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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 1  |  Issue : 3  |  Page : 75-78

Clinical course of a case of elizabethkingia meningoseptica in a critical neonate at a tertiary care hospital in Saudi Arabia


1 King Abdul-Aziz Medical City, Ministry of National Guard, Health Affairs; King Saud Bin Abdul-Aziz University for Health Science, Riyadh, Saudi Arabia
2 Department of Internal Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
3 College of Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
4 Neonatal Intensive Care Unit, King Abdulaziz Medical City, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia

Date of Submission17-Apr-2022
Date of Acceptance04-Sep-2022
Date of Web Publication30-Sep-2022

Correspondence Address:
Dr. Faisal Aqeel AlSehli
King Abdul-Aziz Medical City, Ministry of National Guard, Health Affairs, PO Box 22490, Riyadh 11426
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjcp.sjcp_11_22

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  Abstract 

Case Report: In this paper we discuss the clinical course of a 25-week gestational age preterm neonate who suffered with multiple comorbidities atop of an E. meningoseptica infection causing meningitis and hydrocephalus. A multitude of antibiotics were administered to the child, such as vancomycin, ciprofloxacin, trimethoprim-sulfamethoxazole, and rifampicin. However, the pathogen either had prior resistance to the agents or newly developed resistance along the disease course. After many trials of antibiotics, the usage of ceftazidime/avibactam and moxifloxacin dual therapy induced clinical and microbiological eradication of the pathogen. Objective: This case report aims to discuss the multidrug approach used to treat a preterm neonates Elizabethkingia Meningoseptica infection in a Tertiary Care Hospital in Saudi Arabia. Conclusion: E. meningoseptica is an uncommon infectious agent which can cause meningitis and even sepsis that is difficult to treat due to its multidrug resistance phenotype. Continuous reviews of new case reports on successful attempts of treating E. meningoseptica are paramount to maintaining updated therapy options for newly encountered cases in day-to-day practice in the neonatal intensive care unit (NICU).

Keywords: Antibiotic, avibactam, bacteremia, ceftazidime, Elizabethkingea meningoseptica, infection, intensive care unit, meningitis, moxifloxacin, neonate


How to cite this article:
AlSehli FA, Alsaeed NS, Rajah AT, AlSaif S. Clinical course of a case of elizabethkingia meningoseptica in a critical neonate at a tertiary care hospital in Saudi Arabia. Saudi J Clin Pharm 2022;1:75-8

How to cite this URL:
AlSehli FA, Alsaeed NS, Rajah AT, AlSaif S. Clinical course of a case of elizabethkingia meningoseptica in a critical neonate at a tertiary care hospital in Saudi Arabia. Saudi J Clin Pharm [serial online] 2022 [cited 2022 Dec 2];1:75-8. Available from: http://www.sjcp.org/text.asp?2022/1/3/75/357707


  Introduction Top


Elizabethkingia meningoseptica (E. meningoseptica) is a ubiquitous, aerobic, gram-negative bacillus. Though commonly present in water, soil, and hospital settings, it is rarely seen in clinical practice.[1],[2] The scarcity of studies on E. meningoseptica globally indicates how uncommon the disease is encountered, however, the incidence has increased over the last decade. Approximately 5 to 10 cases of E. meningoseptica infection are reported each year in the United States.[2],[3] Despite its rarity, it is an important cause of severe infection, such as sepsis, pneumonia, meningitis, encephalitis and endocarditis.

The risk factors of infection by E. meningoseptica predominantly include premature neonates and immunocompromised patients in intensive care settings.[1]E. meningoseptica is considered an important threat due to its multidrug resistance phenotype against antimicrobial agents; namely aminoglycosides, tetracycline, aztreonam, imipenem, third generation cephalosporins, piperacillin, and ticarcillin. This resistance mechanism explains the challenges faced in treating E. meningoseptica, as is seen in many case reports.[4],[5]

A recent case report conducted in 2021, discusses the management of E. meningoseptica meningitis and sepsis in a 70 year old immunocompramised individual. The patient underwent multiple treatment regimens due to the mircobes continuous resisteant status. However, the last regimen before a negative culture was levofloxacin, minocycline, and rifampin for the patient presented in their study.[6] Another case seen in veitnam was published in 2021. It discusses a case of 55 year old patient infected by E. meningoseptica soon after liver transplant immunosuppression. Intravenous levofloxacin was administered to the patient for 10 days and she showed an excellent treatment response to the antibiotic therapy and was discharged.[3]

Morever, some health care practitioners at Prince Sultan Military Medical City in Riyadh, Saudi Arabia conducted a study between June 2013 and May 2019 conducted a study on 12 cases of E. meningoseptica bacteremia; none of which were neonates. The aim of their study was to describe the epidemiological data, clinical features and outcome of patients with E.meningoseptica bacteraemia and to report the antimicrobial susceptibility pattern. The results of their research showed that all E. meningoseptica isolates were susceptible to trimethoprim/sulfamethoxazole, piperacillin/tazobactam and moxifloxacin. However, the isolates showed a high degree of resistance to β-lactam antibiotics, aminoglycosides and carbapenems.[7]

A 22-month outbreak of E. meningoseptica acquisition affecting 30 adult patients in a London, UK, critical care unit was reported in a study in 2016. The isolate causing the outbreak was analyzed and shown to be susceptible to piperacillin/tazobactam and trimethoprim/sulfamethaxole only but resistant to ceftazidime.[8]

Our paper is a case report of a resistant case of E. meningoseptica which was treated with a combination of antimicrobials with the final antibiotics used being moxifloxacin along with ceftazadime/avibactam. The objective of this case report is to discuss the multidrug approach used to treat a preterm neonates Elizabethkingia Meningoseptica infection in a Tertiary Care Hospital in Saudi Arabia.


  Case History Top


A 25-week-old premature neonate was delivered via cesarean section (CS) due to fetal distress to a 23-year-old mother, a known case of insulin-dependent diabetes mellitus. The mother received a course of dexamethasone prior to the operation and tested negative for group-B streptococci. The delivery was uncomplicated, and the neonate was delivered with an APGAR score of 5 in the 1st minute and 8 in the 5th minute, weighing 900 grams. The baby was then admitted to the neonatal intensive care unit (NICU) as a case of respiratory distress syndrome and was started on positive pressure ventilation (PPV). The patient had a blood pressure of 49/25, pulse of 150 beats/ minute, temperature of 36.1° Celsius, respiratory rate of 29 per minute, and O2 saturation of 97% with PPV. The neonate’s blood gases revealed a pattern of metabolic acidosis. Clinically, a weak cry, normal tone and normal activity were seen. An umbilical venous catheter was inserted for fluid replacement and parenteral nutrition.

On the 3rd day, the patient was active and was treated with phototherapy due to existing neonatal jaundice and was started on prophylactic fluconazole. On the 7th day, a blood culture was conducted showing no growth of microorganisms. On the 8th day, an echocardiogram was performed and showed normal left ventricular function. On the 9th day, the patient underwent a Peripherally Inserted Central Catheter placement and was given prophylactic vancomycin and ceftazidime post procedure to minimize risk of post PICC line sepsis [Table 1].
Table 1: Antibiotic sensitivity testing

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Upon examination on the 19th day, however, the patient was suddenly hypoactive, dusky pale, had a new onset bradycardia, abdominal distension, and started to desaturate. A septic workup was initiated, and the patient was started on empiric vancomycin and cefotaxime. On day 20, the blood culture result came back showing gram negative bacilli growth, and the cefotaxime was replaced with meropenem.

However, two days later, the neonate’s condition worsened, requiring endotracheal intubation under fentanyl sedation and fluconazole was added to the current regimen of meropenem and vancomycin. Further laboratory tests were conducted and a lumber puncture to confirm the diagnosis. Blood and cerebrospinal fluid (CSF) culture and susceptibility testing was done for the causative pathogen showing sensitivity to ciprofloxacin only. The baby was initiated on a new regimen of vancomycin and ciprofloxacin. On day 27 a repeat CSF culture and sensitivity test was done showing persistently positive tests for E. meningoseptica. However, this time the organism developed resistance to Ciprofloxacin. The patient was switched to vancomycin with rifampicin. Initially, the patient improved and was more active with sufficient response to a 2-liter nasal cannula. The patient also had an MRI done on day 29 which showed hyperintense signaling spread diffusely throughout the white matter, possibly indicating cerebral edema. Repeat CSF and blood cultures were done on day 34 showing growth in the CSF cultures but negative blood cultures. On day 36 the patient’s regimen was switched to Moxifloxacin and Ceftazidime/Avibactam. On day 38 the patient underwent another MRI showing supratentorial ventricular system dilation consistent with active hydrocephalus. On the 42nd day, a repeat CSF was done and was negative for E. meningoseptica [Table 2].
Table 2: CSF Culture Results

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On the 43rd, 44th, 45th, and 46th day, CSF cultures were taken and were negative and the infection was deemed cleared. On day 56, the patient had finished the course of Moxifloxacin and Ceftazidime/Avibactam. On day 70 the patient underwent a ventriculoperitoneal shunt placement for the hydrocephalus. Finally, the patient was discharged on day 75 [Table 3].
Table 3: Doses used during treatment

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  Discussion Top


E. meningoseptica has been reported to infect mainly immunocompromised hosts such as premature neonates causing meningitis, with or without neurological complications, and even sepsis. This is because the majority of the neonates within intensive care units have weakened immune systems secondary to medical interventions as well as their prematurity. The subject presented in this case report, however, was a preterm neonate born at 28 weeks and admitted into the NICU for respiratory distress accompanied by a series of acute complications as well as newly developed resistances (e.g., ciprofloxacin, TMP-SMX, as well as rifampicin) throughout her treatment course.

Several case reports and reviews have found that E. meningoseptica has unusual resistance patterns and mechanisms. It has shown to be highly resistant to β-lactams especially cephalosporins and carbapenem with a moderate susceptibility to piperacillin. The bacterium has also been resistant to aminoglycosides and chloramphenicol, which generally used for gram negative coverage, but is somewhat susceptible to rifampicin, quinolones, vancomycin, and trimethoprim-sulfamethoxazole.[2]

A recent case report conducted in 2021, discusses the management of E. meningoseptica meningitis and sepsis in a 70 year old immunocompramised individual. The patient underwent multiple treatment regimens due to the mircobes continuous resisteant status. However, the last regimen before a negative culture was levofloxacin, minocycline, and rifampin for the patient presented in their study.

The cultures retrieved from our patient also showed initial rifampin, vancomycin, trimethoprim- sulfamethoxazole sensitive E. meningoseptica, as is seen in this case, is gradually becoming more and more resistant.


  Conclusion Top


The antibiotic regimen that possibly cleared E. meningoseptica meningitis from the patient was a combination of Ceftazidime/Avibactam 42.8 mg/kg and Moxifloxacin 4.6mg/kg. It is unclear whether there was a synergistic effect from both antibiotics contributing to the infection resolution or if only one of the agents was effective. In addition, no drug of choice has been available for patients with E. meningoseptica to present day. It is recommended that healthcare practitooners be watchful once the organism is identified and optimaly treat the infection based on the specific patient case and on time to reduce morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arbune M, Fotea S, Nechita A, Stefanescu V. Emerging infection with elizabethkingia meningoseptica in neonate. A case report. J Crit Care Med (Targu Mures) 2018;4:96-100.  Back to cited text no. 1
    
2.
Magiorakos AP, Monnet DL, Weber JT, Vatopoulos A, Carey RB, Srinivasan A. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: An international expert proposal for interim standard definitions for acquired resistance. Eur Soc Clin Microbiol Infect Dis 2016. Available from https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)61632-3/fulltext. [Last accessed on 2021 Dec 18].  Back to cited text no. 2
    
3.
Hai PD. A rare case of Elizabethkingia meningoseptica Bacteremia After Liver Transplantation. The American Journal of Case Reports 2021;22:e933992-1.  Back to cited text no. 3
    
4.
Wisplinghoff H, Seifert H. (n.d.). Elizabethkingia meningoseptica. Elizabethkingia Meningoseptica - an overview | ScienceDirect Topics. Available from https://www.sciencedirect.com/topics/medicine-and-dentistry/elizabethkingia-meningoseptica. [Last accessed on 2021 Dec 18].  Back to cited text no. 4
    
5.
Jean SS, Lee WS, Chen FL, Ou TY, Hsueh PR. Elizabethkingia meningoseptica: An important emerging pathogen causing healthcare-associated infections. J Hosp Infect2014. Available from https://www.sciencedirect.com/science/article/abs/pii/S0195670114000577. [Last accessed on 2021 Dec 18].  Back to cited text no. 5
    
6.
Waleed MS, Varughese AA, Amba V, Pathalapati R. Bardet-biedl syndrome with renal, cardiac, and genitourinary malformations: A case report. Cureus 2021;13:e20577.  Back to cited text no. 6
    
7.
Aldoghaim FS, Kaabia N, Alyami AM, Alqasim MA, Ahmed MA, Al Aidaroos A, et al. Elizabethkingia meningoseptica (chryseobacterium meningosepticum) bacteraemia: A series of 12 cases at prince sultan military medical city Ksa. New Microbes New Infect 2019;32:100617.  Back to cited text no. 7
    
8.
Moore LS, Owens DS, Jepson A, Turton JF, Ashworth S, Donaldson H, et al. Waterborne elizabethkingia meningoseptica in adult critical care. Emerg Infect Dis 2016;22:9-17.  Back to cited text no. 8
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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