|Year : 2018 | Volume
| Issue : 1 | Page : 117-119
First case report of surgical site infection due to Buttiauxella agrestis in a neurocare center in India
Nivedita Patra1, Mridula Raj Prakash1, Shripad Patil1, Malla Bhaskar Rao2
1 Department of Neuromicrobiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
|Date of Web Publication||11-Jun-2018|
Dr. Nivedita Patra
Department of Neuromicrobiology, National Institute of Mental Health and Neurosciences, Bangalore - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
Buttiauxella agrestis, a member of the Enterobacteriaceae family, is usually isolated from soil, water, fish, mollusks, and rarely associated with human infections. Here, we report a rare case of postcraniotomy surgical site infection by B. agrestis in a neurosurgical center which was easily controlled by antibiotic. To the best of our knowledge, this is the first case report from India implicating B. agrestis as a cause of human infection. The infection along with microbiological characteristics and clinical significance of the organism is described.
Keywords: Buttiauxella agrestis, Enterobacteriaceae, postcraniotomy
|How to cite this article:|
Patra N, Prakash MR, Patil S, Rao MB. First case report of surgical site infection due to Buttiauxella agrestis in a neurocare center in India. Arch Med Health Sci 2018;6:117-9
|How to cite this URL:|
Patra N, Prakash MR, Patil S, Rao MB. First case report of surgical site infection due to Buttiauxella agrestis in a neurocare center in India. Arch Med Health Sci [serial online] 2018 [cited 2019 May 25];6:117-9. Available from: http://www.amhsjournal.org/text.asp?2018/6/1/117/234095
| Introduction|| |
Buttiauxella agrestis, a member of the Enterobacteriaceae family, is a small Gram-negative rod-shaped facultative anaerobic organism found in a variety of places in nature: soil, water, fish, cockroaches, and mollusks, including slugs and snails. There are only a few clinical case reports of wound infection caused by B. agrestis till now. This organism has been reported as a cause of appendicitis  and postcesarean surgical site infection. Here, we report a rare case of post-craniotomy surgical site infection due to B. agrestis in a neurosurgical center.
| Case Report|| |
A 37-year-old healthy male was admitted to our hospital following a road traffic accident with head injury. He had one episode of vomiting with altered sensorium. There was no loss of consciousness, seizure, or limb weakness. On examination, Glasgow coma scale was E2M5V3 and vitals were stable. Computed tomography revealed left temporo-parietal hematoma with midline shift of 0.7 cm. Laboratory tests showed hemoglobin concentration of 12.9 g/dl, platelet count of 214000/μl, leukocyte count of 17,500/μl, red blood cell count of 4.35 million/μl, mean corpuscular hemoglobin (MCH) of 29.7 pg, MCH concentration of 32.3 g/dl, MCV of 92 fl, and packed cell volume of 40%. Serum electrolytes levels were in normal limit. He underwent left fronto-temporo-parietal decompressive craniotomy with evacuation of contusion under antibiotic prophylaxis (1 g cefazolin intravenously twice a day). On the 2nd postoperative day, he developed a fever (101°F) with pus discharge from the surgical site. Pus sample was collected and sent to the department of microbiology for processing. Gram's staining showed the presence of polymorphonuclear leukocytes and Gram-negative bacteria. The sample was inoculated into 5% sheep blood agar and MacConkey's Agar media. After 24 h of aerobic incubation of plates at 37°C, the colonies on 5% sheep blood agar were about one mm in diameter, circular, low convex, smooth with entire margin; on MacConkey's Agar colonies were mucoid and lactose fermenting. On Gram staining from culture plates showed the presence of Gram-negative bacilli. The organism was motile, oxidase negative, catalase positive, lactose fermenter, mannitol fermenter, acidic butt and acidic slant without any gas or, H2S formation on triple sugar iron medium, indole negative, citrate positive, and urease negative. With above biochemical features and colony characteristics, it was thought to be Citrobacter freundii. When the isolate was tested by Vitek 2C-60 (BioMe'rieux, Marcy l'Etoile, France), it was identified as B. agrestis with 94% probability. As Vitek 2C-60 database has limited ability in performing susceptibility test of many newer genera, antibiotic susceptibility was determined by Kirby Bauer's disc diffusion method. The isolate was sensitive to gentamicin (10 μg/disc), amikacin (30 μg/disc), ciprofloxacin (5 μg/disc), imipenem (10 μg/disc), ofloxacin (5 μg/disc), piperacillin/tazobactam (100/10 μg/disc), aztreonam (30 μg/disc), piperacillin (30 μg/disc), ceftazidime (30 μg/disc), ceftriaxone (30 μg/disc), cefepime (30 μg/disc) and resistant to ampicillin (10 μg/disc), and cefoxitin (30 μg/disc). Surgical drainage was done with intravenous administration of amikacin (15 mg/kg/day in three divided doses) and ceftriaxone (2 g in two divided doses) along with other supportive management. After 7 days of treatment, the patient became afebrile with no pus discharge, and he was discharged from the hospital with oral prescription of cefuroxime for 7 days. On follow-up as an outpatient, he remained well.
| Discussion|| |
Members of Enterobacteriaceae family are the most common cause of nosocomial infections. Many new members of the family Enterobacteriaceae were described in the last three decades, but clinical significance of these new species are still unknown. The genus Buttiauxella consists of seven named species whose primary ecologic niche appears to be as inhabitants of mollusks. The genus Buttiauxella was initially defined by Ferragut et al. in 1981 as a new genus in the family Enterobacteriaceae with only one species, B. agrestis. All of the strains were from water and previously had been called “Group F” by Gavini et al. and were not to be confused with “Group F” of halophilic vibrios described by Furniss et al. Originally, Gavini et al. thought that these strains resembled Citrobacter because both groups are indole negative, methyl red positive, Voges–Proskauer negative, and citrate positive. However, phenotypically, the genus Buttiauxella most closely resembles Kluyvera. By DNA hybridization, Buttiauxella, and Kluyvera were only 30%–36% related. There was also a difference in the guanine plus cytosine (G + C) content of DNA of the two genera; Kluyvera had 55%–56% G + C, and Buttiauxella had 49% G + C. Over a decade later, the genus was amended to include six additional species based on the analysis of over 200 snail and slug strains. The type strains of Buttiauxella species are B. agrestis, Buttiauxella brennerae, Buttiauxella ferragutiae, Buttiauxella gavinae, Buttiauxella izardii, Buttiauxella noackiae, and Buttiauxella warmboldiae.
There are only few cases of isolation of Buttiauxella as human pathogen in medical literature like B. agrestis causing postcesarean surgical site infection, which is similar to our study, Buttiauxella gaviniae from urine sample of a spinal cord patient  and one clinical isolate (CDC 1650-80) belonging to B. noackiae has been described thus far.
Limited susceptibility studies have been performed on B. agrestis. The results for strains tested by broth microdilution have indicated that the isolates were resistant to ampicillin, amoxicillin–clavulanic acid, ticarcillin, cephalothin, cefoxitin, cefotaxime, doxycycline, trimethoprim, and chloramphenicol, based upon MIC90 values. However, MIC50 has indicated that many isolates are susceptible to gentamicin, amikacin, and colistin. Another report regarding the Buttiauxella species (including one case of B. agrestis) showed susceptibility to ampicillin, sulbactam, tazobactam, and cephalosporins of all generations.
This isolate was sensitive to gentamicin, amikacin, ciprofloxacin, imipenem, ofloxacin, piperacillin/tazobactam, aztreonam, piperacillin, ceftazidime, ceftriaxone, cefepime and resistant to ampicillin, cefoxitin.
According to Stone et al., the VITEK 2 system identified 90% of the subset of isolates in its database correctly but provided MIC interpretations for only 55% of them. Thus, disk diffusion provides a reliable alternative for testing of unusual Enterobacteriaceae, some of which cannot be tested by automated methods.
Investigation for the source of this organism could not be established. Although nucleic acid analysis is considered gold standard method for bacterial identification, we could not perform these tests as they were not available in our center. This is a rare case report of craniotomy surgical site infection due to B. agrestis which responded well to treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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