Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 5  |  Issue : 2  |  Page : 151-153  

Isolation of Acinetobacter baumannii from cerebrospinal fluid following craniotomy


Department of Microbiology, Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra, India

Date of Web Publication10-Nov-2012

Correspondence Address:
Nageshwari R Gandham
Department of Microbiology, Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.103347

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  Abstract 

Central nervous system infection due to multi-drug resistant Acinetobacter baumannii is being increasingly reported. Here we report a case of infection by multi-drug resistant Acinetobacter baumannii following a craniotomy for biparietal epidermoid. The organism, in vitro, showed multi-drug resistance, which was confirmed by automated identification and susceptibility system. However the patient responded to a combination of Amikacin and Cefotaxim therapy. Multiple drug resistance in Acinetobacter baumannii is mostly plasmid mediated; hence, the case report emphasizes the importance of the identification and susceptibility testing of any non-fermented isolate from clinical samples.

Keywords: Acinetobacter baumannii , central nervous system infection, multi-drug resistance


How to cite this article:
Gandham NR, Gupta N, Jadhav SV, Misra RN. Isolation of Acinetobacter baumannii from cerebrospinal fluid following craniotomy. Med J DY Patil Univ 2012;5:151-3

How to cite this URL:
Gandham NR, Gupta N, Jadhav SV, Misra RN. Isolation of Acinetobacter baumannii from cerebrospinal fluid following craniotomy. Med J DY Patil Univ [serial online] 2012 [cited 2024 Mar 29];5:151-3. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2012/5/2/151/103347


  Introduction Top


Members of the genus Acinetobacter are acknowledged to be opportunists in hospitalized patients. They are ubiquitous, free living, small, aerobic gram-negative cocobacilli with ability to colonize healthy or damaged tissues. Due to this they are one of the most important nosocomial pathogens. They can cause supportive infections in virtually every organ system. [1] Acinetobacter is reported in about 10% of nosocomial infection in intensive care unit patients. Among the species, Acinetobacter baumannii shows pre dominance. Other species identified are Acinetobacter haemolyticus and Acinetobacter lwoffii. Acinetobacter baumannii has the ability to acquire resistance to major class of antibiotics. The isolates readily develop resistance to second and third generation antibiotics such as those of cephalosporins and fluoroquinolones. The resistance is principally plasmid borne. [2] Therefore, the presence of these multi-drug resistant Acinetobacter baumannii strains relates to transferable antibiotics resistance in hospital flora. Here we report a case of multi-drug resistance Acinetobacter baumannii isolation from a post-craniotomy site infection.


  Case Report Top


A 40-year-old female was admitted under Neurosurgery Department in surgical intensive care unit with a history of altered sensorium for 15 days. Following various investigations, she was diagnosed to be a case of bi-parietal epidermoid. Craniotomy was performed and she was discharged on the fourth postoperative day. She went for suture removal to a private hospital located near to her residence following which she was re-admitted 5 days later with history of fever and cerebrospinal fluid leak from the site of incision. She also complained of neck stiffness. In the complete blood count, hemoglobin was 6.7 g/dL, erythrocyte sedimentation rate was 62 mm/h, and total leukocyte count was 17,400/mm 3 (polymorphs-78%, lymphocytes-20%, eosinophils-2%). Liver function and renal function was within normal limits. She was re-operated 5 days later and surgeons found pseudomeningocele formation. This was aspirated and sent for investigation.

The cerebrospinal fluid analysis showed turbid, yellowish appearance - sugar (decreased) 20 mg/dL, protein 350 mg/ dL, CSF TLC was 700 mm 3 . Cells were predominantly neutrophils. On culture, pale, mucoid colonies were grown on MacConkey agar. The gram stain revealed gram-negative coccobacilli [Figure 1], which was identified as Acinetobacter on the basis of biochemical reactions. [3]
Figure 1: Colony smear showing gram-negative coccobacilli

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The antibiotic susceptibility was done on Kirby-Bauer disc diffusion method with CLSI guidelines. The organism was resistant to Gentamicin (30 mcg), Ciprofloxacin (5 mcg), Cefotaxim (30 mcg) and showed intermediate resistance to Amikacin (10 mcg) Levofloxacin (5 mcg) and Cotrimoxazole (25 mcg). The organism was further identified as Acinetobacter baumannii on the basis of glucose oxidation, gelatin liquefaction, hemolysis, growth at 37°C and 42°C, and also confirmed by an automated system. On further testing, it was confirmed to be an Extended Spectrum Beta Lactamase (ESBL) producer. Meanwhile the patient was started on Amikacin and Cefotaxim and showed improvement, so was shifted from surgical intnsive care unit to female surgical ward and was discharged after an uneventful hospital stay.


  Discussion Top


Acinetobacter baumannii is an important nosocomial pathogen that is often multi-drug resistant and hence associated with life-threatening infections and prolonged hospital stay. Acinetobacter baumannii is a clinically predominant species with a tendency toward causing infection particularly in intensive care units where it has been reported to cause outbreaks. [2],[4],[5] During routine clinical bacteriology the non-fermented gram-negative bacilli other than Pseudomonas aeruginosa should be pursued for identification. Their presence should be correlated with clinical findings before being labeled as pathogens, colonizers or contaminants.

Though all bacterial isolates show high frequency of resistance to multiple antibiotics, maximum resistance is being observed in Acinetobacter isolates. They may be a reservoir of antibiotic resistant genes in hospital environment. In this case the isolate showed resistance to most commonly used antibiotics as well as newer brand cephalosporins. It was susceptible to polymyxin B, which is in agreement with other studies. Multi-drug resistance in Acinetobacter is defined by CDC (Center for Disease Control, Atlanta) as resistance to all but one antimicrobial drug class commonly prescribed for treatment with exclusion of polymyxins. [4] Carbapenem resistance is regarded as a sentinel event for the emergence of antimicrobial resistance in Acinetobacter baumannii. [6] Infection with such multi-drug resistant Acinetobacter leads to increase in length of hospitalization and hence the need for strategies to prevent cross-infection in health care settings. Multi-drug resistance is mostly plasmid mediated and its transfer can create complications in treatment of patients. Therefore steps must be taken to control such infections.

In a study carried out in JIPMER, Pondicherry, India, 43 patients admitted to the hospital who developed Acinetobacter species infection or colonization were evaluated. Among these it was seen that respiratory tract infections accounted for maximum (48.8%) isolation followed by blood stream infection (16.27%), followed by secondary meningitis (14%). Other infections included urinary tract infections, peritonitis, corneal infection, necrotizing fascitis and osteomylelitis. Of the Acinetobacter species from secondary meningitis, Acinetobacter johnsonii was isolated in one case and the rest were Acinetobacter baumannii. [7]

In another study in Australia, of the 5 cases of central nervous system infection with multi-drug resistant Acinetobacter baumannii, one infection was following craniotomy. The rest were associated with external ventricular devices. [8]


  Conclusions Top


To conclude, antibiotic-resistant bacterial nosocomial infection is a major problem with the Acinetobacter species causing a great problem. Hence, it is important to identify Acinetobacter infections with their antibiotic sensitivity pattern at the earliest in the laboratory. Subsequently, swift and efficient infection control measures should be implemented to nip this problem in the bud. This would result in prevention of epidemic outbreaks and endemicity with high mortality rates.


  Acknowledgement Top


We would like to thank the Department of Neurosurgery, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Center, Pimpri, Pune, for their support.

 
  References Top

1.Srinivasa Rao R, Uma Karthika R, Singh Sp, Shashikala P, Kanungo R, Jayachandram S, et al. Correlation between biofilm production and multi-drug resistance in imipenem resistant clinical isolates of Acinetobacter baumannii. Indian J Med Microbiol 2008;26:333-7.  Back to cited text no. 1
    
2.Patwardhan RB, Dhakephalkar PK, Niphadkar KB, Chopade BA. A study on nosocomial pathogensin ICU with special reference to multi-drug resistant Acinetobacter harbouring multiple plasmids. Indian J Med Res 2008;128:178-87.  Back to cited text no. 2
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3.Acinetobacter, Stenotrophomonas and other organisms. In: Forbes BA, Sahm DF, Weissfeld AS, editors. Bailey and Scott's Diagnostic Microbiology, 12 th ed. China: Elsevier; 2007. p. 334- 8.  Back to cited text no. 3
    
4.Sunenshine RH, Wright MO, Moragakis LL, Harris AD, Song X, Hebden J, et al. Multi-drug resistant Acinetobacter infection Mortality rates and length of hospitalization. Emerg Infect Dis 2007;13:97-103.  Back to cited text no. 4
    
5.Boo TW, Walsh F, Crowley B. Molecular characterization of carbapenam-resistant acinetobacter species in an Irish university hospital: Predominance of Acinetobacter genomic species. J Med Microbiol 2009;58:209-16.  Back to cited text no. 5
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6.Kohlenberg A, Brummer S, Higgins PG, Sohr D, Piening BC, De Grahl C, et al. Outbreak of carbapenems-resistant Acinetobacter baumannii carrying the carbapenemase OXA-23 in a Germany university medical center. J Med Microbiol 2009;58:1499-507.  Back to cited text no. 6
    
7.Prashnath K, Badrinath S. Nosocomial Infections due to Acinetobacter species: Clinical findings, risk and prognostic factors. Indian J Med Microbiol 2008;26;3:243-5.  Back to cited text no. 7
    
8.John NG, Gosbell IB, Kelly JA, Boyle MJ, Ferguson JK. Cure of multi-drug resistant Acinetobacter baumannii central nervous system infections with intraventricular or intrathecal colistin: Case reviews and literature review. J Antimicrob Chemother 2006;58:1078-81.  Back to cited text no. 8
    


    Figures

  [Figure 1]


This article has been cited by
1 Molecular Characterization of Carbapenem-Resistant Acinetobacter baumannii with Special Reference to Carbapenemases: A Systematic Review
Neetu Gupta, Kalpana Angadi, Savita Jadhav
Infection and Drug Resistance. 2022; Volume 15: 7631
[Pubmed] | [DOI]



 

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