Case Report

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Journal of Taibah University Medical Sciences (2014) xxx, xxx–xxx

Taibah University

Journal of Taibah University Medical Sciences

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aoultella planticola, a central venous line exit site infection

okhary Nada, MD a,* and Mufti Areej, MD b

Department of General Pediatric, King Abdul-Aziz Medical City, Jeddah, Kingdom of Saudi ArabiaDepartment of Medical Microbiology, King Abdul-Aziz Medical City, Jeddah, Kingdom of Saudi Arabia

eceived 22 September 2013; revised 31 October 2013; accepted 1 November 2013

صخلملاريغ،ةيئاوهلا،مارغلاةيبلستايصعلاعاونأنمعونيهالوكيتنالبالتلويوار

اماردانيتلاةيئيبلاايريتكبلاعاونأنملوألاماقملايفربتعتيتلاةكرحتملا.ةيرشبىودعتالاحبببستت

15اهرمعةلفطلةيزكرملاةرطثقلاجورخناكميفحرجلاىودعةلاحلضرعنمت.عضبلللاتقتفحالصإويفئافللارغفقالغاةيلمعءارجإلاهميونتمت،ًارهش.%99ةيلامتحاب"2كتف"يويحلايئايميكلاماظنلامادختسابايرتكبلاىلعفرعتلا،نيسيماتنجلاو،نيلسبمألاةيويحلاتاداضملاذخأةضيرملاتأدبونأودبيو.ةيزكرملاةرطثقلاةلازإمتوةيلمعلاءارجإلبق،لوزادينورتيملاو.نيسيماتنجلاريثأتوةرطثقلاةلازإباهيلعيضُقىودعلا

ببسبةيزكرملاةرطسقلاناكمحرجلابىودعنمتناعةضيرملاهذهنإفهيلعايتاذةددحمىودعلانأودبيامك.يحلانئاكلاتابنتسابتدكأت،الوكيتنالبالتلويوارةيويحتاداضممادختساوأةيويحلاتاداضملارييغتىلإةضيرملاجاتحتملو.ىرخأةيعضوم

ةيزكرملاةرطثقلاجورخحرجىودع;الوكيتنالبالتلويوار:ةيحاتفملاتاملكلا

Abstract

Raoultella planticola is a Gram negative, aerobic, non-

motile bacilli primarily considered to be environmental bac-

teria. It is a rare cause of human infections. We report a

case of central catheter line exit site wound infection in a

15-month-old baby girl who was admitted electively for clo-

sure of ileostomy and incisional hernia repair. We identify

the organism as R. planticola using Vitek2 biochemical

identification system with a 99% probability. The patient

was already on ampicillin, gentamicin and metronidazole

started preoperatively and the central catheter was

removed. Apparently the infection was eradicated by

removal of the catheter and the effect of gentamicin, and

the patient did not require changing the antibiotic or using

other local antibiotic.

Keywords: Central catheter line exit site infection; Raoultella

planticola

� 2014 Taibah University. Production and hosting by Elsevier

Ltd. All rights reserved.

* Corresponding address: Fellow, Pediatrics Department, Section of

audi Arabia. Tel.: +966 12 6240000.

E-mail: bokharyf@yahoo.com (B. Nada)

eer review under responsibility of Taibah University.

Production and hosting by Elsevier

658-3612 � 2014 Taibah University. Production and hosting by Elsev

ttp://dx.doi.org/10.1016/j.jtumed.2013.11.008

lease cite this article in press as: Nada B., Areej M. Raoultella planticedical Sciences (2014), http://dx.doi.org/10.1016/j.jtumed.2013.11.00

Introduction

Raoultella planticola is an aquatic, botanical and soil organismthat does not typically cause invasive infections in humans.This organism and Raoultella ornithinolytica produce histidine

decarboxylase and have been implicated in scombroid (hista-mine) fish poisoning, but the clinical significance of this organ-ism in humans has not been characterized. R. planticola was

included in the genus Klebsiella until the late 1990s. It was firstdescribed as Klebsiella planticola in 19811 and as Klebsiellatrevisanii in 1983.2 In 1986, the two organisms were placed in

Infectious Disease, King Abdul-Aziz Medical City, Jeddah, Kingdom of

ier Ltd. All rights reserved.

ola, a central venous line exit site infection. Journal of Taibah University8

2 B. Nada, M. Areej

the same species because of their extensive DNA sequence sim-ilarity;3 however, on the basis of the 16S rRNA gene and rpoBsequence analysis, the new genus Raoultella was created, and

the name R. planticola was proposed to accommodate K.planticola.4 The first case of human infection with this organ-ism was reported in 1984 in a patient with sepsis admitted to

an intensive care unit in France.5 In 1986, two other cases werereported, the first a bloodstream infection after mitral valvereplacement for infective endocarditis and the second a case

of bacteraemic pneumonia after coronary artery graft surgery.6

A survey of newborns in a neonatal ward in Germany over1 year showed that 72% of Klebsiella species were Klebsiellaoxytoca and 8.7% were K. planticola recovered from oropha-

ryngeal and rectal swab specimens.7 Alves et al.8 reported acase of severe pancreatitis complicated by R. planticola infec-tion. Two strains of R. planticola showing resistance to carba-

penem were recovered from patients hospitalized in the USA.One had been admitted for pneumonia and bacteraemia, whilethe other was known to have pre-acute B-lymphoblastic leuke-

mia and developed a perirectal abscess, which requireddebridement. Unfortunately, both patients died even afterthe antibiotics were changed. These strains harbored blaKPC-2and blaKPC-3.

9 In 2010, Wolcott et al. described a case ofpolymicrobial surgical site infection primarily due to R. planti-cola in a male patient with a fractured left tibia who had anopen reduction internal fixation of his left ankle; he was trea-

ted with ertapenem.10 Recent case reports include a rare caseof serious soft tissue infection in the thumb of a young male11

and a case of cholecystitis caused by R. planticola in a 62-year-

old woman.12 Kim et al.13 reported the first case of necrotizingfasciitis involving the chest and abdominal wall caused by R.planticola.

Three cases of cholangitis associated with R. planticolainfection were reported in 2012, all in immunocompromisedpatients who underwent procedural intervention with endo-

scopic retrograde cholangiopancreatography.14–16

A novel case of R. planticola urinary tract infection was re-ported as a first case of cystitis.17 Gastroenteritis developed ina patient who ate undercooked fish (sole), and R. planticola

bacteremia was reported.18

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Table 1: Reported cases of R planticola infections.

References Clinical manifestation

Freney J et al. (1984)5 Septicemia

Freney J et al. (1986)6 Bacteremia

Freney J et al. (1986)6 Septicemia

Alves MS et al. (2007)8 Pancreatitis

Mariana C et al. (2009)9 Pneumonia

Mariana C et al. (2009)9 Leukemia

Wolcott R et al. (2010)10 Surgical site/fracture

O’ Connell K et al. (2010)11 Soft tissue infection

Teo I et al. (2012)12 Cholecystitis

Kim Si K et al. (2012)13 Necrotizing fasciitis

Kazuhisa Y et al. (2012) 14 Cholangitis/septic shock/cancer

Jae H et al. (2012)15 Cholangitis/cancer

Amy Y.H et al. (2012) 16 Bacteremia

Olson DS Jr, et al. (2013)17 Urinary tract infection

Puerta S et al. (2013) 18 Bacteremia/gastroenteritis

Current report Central venous line exit site infection

Please cite this article in press as: Nada B., Areej M. Raoultella planMedical Sciences (2014), http://dx.doi.org/10.1016/j.jtumed.2013.11.

We report a case of central line exit wound infection causedy R. planticola. To our knowledge, this is the first reportedase of human infection with this organism in Saudi Arabia.

ase report

girl born at King Abdul-Aziz Medical City, Jeddah, at

5 weeks’ gestational age was found by ultrasound to haven intestinal obstruction in utero. Examination after birth re-ealed a distended abdomen with bilious vomitus and intesti-

al obstruction, and abdominal ultrasound showed aomplex cystic mass in the abdomen. She underwent laparot-my and peritoneal lavage with excision of the mass, which

as confirmed to be a meconium cyst. Post-operatively, sheeveloped a complicated meconium ileus and peritonitis,hich required ileostomy. She was discharged home in a good

ondition with regular follow-up in the clinic and grew welluring the neonatal period.At 15 months, she was admitted electively for closure of the

leostomy and incisional hernia repair in February 2013. On

dmission, her temperature was 36.8 �C, her respiratory rate3/min, her blood pressure 90/49 mmHg, her pulse rate 110/in, her body weight 7.56 kg and her height 65 cm. An inter-

al jugular line was inserted in the operating room, and sheas started on ampicillin, gentamicin, and metronidazole.n day 6 postoperatively, she had two spikes of fever of 38 �and was found to have pus at the exit site of the central line.eptic screening was done, the central line was removed, andhe exit site was cleaned aseptically. Investigations showed aegative blood culture, but a swab from the exit site showed

. planticola with 99% probability in the Vitek2 biochemicaldentification system.

No other organisms were isolated from cultures at other

ites. The organism was resistant to ampicillin, piperacillinnd trimethoprim/sulfamethoxazole but sensitive to amoxicil-in and clavulanic acid, piperacillin and tazobactam, cefalotin,

efazolin, cefuroxime axetil, cefuroxime, cefoxitin, cefpodox-me, cefotaxime, ceftazidim, cefepime, meropenem, amikacin,entamicin, tobramycin and ciprofloxacin. The patient com-

leted a 10-day course of ampicillin, gentamicin and

Age Treatment Outcome

47/male Cefotaxim, tobramycin Recovered

57/male Ceftriaxon Recovered

69/male Ceftriaxon, tobramycin Recovered

45/male Imipenem, amikacin Recovered

83/female Carbapenem Died

64/male Imipenem/doxycycline Died

66/male Ertapenem Recovered

30/male Ciprofloxacin Recovered

62/female Co-amoxiclav Recovered

66 /male Ceftriaxon, levofloxacin, tigecycline Recovered

65/male Pipracillin-tazobactam Recovered

75/male Cefotaxime, metronidazole Died

59/male Pipracillin-tazobactam Recovered

89/male Ciprofloxacin Recovered

63/male Cefotaxime Recovered

15 months/female Ampicillin, gentamicin, metronidazole Recovered

ticola, a central venous line exit site infection. Journal of Taibah University008

metronidazole and required no further treatment for this infec-tion. She was discharged home in good general condition. Atfollow-up in the outpatient clinic, the exit site of central line

was clean, with complete healing.

Discussion

The patient in this case report experienced an exit site infectionof the central catheter line caused by R. planticola, isolated byculture. The organism was identified by Vitek2 with 99% prob-

ability. The infection was probably eradicated by removal ofthe catheter and the effect of gentamicin and did not requirechanging the antibiotic or using a local antibiotic. As the child

was already on ampicillin, gentamicin and metronidazole,which were started on the day of surgical repair of the herniaand closure of the ileostomy, we decided to continue the same

antibiotics and to remove the central line, with close observa-tion and aseptic cleaning of the site. With clinical improvementand good healing at the wound site, the child was dischargedwith follow-up.

Table 1 summarizes all the reported cases and outcomes ofR. planticola infections in humans. The source of the organismin our patient might have contaminated infant formula or

environmental sources, such as earth or water, but the originwas not studied.

Conclusion

R. planticola has been identified on a few occasions as thecause of human infection. It has been reported to be present

in clinical specimens and should be suspected in immunocom-promised patients and after procedural interventions. As thisorganism can cause significant comorbidity, it must be cor-

rectly identified and its susceptibility tested to guide antimicro-bial therapy and improve outcome.

Ethics of publishing

The approval of the parents of the child for publication wasobtained.

Conflict of interest

None declared.

References

1. Bagley ST, Seidler RJ, Brenner DJ. Klebsiella planticola SP nov.: a

new species of Enterobacteriaceae found primarily in nonclinical

environments. Curr Microbiol 1981; 6: 105–109.

2. Ferragut C, Izard D, Gavini F, Kersters K, De Ley J, Leclerc H.

Klebsiella trevisanii: a new species from water and soil. Int J Sys

Bacteriol 1983; 33: 133–142.

3. Gavini F, Izard D, Grimont PAD, Beji A, Ageron E, Leclerc H.

Priority of Klebsiella planticola Bagley, Seidler and Brenner 1982

over Klebseiella trevisani Ferragout, Izard, Gavini, Kersters,

Deley, and Leclerc 1983. Int J Sys Bacteriol 1986; 36: 486.

4. Drancourt M, Bollet C, Carta A, Rousselier P. Phylogenetic

analyses of Klebsiella species delineate Klebsiella and raoultella

gen. nov. with description of Raoultella ornithinolytica comb. nov.

Raoultella terrigena comb. nov. and Raoultella planticola comb.

nov. Int J Sys Evol Microbial 2001; 51: 925–932.

5. Freney J, Fleurette J, Gruer LD, Desmonceaux M, Gavini F,

Leclerc H. Klebsiella trevisanii colonization and septicaemia.

Lancet 1984; 8382: 909.

6. Freney J, Gavini F, Alexandre H, Madier S, Izard D, Leclerc H,

Fleurette J. Nosocomial infection and colonization by Klebsiella

trevisani. J Clin Microbiol 1986; 23: 948–950.

7. Podschun R, Acktun H, Okpara J, Linerkamp O, Ullmann U,

Borneff-Lipp M. Isolation of Klebsiella planticola from newborns

in neonatal ward. J Clin Microbiol 1998; 36: 2331–2332.

8. Alves MS, Riley LW, Moreira BM. A case of severe pancreatitis

complicated by Raoultella planticola infection. J Med Microbiol

2007; 56: 696–698.

9. Castanheira M, Deshpande LM, DiPersio JR, Kang J, Weinstein

RN, Jones RN. First descriptions of blaKPC in Raoultella spp. (R.

planticola and R. ornithinolytica): report from the SENTRY

antimicrobial surveillance program. J Clin Microbiol 2009; 47:

4129–4130.

10. Wolcott R, Dowd S. Molecular diagnosis of Raoultella planticola

infection of a surgical site. J Wound Care 2010; 19: 329–332.

11. O’Connell K, Kelly J, Niriain U. A rare case of soft tissue

infection caused by Raoultella planticola. Case Rep Med 2010;

Article ID 134086.

12. Teo I, Wild J, Ray S, Chadwick D. A rare case of cholecystitis

caused by Raoultella planticola. Case Rep Med 2012; Article ID

601641. http://dx.doi.org/10.1155/2012/601641.

13. Kim SH, Roh KH, Yoon YK, Kang DO, Lee DW, KimMJ, Sohn

JW. Necrotizing fasciitis involving the chest and abdominal wall

caused by Raoultella planticola. BMC Infect Dis 2012; 12: 59.

14. Kazuhisa Y, Harumi G, Yoshimasa M, Kentaro S, Yuji M.

Cholangitis with septic shock caused by Raoultella planticola. J

Med Microbiol 2012; 61: 446–449.

15. Jae HL, Won SC, Seung HK, Dae WY, Ja SK, Jai HC. A case of

severe cholangitis caused by Raoultella planticola in a patient with

pancreatic cancer. Infect Chemother 2012; 44: 210–212.

16. Hu AY, Leslie KA, Baskette J, Elsayed S. Raoultella planticola

bacteraemia. J Med Microbiol 2012; 61: 1488–1489.

17. Olson Jr DS, Asare K, Lyons M, Hoflinger DM. A novel case of

Raoltella planticola urinary tract infection. Infection 2013; 41:

259–261.

18. Puerta SF, Miralles FL, Sanchez MVS, Bernal MRL, Gomez RH.

Raoultella planticola bacteraemia secondary to gastroenteritis. Clin

Microbiol Infect 2013; 19: E236–E237.

R. planticola, a rare pathogen 3

Please cite this article in press as: Nada B., Areej M. Raoultella planticola, a central venous line exit site infection. Journal of Taibah UniversityMedical Sciences (2014), http://dx.doi.org/10.1016/j.jtumed.2013.11.008