.jiac.2014.11.005
Contents lists available at ScienceDirect
Journal of Infection and Chemotherapy journal homepage: http://www.elsevier.com/locate/jic
Case report
Catheter-related bacteremia caused by Kocuria salsicia: The first case Kyung Mok Sohn a, *, Jin-Yang Baek b, So Hyun Kim b, Shinhye Cheon a, Yeon-Sook Kim a a b
Division of Infectious Diseases, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea Asia Pacific Foundation for Infectious Diseases (APFID), Seoul, South Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Received 28 August 2014 Received in revised form 30 October 2014 Accepted 4 November 2014 Available online xxx
We report the first case of catheter-related bacteremia caused by Kocuria salsicia in a patient with short bowel syndrome. The pathogen was initially identified as Kocuria varians by a Vitek 2-based assessment, but its 16S rRNA gene sequence showed 100% similarity to K. salsicia. The patient was successfully treated with vancomycin and removal of the catheter. © 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Keywords: Kocuria Bacteremia Catheter-related infections Vancomycin
1. Introduction Kocuria species are coagulase-negative, gram-positive cocci that belong to the family Micrococcaceae. They can be found in a variety of animals and soil. In humans, they are normal microflora of the skin and mucous membranes [1,2]. These microorganisms are usually considered to be contaminants, but they can cause major infections, mostly in immunocompromised hosts or patients with serious underlying conditions [3]. Eighteen Kocuria species have been described thus far [2]. Among these, only five Kocuria species (Kocuria kristinae, Kocuria varians, Kocuria rhizophila, Kocuria rosea, Kocuria marinia) have been documented to cause infections in humans. To our knowledge, there have been no reports of Kocuria salsicia being isolated from clinical specimens. Here, we present the first case of catheter-related bacteremia associated with K. salsicia. 2. Case report A 67-year-old female was referred to our hospital with a fourday history of fever and vomiting. She had been diagnosed with multiple cerebral infarctions two years earlier, but was not compliant with medications. Five months prior to the current
* Corresponding author. Division of Infectious Diseases, Chungnam National University Hospital, Chungnam National University School of Medicine, 282 Munhwa-ro, Jung-gu, Daejeon 301-721, South Korea. Tel.: þ82 42 280 7126; fax: þ82 42 280 8125. E-mail address: [email protected] (K.M. Sohn).
admission, she required a massive small bowel resection due to acute mesenteric ischemia. This surgery resulted in short bowel syndrome and a Hickman-type central venous catheter was implanted for nutritional support. On admission, the patient was alert and well-oriented. However, she was unable to leave her bed due to general weakness and sequelae of cerebral infarction. Her body temperature was 39.5 C, blood pressure was 140/95 mmHg, and heart rate was 125 beats per minute. On the second hospital day blood cultures from the date of admission grew gram-positive cocci. Blood cultures were repeated and empirical intravenous vancomycin was started. We removed the central venous catheter and cultured the tip since the time to positivity between the peripheral and central blood cultures was greater than two hours. Additional blood cultures and the tip culture grew gram-positive cocci in tetrads or clusters. Colonies were lemon-yellow in color, opaque and circular with entire margins on sheep blood agar rieux (Fig. 1). Isolates were identified by the Vitek 2 system (bioMe Inc., Durham, NC, USA) as Kocuria varians. However, the colony color was not consistent with that of K. varians. The 16S rRNA gene sequence (1417 bp) was compared using BLAST searches in the GenBank and EzTaxon public databases. The sequence was 100% identical to that of K. salsicia (GenBank accession number GQ352404). The second closest match was K. rhizophila with 98.9% homology (accession number Y16264). The repeated isolation of K. salsicia from different blood and catheter tip cultures suggests that K. salsicia was the cause of the patient's catheter-related blood rieux Inc.), stream infection. According to the Vitek system (bioMe the isolates were susceptible to vancomycin, ciprofloxacin,
http://dx.doi.org/10.1016/j.jiac.2014.11.005 1341-321X/© 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Sohn KM, et al., Catheter-related bacteremia caused by Kocuria salsicia: The first case, J Infect Chemother (2014), http://dx.doi.org/10.1016/j.jiac.2014.11.005
2
K.M. Sohn et al. / J Infect Chemother xxx (2014) 1e3
Fig. 1. Growth of Kocuria salsicia on a blood agar plate after 48 h of incubation, showing non-hemolytic, lemon-yellow colonies.
tetracycline, gentamicin, rifampicin, erythromycin, trimethoprim/ sulfamethoxazole, and clindamycin, but were resistant to oxacillin, mupirocin, and nitrofurantoin (Table 1). We did not perform further susceptibility testing because breakpoints for Kocuria have not been established. The patient's fever rapidly resolved after catheter removal. She received a total of two weeks of intravenous vancomycin, and repeated blood cultures were sterile. We implanted a Hickman-type catheter after completion of antibiotic therapy for management of her short bowel syndrome. The patient was transferred to a long-term care facility in her usual condition. 3. Discussion Kocuria species had been included in the genus Micrococcus, but were reclassified in 1995 into the genus Kocuria based on phylogenetic analysis and chemotaxonomic characteristics [2]. They are catalase-positive, non-motile, mesophilic, non-hemolytic cocci and appear in tetrads, clusters or pairs. Kocuria salsicia was first described in 2010, isolated from salt-fermented Korean seafood (flatfish) called gajami-sikhae [4]. On the agar surface, colonies of isolates from our case appeared lemon-yellow pigmentation, which
Table 1 Antimicrobial susceptibility profiles of Kocuria salsicia. Antibiotics
MIC (mg/mL)
Susceptibilitya
Ciprofloxacin Clindamycin Cotrimoxazole Erythromycin Fusidic acid Gentamicin Arbekacin Linezolid Mupirocin Nitrofurantoin Oxacillin Penicillin Rifampicin Teicoplanin Tetracycline Tigecycline Vancomycin
1 0.25 10 0.25 2 0.5 1 2 512 256 4 0.5 0.5 2 1 0.12 1
S S S S S S S S R R R R S S S S S
MIC, minimum inhibitory concentration; S, susceptible; R, resistant. a Because breakpoints for Kocuria have not been established, this result was referred to criteria for Staphylococcus.
is compatible with the characteristics of K. salsicia [3]. The closest species to K. salsicia is K. rhizophila, as shown in the present case. Infections in animals or humans have not yet been described. Twenty-five cases of bacteremia caused by Kocuria species have been reported in the literature [1,5e19]. Seventeen of these 25 patients (68%) were infected with K. kristinae, and the remaining patients with K. rosea (4), K. rhizophila (2), K. varians (1), or Kocuria marina (1). In contrast, according to a review of Kocuria-species peritonitis, K. varians was the most frequent pathogen (41.7%, 5 of 12 episodes) [20]. Because infections due to Kocuria species are rare, they may be misidentified or considered culture contaminants. However, a number of severe infections with Kocuria species have been reported, including central venous catheter-related bacteremia, endocarditis, cholecystitis, brain abscess, peritonitis in peritoneal dialysis patients, synovitis, bursitis, septic arthritis, and urinary tract infection [2,20]. Although most patients infected with Kocuria have serious underlying diseases or are immunocompromised, Kocuria can cause severe infections in immunocompetent hosts [9]. Kocuria bacteremia has frequently been observed in central venous-catheter-related infections in patients receiving total parenteral nutrition (TPN), as in our case. This indicates that TPN may be a potential risk factor for infection with Kocuria [9]. We could not find the source of K. salsicia infection. The patient had no history of eating fermented seafood like gajami-sikhae. rieux) results, the strain in In the API Staph and API ZYM (bioMe this case was positive for alkaline phosphatase, esterase lipase C8, urease and nitrate reduction, but negative for leucine arylamidase, valine arylamidase, cystine arylamidase, trypsin, acid phophatase, a-galactosidase, b-glucuronidase, a-glucosidase, b-glucosidase and arginine dihydrolase activities. It was positive for the assimilation of glucose, fructose, mannose, and maltose, but could not utilize mannitol and N-acetyl-glucosamine. These phenotypic characteristics were compatible with those of K. salsicia described by Yun et al. [4]. However, because the enzymatic activities, carbon source utilization, and nitrate reduction are heterogeneous in the different strains [3], we had to conduct genomic investigation for correct identification. Commercial identification systems can misidentify coagulasenegative staphylococci as Kocuria species or vice versa [2]. Although the recent Vitek 2 GP card introduced a supplementary database for the identification of K. kristinae and showed improved accuracy, commercial systems do not include all Kocuria species in their databases [2,3,10]. Because different species of Kocuria exhibit heterogeneous biochemical and carbon assimilation test results, phenotypic identification may not differentiate all Kocuria species [3]. Furthermore, because commercial identification systems can also misidentify within the Kocuria genus as in this report, precise identification of Kocuria to the species level requires genomic methods [19]. Matrix-assisted laser desorption/ionization time-offlight mass spectrometry (MALDI-TOF) correctly identified K. kristinae and K. rhizophila [15,12]. This method needs further evaluation for the identification of all classified Kocuria species. Most cases of catheter-associated bloodstream infection due to Kocuria resolved after catheter removal [1,6,9e11,14,19]. In one study, Kocuria rosea did not produce biofilm [2]. Although the ability of other Kocuria species to produce biofilm is unknown, recurrent bacteremia related to catheter use might imply biofilm formation [1,20]. In addition, glycopeptide therapy does not change the clinical course of bacteremia until the catheter is removed [1,5]. Therefore, catheter removal is likely necessary when Kocuria species involvement is suspected [9,10]. There are no treatment guidelines or susceptibility criteria for Kocuria. As a result, many studies referred to criteria for Staphylococcus. According to a review of in vitro susceptibilities of Kocuria species, there is no evidence of resistance to glycopeptides, fusidic
Please cite this article in press as: Sohn KM, et al., Catheter-related bacteremia caused by Kocuria salsicia: The first case, J Infect Chemother (2014), http://dx.doi.org/10.1016/j.jiac.2014.11.005
K.M. Sohn et al. / J Infect Chemother xxx (2014) 1e3
acid, rifampicin or linezolid, and variable susceptibility to betalactams, quinolones, and trimethoprim/sulfamethoxazole is observed [3]. Based on interpretative criteria for staphylococci, K. kristinae showed resistance to penicillin and oxacillin, but sensitivity to ampicillin and amoxicillin/clavulanate [10]. In contrast, Dunn et al. reported that K. kristinae was susceptible to all antibiotics tested [9]. Our strain (K. salsicia) was resistant to oxacillin (MIC 4 mg/L). Accordingly, we treated this isolate as panbeta-lactam-resistant to avoid clinical failure. This report is the first case of K. salsicia causing bacteremia related to central venous catheter use. Although infections caused by Kocuria species are believed to be rare, results from automated identification systems should be interpreted with caution and may require molecular methods such as 16S rRNA gene sequencing analysis for accurate identification of Kocuria species. Clinicians should not underestimate the importance of Kocuria, especially when the patient has an implanted medical device. Conflict of interest No conflicts of interest. References [1] Basaglia G, Carretto E, Barbarini D, Moras L, Scalone S, Marone P, et al. Catheter-related bacteremia due to Kocuria kristinae in a patient with ovarian cancer. J Clin Microbiol 2002;40:311e3. [2] Purty S, Saranathan R, Prashanth K, Narayanan K, Asir J, Devi CS, et al. The expanding spectrum of human infections caused by Kocuria species: a case report and literature review. Emerg Microbes Infect 2013;2. e71. [3] Savini V, Catavitello C, Masciarelli G, Astolfi D, Balbinot A, Bianco A, et al. Drug sensitivity and clinical impact of members of the genus Kocuria. J Med Microbiol 2010;59:1395e402. [4] Yun JH, Roh SW, Jung MJ, Kim MS, Park EJ, Shin KS, et al. Kocuria salsicia sp. nov., isolated from salt-fermented seafood. Int J Syst Evol Microbiol 2011;61: 286e9. [5] Altuntas F, Yildiz O, Eser B, Gundogan K, Sumerkan B, Cetin M. Catheterrelated bacteremia due to Kocuria rosea in a patient undergoing peripheral blood stem cell transplantation. BMC Infect Dis 2004;4:62.
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Please cite this article in press as: Sohn KM, et al., Catheter-related bacteremia caused by Kocuria salsicia: The first case, J Infect Chemother (2014), http://dx.doi.org/10.1016/j.jiac.2014.11.005
