An increasing number of anaerobic bacteremias of oral origin have been described during the recent years as a cause of fever in neutropenic cancer patients. In this paper, we describe a case of Prevotella buccae bacteremia, the first one to our knowledge, emphasizing thus the importance of considering the oral commensals when selecting antimicrobial regimens

Androulakis, Ioannis I.

Aoun, Michael F.

Fanourgiakis, Panagiotis S.

Georgala, Aspasia G.

Skoutelis, Athanasios T.

Vandermies, Ann M.

Wolff, Fleur C.

Hospital Chronicles (E-Journal)

PREVOTELLA BUCCAE BACTEREMIA AND FEBRILE NEUTROPENIA49Prevotella Buccae Bacteremia and Febrile Neutropenia: Report of one CasePanagiotis S. Fanourgiakis1*, Aspasia G. Georgala2, Ioannis I. Androulakis1, Ann M. Vandermies2, Fleur C. Wolff2, Athanasios T. Skoutelis1, Michael F. Aoun2A B S T R A C TAn increasing number of anaerobic bacteremias of oral origin have been described during the recent years as a cause of fever in neutropenic cancer patients. In this paper, we describe a case of Prevotella buccae bacteremia, the first one to our know-ledge, emphasizing thus the importance of considering the oral commensals when selecting antimicrobial regimens.I N T R O D U C T I O NAny organism, even what is thought to be a harmless commensal, has the poten-tial to cause significant infections in cancer neutropenic patients. “New” pathogens emerged in the past few years as a result of the potent chemotherapeutic regimens [1]. We describe a case of febrile neutropenia, due to Prevotella buccae bacteremia, which, to our knowledge, is the first in the literature.C A S E  R E P O R TA 24-year-old man, with an acute myeloid leukemia in complete remission, un-derwent a conditioning regimen, consisting of melphalan, fludarabine, antithymocyte globulin and total body irradiation, before the allogeneic bone marrow transplantation. As infection prophylaxis, ciprofloxacin, trimethoprim/sulfamethoxasole, itraconazol and acyclovir were administered. On day 10 of the post-chemotherapy period, the patient developed fever (38.3°C), without rigors, and signs of hemodynamic decom-pensation. He complained also of dysphagia and retrosternal pain. Mild oral mucositis was present with probable esophagitis, but esophagoscopy was not performed. With the exception of severe neutropenia (<50/mm3) and thrombocytopenia (11,000/mm3), no other severe abnormalities were detected in his hematological and biochemical profile. Urine examination and chest x-ray were normal. Three sets of blood cultures were drawn and treatment with piperacillin/tazobactam 4gr qid IV was initiated. The stem cells were infused the day after and two days later the temperature was normalized. All blood cultures revealed Prevotella buccae.CASE REPORT* 15th Department of Internal Medicine & Infectious Diseases Unit. Evangelismos Hospital, 45 Ipsilantou Str., Athens 106 76, Greece2Département des Maladies Infectieuses et Laboratoire des Maladies Infectieuses. Institut Jules Bordet, rue Héger-Bordet 1, 1000 Bruxelles, BelgiqueKEY WORDS: Febrile neutropenia, Prevotella, BacteremiaHOSPITAL CHRONICLES 2006, 1(1): 49–51Address for correspondence:Fanourgiakis P.,5th Department of Internal Medicine & Infectious Diseases Unit. Evangelismos Hospital, 45 Ipsilantou Str., Athens 106 76, Greece, Tel: 2107201830; Fax: 2107216408, e-mail: agoritsa@otenet.gr50HOSPITAL CHRONICLES 1(1), 2006 PREVOTELLA BUCCAE BACTEREMIA AND FEBRILE NEUTROPENIA51M I C R O B I O L O G I C A L  D A T ASpecimens were processed using the BACTEC 9240 non-radiometric continuous monitoring blood culture system. All three blood culture sets had the anaerobic bottles lagged as positive on day two; two aerobic bottles also turned positive on days seven and eight. Direct examination of the smear revealed Gram negative rods. The aliquot was subcultured onto Columbia blood agar 5% SB both aerobically and an-aerobically and onto Schaedler 5% SB supplemented with Vitamin K1 anaerobically. The ANOXOMAT system was used as anaerobic environment while the BBL Crystal Iden-tification System (Anaerobe ID kit) was also used. Antibiotic susceptibility testing was done on the basis of Kirby Bauer disk diffusion. The germ proved to be intermediately resistant to penicillin and susceptible to the other agents tested (amoxi-cillin-clavulanate, piperacillin-tazobactam, clindamycin, imipenem, metronidazole).D I S C U S S I O NThe relatively new genus Prevotella, named so in 1990, was previously included in the genus Bacteroides. It includes saccharolytic pigmented and non- pigmented anaerobic gram negative rods. Prevotella, along with Bacteroides spp., are numerically the most prevalent organisms of the normal human bacterial flora. Most species are encountered mainly in the oral cavity and the pharynx, but the alimentary and the female genital tract are also normal habitats for some of them [2-4]. Prevotella spp., usually as part of a mixed flora, are implicated in dental, oropharyngeal, pleuropulmonary, abdominal and gynaecological infections [5-9]. They are not a frequent cause of bacteremia. In an analysis of 281,797 con-secutive blood cultures performed at the Mayo Clinic over an eight-year period (1984-92), among the 20,456 probable pathogens detected, only 28 (0.1%) were Prevotella spp. [10]. In the Jules Bordet Institute, only three Prevotella spp. have been isolated in blood cultures over the past six years, while the total number of positives was approximately 1150. Resistance to beta-lactams is secondary to beta-lactamase production and is encountered in 40% of isolates [3]. Prevotella buccae is a non pigmented, pentose fermenting species. It is a com-mensal of oropharynx and is mainly involved in dental, oral and respiratory infections [2,3,7,8,11]. Furthermore, only one case of clinically significant bacteremia due to P.buccae was identified by searching in MEDLINE [12].It is well known that normal oral commensals, both aero-bic and anaerobic, gain access to the blood stream through breaches of the mucosa in cancer neutropenic patients. The selective pressure of quinolone prophylaxis and the profound and prolonged neutropenia along with the oral lesions (mainly due to post-chemotherapy mucositis but also to infections and bleeding) resulted in the emergence of new pathogens. Some of these germs, considered of low virulence, proved to be liable for the cause of clinically significant bacteremias [1]. Strepto-coccus viridans remains the most commonly involved germ of the oral flora, but Stomatococcus mucilaginosus [13], Capno-cytophaga spp. [14], Leptotrichia bucallis [15], Eubacterium spp. [16] and Fusobacterium spp. [17] have also been reported in recent years as etiologic agents of febrile neutropenia. In the Jules Bordet Institute, S. mucilaginosus and Fusobacterium spp. proved to be responsible for 5.3% and 5% of bacteremias in febrile neutropenic patients [13,17]. It is the first time that Prevotella buccae bacteremia is recognized as a cause of fe-brile neutropenia. All aforementioned predisposing factors were present. No special symptoms or signs were detected, and the evolution was benign, comparable to that attested in our Fusobacterium series [17].In summary, one more oral anaerobe, Prevotella buc-cae, proved to be a potential pathogen in granulocytopenic patients and it is possible that this will be the case for more commensals of the mouth. This emphasises the need of mea-sures for prevention and control of the mucositis. Clinicians, therefore, have to be aware of the spectrum and the suscep-tibility patterns of these germs. In case of mucositis, if fever persists, despite first line empirical therapy lacking specific antianaerobic activity, the pathogens should be covered, even if cultures are negative. It seems that combinations of beta-lactams and beta-lactamase inhibitors are efficient, safe and probably cost effective.R E F E R E N C E S 1.  Zinner SH. Changing epidemiology of infections in patients with neutropenia and cancer: emphasis on gram-positive and resistant bacteria. Clin Infect Dis 1999, 29:490-494. 2.  Jousimies-Somer H, Summnen P, Finegold S. Bacteroides, Porphyromonas Prevotella, and Fusobacterium species and other anaerobic Gram negative rods and cocci. In: Murray PR, Baron EJ, Pfaller MA, Tenover FC, Yolken RH (eds) Manual of Clinical Microbiology (7th ed). American Society for Micro-biology, Washington DC, 1999, pp 690-711. 3. Avril JL, Dabernat H, Denis F, Monteil H. Bacilles à gram négatif anaerobies. In: Bactériologie clinique 3e édition, El-lipses, 2000, pp. 445-463. 4. Hentges D. The anaerobic microflora of the human body. Clin Infect Dis 1993, Suppl 4:S175-S180. 5. Finegold S. Anaerobic bacteria: general concepts. In: Mandell G, Douglas RG, Bennet J (eds). Principles and practice of infectious diseases, (5th ed), Churchill Livingstone, 2000, pp. 2519-2537. 6. Lorber B. Bacteroides, Prevotella, Porphyromonas and Fuso-bacterium species and other medically important anaerobic Gram negative bacilli. In: Mandell G, Douglas RG, Bennet J 50HOSPITAL CHRONICLES 1(1), 2006 PREVOTELLA BUCCAE BACTEREMIA AND FEBRILE NEUTROPENIA51(eds). Principles and practice of infectious diseases, (5th ed), Churchill Livingstone 2000, pp. 2561-2570. 7. Jousimies-Somer H, Savolainen S, Makitie A, Ylikoski J. Bac-teriologic findings in peritonsillar abscesses in young adults. Clin Infect Dis 1993, Suppl 4:S292-S298. 8. Marina M, Strong CA, Civen R, et al. Bacteriology of anaerobic pleuropulmonary infections: preliminary report. Clin Infect Dis 1993, Suppl 4:S256-S262. 9. Eschenbach D. Bacterial vaginosis and anaerobes in obstetric-gynecologic infection. Clin Infect Dis 1993, Suppl 4:S282-S287. 10. Cockerill FR 3rd, Hughes JG, Vetter EA, et al. Analysis of 281,797 consecutive blood cultures performed over an eight-year period: trends in microorganisms isolated and the value of anaerobic culture of blood. Clin Infect Dis 1997, 24:403-418. 11. Civen R, Vaisanen ML, Finegold SM. Peritonsillar abscess, retropharyngeal abscess, mediastinitis, and nonclostridial an-aerobic myonecrosis: a case report. Clin Infect Dis 1993, Suppl 4:S299-S303. 12.  Mohammedi I, Streichenberger T, Beck F, et al. Prevotella buccae bacteraemia associated with infection of a pseudoaneu-rysm. Eur J Vasc Endovasc Surg 1998, 15:175-176. 13. Fanourgiakis P, Georgala A, Vekemans M, et al. Bacteremia due to Stomatococcus mucilaginosus in neutropenic patients in the setting of Cancer Institute. Clinical Microbiol Infect 2003, 9:1068-1072. 14. Martino R, Ramila E, Capdevila JA, et al. Bacteremia caused by Capnocytophaga species in patients with neutropenia and cancer: results of a multicenter study. Clin Infect Dis 2001, 33:E20-22. 15. Weinberger M, Wu T, Rubin M, et al. Leptotrichia buccalis bacteremia in patients with cancer: report of four cases and review. Rev Infect Dis 1991; 13:201-206. 16. Vidal AM, Sarria JC, Kimbrough RC 3rd, Keung YK. Anaero-bic bacteremia in a neutropenic patient with oral mucositis. Am J Med Sci 2000; 319:189-190. 17. Fanourgiakis P, Vekemans M, Georgala A, et al. Febrile neu-tropenia and Fusobacterium spp. bacteraemia: Clinical experi-ence with 13 cases. Support Care Cancer 2003; 11:332-335.

Prevotella Buccae Bacteremia and Febrile Neutropenia: Report of one Case

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Prevotella Buccae Bacteremia and Febrile Neutropenia: Report of one Case

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