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| CASE REPORT |
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| Year : 2016 | Volume
: 18
| Issue : 1 | Page : 50-51 |
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Vancomycin-resistant Enterococcus faecium causing perinephric abscess
Priyanka Raveendranadhan Nair, Resmi Rajan, Preetha Rajan
Department of Microbiology, Government Medical College, Thiruvananthapuram, Kerala, India
| Date of Web Publication | 28-Jun-2016 |
Correspondence Address:
Priyanka Raveendranadhan Nair
Department of Microbiology, Government Medical College, Thiruvananthapuram, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0972-1282.184759
An 8-month-old infant presented with history of recurrent urinary tract infection and was found to have a perinephric abscess on investigation. Enterococcus faecium resistant to Vancomycin and sensitive to Linezolid was obtained from the baby's urine and perinephric collection. The patient was treated successfully with Linezolid. This case report describes the emergence of Vancomycin-resistant enterococc in this hospital. Keywords: Linezolid, perinephric abscess, Vancomycin-resistant enterococci
How to cite this article:
Nair PR, Rajan R, Rajan P. Vancomycin-resistant Enterococcus faecium causing perinephric abscess. J Acad Clin Microbiol 2016;18:50-1 |
| Introduction | |  |
Vancomycin-resistant enterococc (VRE) is an emerging concern, difficult to treat and eradicate.[1] The prevalence of VRE in North India and South India is 2–3% and 4%, respectively. VRE is more prevalent in Enterococcus faecium  90%).[2]
| Case Report | | |
An 8-month-old infant presented with fever and increased frequency of micturition to the paediatric surgery casualty at Medical College, Trivandrum, Kerala, India. The patient was a known case of persistent posterior urethral valve with left hydroureteronephrosis. He has history of recurrent urinary tract infections (UTIs) with three hospitalisations since birth for treatment. Now, the child gave a history of dribbling of urine of two weeks duration.
On examination, the patient was febrile. Abdomen was distended and bladder was palpable per abdomen. Investigation revealed a total count of 21,000 cells/mm 3. Differential count was P - 64%, L - 34% and E - 2%. Liver and renal function tests were normal. Ultrasonogram revealed a perinephric abscess in the left upper pole. Residual urine volume was 15 ml. Micturating cystourethrogram showed a bladder with multiple diverticul and dilated posterior urethral valve.
The patient's urine and pus from perinephric abscess were sent to the laboratory for culture. Urine was turbid and perinephric aspirate was purulent. Gram staining revealed 5–6 pus cells per oil immersion field and Gram-positive cocc in pairs, in both. Blood agar showed growth of grey-white opaque colonies. MacConkey agar showed magenta-coloured pinpoint colonies. Gram staining of colonies showed Gram-positive cocc in pairs and short chains.
Biochemical reactions: The organism was catalase and oxidase negative and non-motile. It hydrolysed bile Aesculin, fermented Arabinose and Mannitol without gas production. It grew on 6.5% sodium chloride broth and was heat resistant. Organism was identified as E. faecium which was later confirmed by Vitek 2.
Antibiotic susceptibility testing showed sensitivity only to Linezolid 30 µg. Vitek 2 revealed a minimum inhibitory concentration (MIC) ≥32 µg/ml for both Vancomycin and Teicoplanin, showing glycopeptide resistance as per the CLSI guidelines 2015.
For confirmation and genetic study, the strain was sent to Christian Medical College, Vellore, Tamil Nadu, India. There, the strain was confirmed by polymerase chain reaction for VanA gene using primers VanA forward - ATG AAT AGA ATA AAA GTT GC (1032 bp), VanA reverse - TCA CCC CTT TAA CGC TAA TA. The positive control for VanA gene used was Enterococcus faecalis and negative control was E. faecalis ATCC 29212 [Figure 1].[3]
The patient was treated with syrup Linezolid (100 mg/5 ml), 4 ml thrice daily for a week. Posterior urethral valve was ablated. On review, the patient was better and asymptomatic. Repeat urine culture showed no bacteriuria.
| Discussion | | |
Perinephric abscess is an uncommon complication of UTI associated with structural anomalies. It is usually caused by Enterobacteriaceae and Gram-positive cocc such as enterococci.[4] Enterococcal UTI is commonly seen in patients with abnormalities of the genitourinary tract and is generally followed by complications such as perinephric abscess and pyelonephritis as seen in the present case. In drug-resistant enterococcal infections, glycopeptides are used as the drug of choice. However, now, glycopeptide-resistant enterococc is being increasingly reported with VanA gene being the most common cause. VanA enterococc show a Vancomycin MIC of 64–1000 µg/ml and Teicoplanin MIC of 16–512 µg/ml.[5] Linezolid, high-dose Penicillin with aminoglycosides, Daptomycin with aminoglycosides, Tigecycline, Nitrofurantoin and Fosfomycin are effective against VRE infections.[4]
This case report describes the emergence of VRE in our geographical area. Strict aseptic measures need to be taken to prevent spread in the Intensive Care units and wards. Prompt treatment based on accurate laboratory diagnosis is needed to eradicate the infection.
Acknowledgement
We thank Dr. V. Balaji, Professor and Head, Department of Clinical Microbiology, Christian Medical College, Vellore, for confirming VanA gene in the strain.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Rubinstein E, Keynan Y. Vancomycin-resistant enterococci. Crit Care Clin 2013;29:841-52.  |
| 2. | Vidyalakshm P, Gopalakrishnan R, Ramasubramanian V, Ghafur KA, Namb PS, Thirunarayana M. Clinical, epidemiological, and microbiological profile of patients with vancomycin-resistant enterococc from a tertiary care hospital. J Glob Infect Dis 2012;4:137-8. |
| 3. | Saadat S, Solhjoo K, Norooz-Nejad MJ, Kazem A. VanA and VanB positive vancomycin-resistant among clinical isolates in Shiraz, South of Iran. Oman Med J 2014;29:335-9. |
| 4. | Mandell GL, Bennett JE, Doblin R. Mandell, Douglas and Bennetts Principles and Practice of Infectious Diseases. 7 th ed., Vol. 3. Canada: Elsevier; 2010. p. 2646-8. |
| 5. | Winn W, Stephen Allen JR, Janada W, Koneman E, Procop G, Berger PS,. Koneman's Color Atlas and Textbook of Diagnostic Microbiology. 6 th ed. USA: Lippincott Williams and Wilkin; 2006. p. 701-4. |
[Figure 1]
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