Moraxella and Psychrobacter Species

CHAPTER

153

835

organism, so clinicians should consider the results of in vitro testing as investigational. Antimicrobial therapy for infections due to C. violaceum should be initiated with parenteral antibiotics until the patient is stable and improving, followed by an oral antimicrobial agent (trimethoprim-sulfamethoxazole or tetracycline) for at least an additional 4 weeks for disseminated infection. As with any rapidly progressive necrotizing skin disease or abscess, lesions should be debrided or drained aggressively at initiation of antimicrobial therapy. Disseminated infection requires aggressive supportive care. Relapse of bacteremia is a documented complication, occurring about 2 weeks after completion of therapy. C. violaceum should be considered among the possible causes of cellulitis or rapidly progressive illness following exposure to soil or water, particularly stagnant water in the southeastern United States; empiric antibiotic therapy should be initiated to target this agent.61

CHAPTER

15 3

Moraxella and Psychrobacter Species

Mario J. Marcon and Katalin Koranyi

species identication of these organisms except for M. catarrhalis. Identication of this organism usually relies on typical appearance of gram-negative diplococci on stain and positive tests for catalase, cytochrome oxidase, and hydrolysis of tributyrin. The latter test should not be used alone because other Moraxella spp. can be positive. Another useful feature for identication of M. catarrhalis is the observation that colonies of this organism can be pushed intact over the surface of a blood agar plate much like an ice-hockey puck is pushed over ice. Finally, isolates of M. catarrhalis are almost always beta-lactamase-positive such that a negative beta-lactamase test result should be cause to re-evaluate the accuracy of the identication. Studies relating to the mechanisms of pathogenesis of Moraxella and Psychrobacter spp. have focused on M. catarrhalis. They have included investigations into the role of mbrial proteins, lipopolysaccharide, hemagglutinins, and several other outer membrane proteins. Fimbrial proteins of M. catarrhalis play a role in the attachment of the organism to specic receptor molecules on respiratory epithelial cells. Hemagglutinin proteins also contribute to adherence and also appear to inhibit the bactericidal activity or normal human serum. Several outer membrane proteins probably play several roles in virulence of the organism, including adherence to mucosal surfaces and resistance to complement-mediated killing of the organism by serum. Some of these proteins, including UspA, TpbB, and CopB, are being investigated as candidates for pediatric vaccines to prevent otitis media and other infections.

CLINICAL MANIFESTATIONS
M. catarrhalis is by far the most important human pathogen in this group of organisms. Colonization rates in the upper respiratory tract vary greatly with age. Rates are highest in young children and in elderly patients with chronic respiratory tract infection, including bronchitis and chronic obstructive pulmonary disease.8 Not surprisingly, colonization rates correlate with the frequency of respiratory tract disease due to this organism. The most frequent infections due to this agent include acute otitis media (AOM), sinusitis, bronchitis, and pneumonia. M. catarrhalis follows Streptococcus pneumoniae and nontypable Haemophilus influenzae as the third most common cause of AOM.9 Most cases of M. catarrhalis AOM resolve spontaneously, unlike AOM caused by Streptococcus pneumoniae. Suppurative complications of AOM, such as mastoiditis, osteomyelitis, meningitis, or brain abscess, are almost never caused by this organism. Sinusitis caused by M. catarrhalis is indistinguishable from sinusitis caused by S. pneumoniae. M. catarrhalis can cause lower respiratory tract infections in normal and immunocompromised children and adults. M. catarrhalis has been isolated from blood and pleural fluid in children with lower respiratory tract infections. In the neonate, M. catarrhalis can be confused with Neisseria gonorrhoeae when Gram stain shows gram-negative intracellular diplococci. Bloodstream infection (BSI) caused by M. catarrhalis has been described in normal and immunocompromised children of all age groups.10 M. catarrhalis can cause purulent conjunctivitis, periorbital cellulitis, meningitis from shunt-associated ventriculitis, septic arthritis, and urinary tract infection.11,12 Other Moraxella and Psychrobacter spp. have been associated with pyogenic arthritis,13 BSI,14 ophthalmic infections,15,16 pericarditis,17 and endocarditis.18 Meningitis caused by P. immobilis in a 2-day-old infant was initially thought to be caused by N. gonorrhoeae.19 Cases of BSI associated with diarrhea in children have been reported; 5 cases were due to M. osloensis, 3 to M. nonliquefaciens, and 1 to M. lacunata.20 M. nonliquefaciens is most commonly associated with respiratory tract infections,6 but it has also been reported to cause meningitis and BSI.20 A case of pyogenic arthritis in an adult undergoing hemodialysis has also been reported.21 M. lacunata is a well-known cause of conjunctivitis and also causes keratitis, sinusitis, and endocarditis. M. osloensis is a common inhabitant of the genital tract and has been associated with osteomyelitis, peritonitis, catheterrelated BSI, and other deep-seated infections. M. canis, an inhabitant

MICROBIOLOGY AND EPIDEMIOLOGY

The genera Moraxella and Psychrobacter are currently members of the family Moraxellaceae, along with the genus Acinetobacter. The organism formerly known as Moraxella urethralis (or Centers for Disease Control and Prevention (CDC) group M-4) has been renamed Oligella urethralis and placed in the unrelated genus Oligella, along with O. urealytica (formerly CDC group IVe). Similarly, Moraxellalike organisms, formerly referred to as CDC groups M-5 and M-6, have been reclassied as Neisseria weaveri and N. elongata subsp. nitroreducens, respectively. The genera Neisseria and Kingella remain in the family Neisseriaceae along with several other genera.17 The genus Moraxella is composed of nonmotile oxidase-positive, catalase-positive, aerobic, asaccharolytic, gram-negative coccobacilli or diplococci that tend to resist decolorization on Gram stain. Select Moraxella spp. may be somewhat fastidious but can be isolated in the laboratory on blood and chocolate agars with incubation in a carbon dioxide-rich environment. Most strains grow poorly or not at all on MacConkey agar. They can be differentiated from Acinetobacter and Kingella spp. on the basis of oxidase and catalase reactions, respectively. In addition, the development of elongated, bacillary forms by Moraxella spp. other than M. catarrhalis in vitro in the presence of subinhibitory concentrations of penicillin and the inability of Moraxella spp. to utilize glucose differentiate members of this genus from most Neisseria spp.13 Moraxella spp. are considered part of the normal flora of the upper respiratory and urogenital tracts of humans and other mammals. In general, they have low pathogenic potential, but several species are recognized to cause local or systemic human infections. Some of these include M. atlantae (formerly CDC group M-3), M. lacunata, M. nonliquefaciens, M. osloensis, and, most notably, M. catarrhalis. Other pathogens include M. phenylpyruvica (formerly CDC group M-2), which has been renamed Psychrobacter phenylpyruvicus and placed in the genus Psychrobacter along with P. immobilis.4 Two newer species recovered from humans, M. canis and M. lincolnii, along with a number of animal species, have also been described as pathogens. Because of their similar clinical signicance and relative biochemical inactivity, most laboratories do not perform

836

SECTION

A Bacteria

of the upper respiratory tract of dogs and cats, has been associated with rare cases of BSI and wound infections following dog bites, and infection of ulcerated metastatic lymph node.22,23 N. weaveri (CDC group M-5) has a similar natural habitat and associated infections.

BOX 154-1. Closely Related Genera Formerly Included with Pseudomonas

Burkholderia Stenotrophomonas Comamomonas Shewanella Ralstonia Methylobacterium Sphingomomonas Acidovorax Brevundimonas

TREATMENT
Most Moraxella and Psychrobacter spp. other than M. catarrhalis are susceptible to penicillin and ampicillin, cephalosporins, tetracyclines, macrolides, and quinolones; however, b-lactamase-producing strains have been identied in some species, including strains of M. osloensis and P. phenylpyruvicus.24 It is therefore prudent to test clinically signicant isolates for b-lactamase production. However, there are currently no methods recommended by the Clinical and Laboratory Standards institute (CLSI) for susceptibility testing of Moraxella spp. other than M. catarrhalis. M. catarrhalis is almost uniformly resistant to penicillin, ampicillin, and amoxicillin due to the production of a Branhamella/Moraxella (BRO)-1 or BRO-2 b-lactamase. Not all b-lactamase tests are of equal sensitivity and only the so-called nitrocen test using this chromogenic cephalosporin as substrate should be used. The drug of choice to treat M. catarrhalis infections is amoxicillin-clavulanate. Trimethoprim-sulfamethoxazole, or a second- or third-generation cephalosporin drug, is an alternative therapeutic agent. There are reports of resistance to erythromycin and trimethoprim-sulfamethoxazole in M. catarrhalis. With a wide variety of antimicrobial agents uniformly active (no resistance reported) against this organism, there is rarely a need for susceptibility testing other than testing for b-lactamase, which is used as an aid in identication. There is a CLSIproposed standard broth microdilution method for minimum inhibitory concentration susceptibility testing against M. catarrhalis.

TABLE 154-1. Human Pathogens Included Within the Genus Pseudomonas (non-aeruginosa)
Species Pseudomonas stutzeri Pseudomonas putida Pseudomonas fluorescens Pseudomonas veronii Pseudomonas monteilii Pseudomonas oryzihabitans Pseudomonas luteola Subspecies 8 genomovars, including new species, Pseudomonas balearica 2 biovars 5 biovars (closely related to Pseudomonas fluorescens) (closely related to Pseudomonas putida) (formerly Flavimonas oryzihabitans) (formerly Chryseomonas luteola)

CHAPTER

15 4

Pseudomonas Species and Related Organisms

Jane L. Burns

Pseudomonas species are primarily waterborne and soilborne organisms of relatively low virulence that are catalase-producing, nonglucose-fermenting gram-negative bacilli that grow well on routine microbiologic culture media at 37C. Pseudomonads are distinguished by positive reaction indophenol-oxidase, and many produce pyoverdins or other visible or fluorescent pigments. Speciation is based primarily on physical characteristics (pigment production, odor, colonial morphology, and flagellar structure) and biochemical proles (including carbohydrate fermentation patterns and pro-duction of arginine dihydrolase and lysine decarboxylase). There are several related genera, many of which used to be within the genus Pseudomonas (Box 154-1). Still remaining within the genus are Pseudomonas aeruginosa, P. stutzeri, P. putida, and P. fluorescens. In addition, P. oryzihabitans (formerly Flavimonas) and P. luteola (formerly Chryseomonas) have been returned to the genus (Table 154-1). As a group, pseudomonads and closely related species are nutritionally diverse, and many are used in industry because of their unique ability to catabolize toxins. Although P. aeruginosa is the most important human pathogen within this group, other species have been reported to cause nosocomial infections in immunocompromised and postoperative patients and those with indwelling catheters, and to

cause infections in previously healthy individuals. In addition, some organisms occupy specic environmental niches. Several of these species, including P. fluorescens and Ralstonia spp., are commonly isolated from the sputum of cystic brosis patients, but are of unknown clinical signicance. R. mannitolilytic is the most commonly isolated Ralstonia species from cystic brosis patients (46% of positive individuals), followed by R. respiraculi and R. pickettii (19% and 18%, respectively).1 Other pediatric isolates of Ralstonia occur mainly in nosocomial infections and infections among young patients with malignancy.25 In 2005, Ralstonia spp. was found contaminating a high heat/humidity/delivery respiratory gas administration device (Vapotherm). Related cases of colonization and infection were found in neonates and children. Nosocomial and community-associated infections, both septicemia and localized infections, caused by Sphingomonas paucimobilis have been reported in children. In previously healthy children, septicemia and localized lymphadenitis have been reported.6 Outbreaks of nosocomial infections, including intravascular catheter-related bloodstream infection, wound infection, ventilator-associated pneumonia, bacteremic biliary tract infection, peritoneal fluid infections in patients on peritoneal dialysis, and localized abscess formation after surgery or trauma,7,8 have occurred in intensive care units9 and epidemiologic studies have suggested that S. paucimobilis may be endemic flora in the hospital environment.10 The organism is susceptible to aminoglycoside agents, fluoroquinolones, trimethoprim-sulfamethoxazole, and chloramphenicol. P. putida has been described in increasing numbers in both nosocomial and community-acquired infections. Fifty-ve cases of P. putida infection in 53 patients during a 5-year period have been reported.11 The most common infections were of the urinary tract, followed by pneumonia and septicemia. Of these infections, 55% were nosocomial, with a case fatality rate of 29%. Isolated case reports include P. putida septicemia in a neonate with staphylococcal scalded skin-like syndrome and in a hypothermic child with panhypopituitarism.12,13 Imipenem and ceftazidime had the greatest in vitro

PART III Etiologic Agents of Infectious Diseases