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mljgoums 2024, 18(4): 27-31 |
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Ahmadnia Z, Rouhi S, Mehdinezhad H, Sabaghi S, Firouzjahi A, Ranaei M, et al . Isolation of Pasteurella multocida and pan-drug-resistant bacteria causing nosocomial infection in a patient with multiple sclerosis: A Case Report and Literature Review. mljgoums 2024; 18 (4) :27-31
URL: http://mlj.goums.ac.ir/article-1-1673-en.html
URL: http://mlj.goums.ac.ir/article-1-1673-en.html
Zahra Ahmadnia1 
, Samane Rouhi1 , Hamed Mehdinezhad1 , Siamak Sabaghi1 , Alireza Firouzjahi1 , Mohammad Ranaei1 , Hossein Ghorbani1 , Maryam Pourtaghi1 , Mana Baziboron2
, Samane Rouhi1 , Hamed Mehdinezhad1 , Siamak Sabaghi1 , Alireza Firouzjahi1 , Mohammad Ranaei1 , Hossein Ghorbani1 , Maryam Pourtaghi1 , Mana Baziboron2
1- Clinical Research Development Unit of Rouhani Hospital, Babol University of Medical Sciences, Babol, Iran
2- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
2- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
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Discussion
P. multocida is part of the natural flora in the nasopharynx or in many digestive tracts in domestic and wild animals. Meningitis related to this bacterium is caused by cat bite (11%), animal contact without a bite (72%), and the absence of recognized animal contact (17%) (11). In the present study, a patient with multiple sclerosis who was referred to the hospital due to difficulty in swallowing food was diagnosed with P. multocida pneumonia and was admitted to the ICU. Bacteremia and septicemia caused by this bacterium are typically observed in immunocompromised patients; however, the infection has also been reported in individuals with healthy immune systems and can be equally dangerous if not treated properly. Non-bite infections from this bacterium require more intensive care than bite infections from animal bites, are more likely to occur in patients with severe comorbidities, and are also more likely to result in death. In a case report, fever, chills, and greenish sputum are reported as clinical manifestations of infection with P. multocida is reported in a 70-year-old man; these presentations were also seen in our patient (12). Moreover, in the literature, there are clinical reports of patients infected with P. multocida who were treated using cefepime (Fourth-generation cephalosporins), amoxicillin (Penicillin)/clavulanic acid (Beta-lactamase inhibitor), piperacillin-tazobactam (Penicillin and beta-lactamase inhibitors), amoxicillin (Penicillin family and beta-lactams) (Table 3) (13-22).
In our patient, the antibiotic resistance pattern showed that the bacteria were sensitive to ceftazidime (Third-generation cephalosporins), meropenem (Beta-lactam antibiotic), and ampicillin (Beta-lactam family)/sulbactam (Beta-lactamase enzyme inhibitor) was used. Antimicrobial resistance in Pasteurella isolates has rarely been reported in human infections. Ampicillin-sulbactam and amoxicillin-clavulanic acid are excellent empirical options and first-line parenteral antibiotic treatments for animal bite injuries. Some studies have shown amoxicillin resistance but sensitivity to amoxicillin-clavulanic acid. This can be attributed to the β-lactamase Temorina (TEM)-1 gene that is detected by the polymerase chain reaction (PCR) (23). The repetition of sample cultures in the following days, according to the treatment with the mentioned antibiotics in various types of research, and negative and partial recovery in patients have also been reported. Similarly in our study, sputum sample cultures were negative in the next visit. Therefore, these results indicate that the mentioned antibiotics can be effective against P. multocida. Thus, treatment with antibiotics that are in the group or family of these antibiotics (Such as ampicillin/sulbactam and piperacillin/tazobactam, tobramycin, trimethoprim/sulfamethoxazole) was the first choice of treatment, and cured a 59-year-old female patient (24). P. multocida can be dangerous and even fatal in 35% of immunocompromised people. There were 49 patients suffering from Pasteurella species peritoneal dialysis (25,26). Infection in people with multiple sclerosis can cause relapse. Chronic prophylactic treatments work differently, but they all modulate and interfere with the patient's immune response. Therefore, these immune system active therapies are likely to help with the emergence of viral, bacterial, or fungal infections. On the other hand, hospital infections in intensive care units are severe problems due to high mortality and complications. Lower respiratory tract infections, pneumonia, ventilator and central venous catheter-related pneumonia, bloodstream infections, and catheter-related urinary tract infections are the most common infections, respectively. Acinetobacter, Klebsiella pneumonia (K. pneumonia), P. aeruginosa, and Candida have been isolated from patients with multi-microbial or mono-microbial infections. In our study, the patient appeared after the treatment of P. multocida infection with Acinetobacter, K. pneumoniae, P. aeruginosa, Citrobacter, and Candida infections which were widely resistant to antibiotics and were isolated from a different patient sample. This indicates a weakness of the immune system and the possibility of hospital infections (27). Hospital infections are widespread in hospitals, especially in intensive care units, and one of the vital goals of hospitals should be to control and manage such a situation. Timely and appropriate therapeutic interventions should be designed to reduce the rate of hospital infections. Hospitals must develop and control comprehensive antibiotic treatment programs based on their surveillance data.
Conclusion
The case reported was a patient with multiple sclerosis who complained of difficulty swallowing without contact with animals. The diagnosis was pneumonia, extensive hydropneumothorax, pneumothorax, cystic bronchiectasis, and lymphadenopathy. The patient's specimens were positive for P. multocida, Acinetobacter, Klebsiella, Citrobacter, P. aeruginosa, and Candida. The patient was resistant to almost all prescribed antibiotics and ultimately died of nosocomial infection and bradycardia, leading to cardiac arrest.
Acknowledgement
The authors wish to thank all the personnel in the Department of Pathology of Babol University of Medical Sciences.
Funding sources
The authors received no financial support for this article's research, authorship, or publication.
Ethical statement
Informed consent was obtained from the patient, and ethical approval was granted by Babol University of Medical Sciences under the code IR.MUBABOL.HRI.REC.1401.140.
Conflicts of interest
The authors declare that there is no conflict of interest regarding the publication of this article.
Author contributions
ZA, SR, HM: Case Presentation and Management, AF, HG, MP: Pathology diagnosis, MR, SS, MB: Preparation of the manuscript.
Full-Text: (164 Views)
Introduction
Hospitalization of patients with multiple sclerosis (MS) is associated with the risk of various infections. The frequency of hospital infections in these patients is 4.26%, and MS patients have a higher rate (1.76%) of different infections (1.25%). The one-month mortality rate in patients with multiple sclerosis after hospitalization due to infection was associated with a relative risk of 4.69% (1,2). Pathogens associated with the development or exacerbation of MS include bacteria such as Chlamydia pneumoniae, Staphylococcus aureus, Candida, herpesviruses such as Epstein-Barr virus and human herpesvirus and human endogenous retroviruses (HERVs) (3). Pasteurella species are one of the most common pathogenic bacteria common to domestic animals and humans. Pasteurella species are commonly cultured from the oral cavity of cats and dogs (4). Pasteurella multocida (P. multocida) is the most frequently isolated species of the Pasteurella genus, linked to both chronic and acute infections. Overall, mortality rates associated with this pathogen are generally low. Most human infections are wound infections associated with cat (75% of injuries from cat bites) and dog (50% of injuries from dog bites) bites or scratches (5). Also, infections may include septic arthritis, osteomyelitis, artificial joint infection, meningitis, respiratory tract infections in patients with underlying airway or lung disorders, endocarditis, sepsis, bacteremia, and colonization in the lower part (6,7). There is evidence that this infection is more common in people with underlying diseases and weak immune systems. In multiple sclerosis, an autoimmune disorder, the body's immune system attacks normal tissues. Individuals affected are susceptible to infections, respiratory issues, muscle spasms, and swallowing difficulties. (7,8). This article presents a patient with multiple sclerosis from whose sputum P. multocida was isolated.
Case presentation
The patient was a 28-year-old man living in the village with a history of multiple sclerosis who complained of difficulty in swallowing food and persistent coughs due to food getting stuck in the throat. About a month ago, until the time of referral, food got stuck in the patient's throat when eating. For a month until the time of referral, he had numerous coughs during the day; after a month, the patient's coughs were more frequent. The patient has been unable to swallow and chew food since October 4, 2022, due to excessive phlegm and secretions. He was also observed to have increased breathing sounds, fever, chills, and sweating. The patient was referred to Ayatollah Rouhani Educational Hospital in Babol after approximately 30 days on May 11, 2022. The patient exhibited several symptoms, including a cough with phlegm, difficulty breathing, sharp chest pain, anxiety, wheezing, headaches, and dizziness. He also experienced a punctured lung and breathlessness, and sometimes noted by a whistling sound during breathing. The patient's initial diagnosis was performed using a computerized tomography (CT) scan. Real-time PCR did not show any sign of Coronavirus disease (COVID-19). Other observations included pneumonia, extensive hydropneumothorax in the left hemithorax and complete collapse of the left lung, pneumothorax, cystic bronchiectasis in the right middle lobe, ground glass appearance or opaque glass opacity, and lymphadenopathy in the paravascular space. Following the patient's initial diagnosis in the intensive care unit (ICU), tracheostomy, nasogastric intubation, and tracheal and intrathoracic intubation were performed (Figure 1).
Hospitalization of patients with multiple sclerosis (MS) is associated with the risk of various infections. The frequency of hospital infections in these patients is 4.26%, and MS patients have a higher rate (1.76%) of different infections (1.25%). The one-month mortality rate in patients with multiple sclerosis after hospitalization due to infection was associated with a relative risk of 4.69% (1,2). Pathogens associated with the development or exacerbation of MS include bacteria such as Chlamydia pneumoniae, Staphylococcus aureus, Candida, herpesviruses such as Epstein-Barr virus and human herpesvirus and human endogenous retroviruses (HERVs) (3). Pasteurella species are one of the most common pathogenic bacteria common to domestic animals and humans. Pasteurella species are commonly cultured from the oral cavity of cats and dogs (4). Pasteurella multocida (P. multocida) is the most frequently isolated species of the Pasteurella genus, linked to both chronic and acute infections. Overall, mortality rates associated with this pathogen are generally low. Most human infections are wound infections associated with cat (75% of injuries from cat bites) and dog (50% of injuries from dog bites) bites or scratches (5). Also, infections may include septic arthritis, osteomyelitis, artificial joint infection, meningitis, respiratory tract infections in patients with underlying airway or lung disorders, endocarditis, sepsis, bacteremia, and colonization in the lower part (6,7). There is evidence that this infection is more common in people with underlying diseases and weak immune systems. In multiple sclerosis, an autoimmune disorder, the body's immune system attacks normal tissues. Individuals affected are susceptible to infections, respiratory issues, muscle spasms, and swallowing difficulties. (7,8). This article presents a patient with multiple sclerosis from whose sputum P. multocida was isolated.
Case presentation
The patient was a 28-year-old man living in the village with a history of multiple sclerosis who complained of difficulty in swallowing food and persistent coughs due to food getting stuck in the throat. About a month ago, until the time of referral, food got stuck in the patient's throat when eating. For a month until the time of referral, he had numerous coughs during the day; after a month, the patient's coughs were more frequent. The patient has been unable to swallow and chew food since October 4, 2022, due to excessive phlegm and secretions. He was also observed to have increased breathing sounds, fever, chills, and sweating. The patient was referred to Ayatollah Rouhani Educational Hospital in Babol after approximately 30 days on May 11, 2022. The patient exhibited several symptoms, including a cough with phlegm, difficulty breathing, sharp chest pain, anxiety, wheezing, headaches, and dizziness. He also experienced a punctured lung and breathlessness, and sometimes noted by a whistling sound during breathing. The patient's initial diagnosis was performed using a computerized tomography (CT) scan. Real-time PCR did not show any sign of Coronavirus disease (COVID-19). Other observations included pneumonia, extensive hydropneumothorax in the left hemithorax and complete collapse of the left lung, pneumothorax, cystic bronchiectasis in the right middle lobe, ground glass appearance or opaque glass opacity, and lymphadenopathy in the paravascular space. Following the patient's initial diagnosis in the intensive care unit (ICU), tracheostomy, nasogastric intubation, and tracheal and intrathoracic intubation were performed (Figure 1).
.PNG) Figure 1. Initial CT scan findings in the patient suffering from multiple sclerosis with a lung infection. |
Following the initial hospital visit, the patient's sputum culture was positive for P. multocida (4) and the Candida genus. We ensured the patient did not come into contact with the related animal. Moreover, there were no signs of bites or wounds caused by the animal's grip on the patient's body. Also, the patient and the patient's family stated that they did not have any pets and that the patient was not in contact with any animals outside of their residence. It should be noted, however, that the patient might have been in contact with the animal unintentionally or accidentally. However, the patient and his companions did not clarify this and denied any association with pets. In the second culture of the patient's sputum, P. multocida and Candida genus were not found, but Acinetobacter and Klebsiella were positive. The patient seemed to suffer from associated bacterial infections or nosocomial infections. It is worth mentioning that the bacteria were resistant to all antibiotics tested in the laboratory. The culture of the patient's sputum and pleural fluid for the third time was again positive due to the presence of Acinetobacter and Klebsiella. Moreover, testing their antibiotic sensitivity pattern for all the antibiotics mentioned in the third and second times, except for colistin (10 µg) in the pleural fluid, was conducted. Pan-drug-resistant Acinetobacter and Klebsiella were observed for the third and second time. The fourth culture to check the infection revealed the presence of Acinetobacter, which was sensitive to amikacin. The Fifth and sixth microbiological cultures showed the presence of Candida in the patient's urine sample. The seventh culture round included Citrobacter infection urine and sputum infected with Pseudomonas aeruginosa (P. aeruginosa) and Citrobacter with a pan-drug-resistant to all antibiotics (9,10). Because the patient was in a critical condition, information about the antibiogram of the specimens taken from the patient was done urgently. Therefore, a phone call was made to the ICU department, and necessary explanations were given to the relevant nurse and specialist. Also, the antibiogram results were sent to the ICU department in writing and recorded in the hospital's health information system (HIS).
Antimicrobial susceptibility testing was performed using the disc diffusion method, following the recommendations of the Clinical and Laboratory Standards Institute (CLSI) (Table 1) (9). Selective and repeated antibiotic treatments included: amikacin (100 mg), ampicillin/sulbactam (1.5 g) (1 g ampicillin/0.5 g sulbactam), and clomycin (1000000 units), clindamycin (150 mg and 300 mg), imipenem (1 g) and meropenem (1 g and 500 mg). Caspofungin (50 mg) and fluconazole (150 mg) were also prescribed to the patient. Chlorhexidine mouthwash 0.2% was recommended to wash the patient's mouth and reduce oral microbes, and diphenhydramine 12.5 mg/ml was used to reduce cough. Following the treatments, bronchoscopy and tracheostomy were performed for the patient. Respiratory distress syndrome was diagnosed in the patient, and fentanyl was prescribed for the patient. The patient's sputum was still abundant and in the form of green and foul-smelling secretions. Acetylcysteine was prescribed to the patient to help expel phlegm from the respiratory tract. Clinical tests revealed a decrease in blood potassium (Hypokalemia) in the patient, and furosemide (40 mg) was prescribed. Since the patient was hospitalized for a long time and many tests were performed, only the first and last tests were presented to check how the treatment progressed. Only the significant tests were mentioned in the text (Table 2).
Antimicrobial susceptibility testing was performed using the disc diffusion method, following the recommendations of the Clinical and Laboratory Standards Institute (CLSI) (Table 1) (9). Selective and repeated antibiotic treatments included: amikacin (100 mg), ampicillin/sulbactam (1.5 g) (1 g ampicillin/0.5 g sulbactam), and clomycin (1000000 units), clindamycin (150 mg and 300 mg), imipenem (1 g) and meropenem (1 g and 500 mg). Caspofungin (50 mg) and fluconazole (150 mg) were also prescribed to the patient. Chlorhexidine mouthwash 0.2% was recommended to wash the patient's mouth and reduce oral microbes, and diphenhydramine 12.5 mg/ml was used to reduce cough. Following the treatments, bronchoscopy and tracheostomy were performed for the patient. Respiratory distress syndrome was diagnosed in the patient, and fentanyl was prescribed for the patient. The patient's sputum was still abundant and in the form of green and foul-smelling secretions. Acetylcysteine was prescribed to the patient to help expel phlegm from the respiratory tract. Clinical tests revealed a decrease in blood potassium (Hypokalemia) in the patient, and furosemide (40 mg) was prescribed. Since the patient was hospitalized for a long time and many tests were performed, only the first and last tests were presented to check how the treatment progressed. Only the significant tests were mentioned in the text (Table 2).
Table 1. Bacteriology findings and antibiogram of the patient suffering from multiple sclerosis..PNG) |
Table 2. General tests were performed (first and last tests) on the patient.PNG) |
A CT scan was conducted on the patient. A Centrilobular lung nodule with a branched appearance in the left lobe of the lung indicated aspiration pneumonia. Para-aortic lymph node and abdominal ascites were prominent. The results of the secondary CT scan in the patient showed mild pleural effusion on the left (With a significant reduction compared to the previous CT scan), pneumothorax, complete collapse, and mild peri-bronchovascular ground glass in the right lobe (Figure 2).
Oxygen saturation measurement (SpO2) indicated a level of less than 95% (Normal SpO2 for both adults and children is between 95% - 100%). Therefore, the patient was connected to a ventilator due to tachycardia and symptoms of stricture and defecation problems. No other abnormal presentations were observed in the patient. On July 14, 2022, the patient was moved to the ward without any signs of respiratory distress. On July 16, 2022, the patient exhibited severe symptoms of the disease and was admitted to the ICU, where a ventilator was connected. Despite the treatments administered, on July 20, 2022, the patient's vital signs deteriorated, leading to a coma and eventual death from cardiac arrest and bradycardia. (Ethic code: IR.MUBABOL.HRI.REC.1401.140).
Oxygen saturation measurement (SpO2) indicated a level of less than 95% (Normal SpO2 for both adults and children is between 95% - 100%). Therefore, the patient was connected to a ventilator due to tachycardia and symptoms of stricture and defecation problems. No other abnormal presentations were observed in the patient. On July 14, 2022, the patient was moved to the ward without any signs of respiratory distress. On July 16, 2022, the patient exhibited severe symptoms of the disease and was admitted to the ICU, where a ventilator was connected. Despite the treatments administered, on July 20, 2022, the patient's vital signs deteriorated, leading to a coma and eventual death from cardiac arrest and bradycardia. (Ethic code: IR.MUBABOL.HRI.REC.1401.140).
.PNG)
Discussion
P. multocida is part of the natural flora in the nasopharynx or in many digestive tracts in domestic and wild animals. Meningitis related to this bacterium is caused by cat bite (11%), animal contact without a bite (72%), and the absence of recognized animal contact (17%) (11). In the present study, a patient with multiple sclerosis who was referred to the hospital due to difficulty in swallowing food was diagnosed with P. multocida pneumonia and was admitted to the ICU. Bacteremia and septicemia caused by this bacterium are typically observed in immunocompromised patients; however, the infection has also been reported in individuals with healthy immune systems and can be equally dangerous if not treated properly. Non-bite infections from this bacterium require more intensive care than bite infections from animal bites, are more likely to occur in patients with severe comorbidities, and are also more likely to result in death. In a case report, fever, chills, and greenish sputum are reported as clinical manifestations of infection with P. multocida is reported in a 70-year-old man; these presentations were also seen in our patient (12). Moreover, in the literature, there are clinical reports of patients infected with P. multocida who were treated using cefepime (Fourth-generation cephalosporins), amoxicillin (Penicillin)/clavulanic acid (Beta-lactamase inhibitor), piperacillin-tazobactam (Penicillin and beta-lactamase inhibitors), amoxicillin (Penicillin family and beta-lactams) (Table 3) (13-22).
In our patient, the antibiotic resistance pattern showed that the bacteria were sensitive to ceftazidime (Third-generation cephalosporins), meropenem (Beta-lactam antibiotic), and ampicillin (Beta-lactam family)/sulbactam (Beta-lactamase enzyme inhibitor) was used. Antimicrobial resistance in Pasteurella isolates has rarely been reported in human infections. Ampicillin-sulbactam and amoxicillin-clavulanic acid are excellent empirical options and first-line parenteral antibiotic treatments for animal bite injuries. Some studies have shown amoxicillin resistance but sensitivity to amoxicillin-clavulanic acid. This can be attributed to the β-lactamase Temorina (TEM)-1 gene that is detected by the polymerase chain reaction (PCR) (23). The repetition of sample cultures in the following days, according to the treatment with the mentioned antibiotics in various types of research, and negative and partial recovery in patients have also been reported. Similarly in our study, sputum sample cultures were negative in the next visit. Therefore, these results indicate that the mentioned antibiotics can be effective against P. multocida. Thus, treatment with antibiotics that are in the group or family of these antibiotics (Such as ampicillin/sulbactam and piperacillin/tazobactam, tobramycin, trimethoprim/sulfamethoxazole) was the first choice of treatment, and cured a 59-year-old female patient (24). P. multocida can be dangerous and even fatal in 35% of immunocompromised people. There were 49 patients suffering from Pasteurella species peritoneal dialysis (25,26). Infection in people with multiple sclerosis can cause relapse. Chronic prophylactic treatments work differently, but they all modulate and interfere with the patient's immune response. Therefore, these immune system active therapies are likely to help with the emergence of viral, bacterial, or fungal infections. On the other hand, hospital infections in intensive care units are severe problems due to high mortality and complications. Lower respiratory tract infections, pneumonia, ventilator and central venous catheter-related pneumonia, bloodstream infections, and catheter-related urinary tract infections are the most common infections, respectively. Acinetobacter, Klebsiella pneumonia (K. pneumonia), P. aeruginosa, and Candida have been isolated from patients with multi-microbial or mono-microbial infections. In our study, the patient appeared after the treatment of P. multocida infection with Acinetobacter, K. pneumoniae, P. aeruginosa, Citrobacter, and Candida infections which were widely resistant to antibiotics and were isolated from a different patient sample. This indicates a weakness of the immune system and the possibility of hospital infections (27). Hospital infections are widespread in hospitals, especially in intensive care units, and one of the vital goals of hospitals should be to control and manage such a situation. Timely and appropriate therapeutic interventions should be designed to reduce the rate of hospital infections. Hospitals must develop and control comprehensive antibiotic treatment programs based on their surveillance data.
|
Table 3. A comparison of results of similar studies as a literature review
.PNG) |
Conclusion
The case reported was a patient with multiple sclerosis who complained of difficulty swallowing without contact with animals. The diagnosis was pneumonia, extensive hydropneumothorax, pneumothorax, cystic bronchiectasis, and lymphadenopathy. The patient's specimens were positive for P. multocida, Acinetobacter, Klebsiella, Citrobacter, P. aeruginosa, and Candida. The patient was resistant to almost all prescribed antibiotics and ultimately died of nosocomial infection and bradycardia, leading to cardiac arrest.
Acknowledgement
The authors wish to thank all the personnel in the Department of Pathology of Babol University of Medical Sciences.
Funding sources
The authors received no financial support for this article's research, authorship, or publication.
Ethical statement
Informed consent was obtained from the patient, and ethical approval was granted by Babol University of Medical Sciences under the code IR.MUBABOL.HRI.REC.1401.140.
Conflicts of interest
The authors declare that there is no conflict of interest regarding the publication of this article.
Author contributions
ZA, SR, HM: Case Presentation and Management, AF, HG, MP: Pathology diagnosis, MR, SS, MB: Preparation of the manuscript.
Research Article: Case Report |
Subject:
bacteriology
Received: 2023/05/31 | Accepted: 2023/09/12 | Published: 2025/03/11 | ePublished: 2025/03/11
Received: 2023/05/31 | Accepted: 2023/09/12 | Published: 2025/03/11 | ePublished: 2025/03/11
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