HAYASHI Toshikiyo

KAWANAKA Norikuni

KISHIMOTO Michihiro

KURIHARA Takeyuki

MIYASHITA Osamu

NANBA Fumiyo

OKIMOTO Niro

TAMADA Sadao

OKIMOTO, Niro

HAYASHI, Toshikiyo

NANBA, Fumiyo

KISHIMOTO, Michihiro

KURIHARA, Takeyuki

KAWANAKA, Norikuni

MIYASHITA, Osamu

TAMADA, Sadao

Kawasaki Medical School Institutional Repository / 川崎医科大学学術機関リポジトリ

57Kawasaki Medical Journal 37（1）：57－62，2011Clinical features of Moraxella catarrhalis respiratory infectionsNiro OKIMOTO,   Toshikiyo HAYASHI,   Fumiyo NANBA,   Michihiro KISHIMOTOTakeyuki KURIHARA,   Norikuni KAWANAKA,   Osamu MIYASHITA,   Sadao TAMADADivision of Respiratory Diseases, Department of General Internal Medicine 1, Kawasaki Hospital,Kawasaki Medical Shool, 2-1-80 Nakasange Kitaku, Okayama 700-8505, JapanABSTRACT  Moraxella catarrhalis  respiratory infection was clinically studied. Subjects were 32 patients with M.  catarrhalis  respiratory infection who were treated in Kawasaki Hospital, Kawasaki Medical School from January 2006 to December 2010. The clinical features of these cases have been retrospectively reviewed. The results showed that: (1) There was not only acute exacerbation of chronic lower respiratory tract infection (in 11) and community-acquired pneumonia (in 18), but also hospital-acquired pneumonia (in 3); (2) There was frequent occurrence in elderly male patients with chronic respiratory disease or malignant tumor as an underlying disease; (3) Most patients were mild or moderate, and rarely severe; (4) Although there are many bacteria resistant to ABPC and ST, sensitivity remains against third- and fourth- generation cephem, carbapenem, and new quinolone; (5) Mixed infections with S. pneumoniae , or H. influenzae  were observed; (6) Prognosis is good when the third- or fourth-generation cephem, carbapenem, or new quinolone is administered (clinical efficacy rate 100 percent, and eradication rate 100 percent). (Accepted on March 30, 2011)Key words： Moraxella catarrhalis,  Community-acquired pneumonia,  Hospital-acquired pneumoniaCorresponding authorNiro OkimotoDepartment of General Internal Medicine 1, Kawasaki Hospital, Kawasaki Medical School, 2-1-80 Nakasange Kitaku, Okayama 700-8505, JapanPhone : 81 86 225 2111Fax : 81 86 232 8343E-mail : n.okimoto@kawasaki-hp.jpINTRODUCTION   Moraxella catarrhlis is important as the causative organism for acute exacerbation of chronic lower respiratory tract infection, and is also said to have high frequency as the causative organism of community-acquired pneumonia following Streptococcus pneumoniae and Haemophilus influenzae1,2,3,4). This study aimed at clarifying the clinical features of M. catarrhlis respiratory infection.SUBJECTS AND METHODSSubjects   The subjects were 32 patients with M. catarrhalis respiratory infection who were treated at Kawasaki Hospital, Kawasaki Medical School from January 2006 to December 2010.   M. catarrhalis respiratory infection is defined as respiratory infection with sputum culture containing 107 /ml or more of M. catarrhalis.58 Kawasaki Medical JournalMethods   Type of respiratory infection, such as acute exacerbation of chronic lower respiratory tract infection, community-acquired pneumonia, and hospital-acquired pneumonia5), severity, underlying disease, sensitivity against various types of antibacterial drugs, simultaneously detected bacteria, treatment, clinical efficacy, and bacteriological efficacy of patients were retrospectively studied.RESULTSCases   Thirty-two patients with M. catarrhalis respiratory infection were examined. The patients included acute exacerbation of chronic lower respiratory tract infection in 11 patients, community-acquired pneumonia in 18, and hospital-acquired pneumonia in 3.Acute exacerbation of chronic lower respiratory tract infection (Table 1)   There were 4 males and 7 females aged 53 to 89 years.   Underlying disease included chronic obstructive pulmonary disease (COPD) in 7 patients, bronchial asthma in 2, old pulmonary tuberculosis in 1, and bronchiectasis in 1.    With regard to sensitivity against various types of antibacterial drugs, 8 (73 percent) of 11 strains were resistant to ampicillin (ABPC), 6 (55 percent) of 11 strains were resistant to ST, 2 (18 percent) of 11 strains were resistant to cefazolin (CEZ), and 1 (9 percent) of 11 strains was resistant to cefotiam (CTM), while all the strains were sensitive to cefotaxime (CTX), imipenem / cilastin (IPM/CS), minocycline (MINO), and levofloxacin (LVFX). One patient developed mixed infection with penicillin-intermittent Streptococcus pneumoniae (PISP).   As t reatment ,  levofloxacin (LVFX) was administered to 5 patients, cefditoren (CDR) to 2 and cefotiam (CTM), cefepim (CFPN), and panipenem / betamipron (PAPM / BP) to 1 , respectively.    Clinical efficacy was good in all patients, and all strains were eradicated. Community-acquired pneumonia (Table 2)   There were 13 males and 5 females aged 58 to 91 years.   Underlying disease included COPD in 5 patients, bronchial asthma in 2, lung cancer in 2, diabetes Table 1.　Clinical features of patients with  Moraxella catarrhalis infection(exacerbations of chronic lower respiratory tract infection)Patients Age(years) GenderUnderlying diseases SeveritySusceptibility M. catarrhalis to antibiotics ConcurrentisolatedbacteriaTreatment ClinicalefficacyBacteriologicalefficacyABPC CEZ CTM CTX IPM/CS MINO LVFX ST1 53 Ｆ COPD － Ⓡ S S S S S S S (-) CDTR Good Eradicated2 65 M COPD － Ⓘ S S S S S S S (-) LVFX Good Eradicated3 65 F COPD － Ⓘ S S S S S S S (-) LVFX Good Eradicated4 71 F Bronchialasthma － S S S S S S S Ⓡ (-) CDTR Good Eradicated5 71 Ｆ COPD － Ⓘ Ⓘ S S S S S Ⓡ (-) LVFX Good Eradicated6 72 M Oldtuberculosis － Ⓡ S S S S S S S (-) LVFX Good Eradicated7 73 F COPD － S S S S S S S S (-) PAPM/BP Good Eradicated8 73 F Bronchiectasis － S S S S S S S Ⓘ (-) CFPM Good Eradicated9 83 F Bronchialasthma － Ⓡ S S S S S S Ⓡ (-) CTM Good Eradicated10 87 M COPD － Ⓡ S S S S S S Ⓡ (-) CPFX Good Eradicated11 89 M COPD － Ⓡ Ⓡ Ⓡ S S S S Ⓘ PISP LVFX Good Eradicated59Okimoto N, et al. : Moraxella catarrhalis respiratory infectionsmellitus in 2, and chronic renal failure (undergoing dialysis), mitral regurgitation, hypertension, and old pulmonary tuberculosis in 1, respectively.    Severity was mild in 1 patient, moderate in 15 and severe in 2.    With regard to sensitivity to various types of antibacterial drugs, 14 (78 percent) of 18 strains were resistant to ABPC, 6 (33 percent) of 18 strains were resistant to ST, and 1 (6 percent) of 18 strains was resistant to CEZ, CTM, and MINO, respectively, while all the strains were sensitive to CTX, IPM/CS, and LVFX. Two patients developed mixed infection with Haemophilus influenzae. One patient developed mixed infection with penicillin-sensitibe S.pneumoniae (PSSP).    As t reatment ,  meropenem (MEPM) was administered to 5 patients, LVFX to 3, cefpirome (CPR) and CPFX to 2,subactam / ampicillin (SBT / ABPC), cefotiam (CTM), CFPM, cefozopran (CZOP), IPM/CS, and garenofloxacin (GRNX) to 1, respectively.     Clinical efficacy was good in all patients, and all strains were eradicated. Hospital-acquired pneumonia (Table 3)   There were 2 males and 1 female aged 65 to 89 years.   Underlying disease included idiopathic interstitial pneumonias, malignant melanoma , and gastric cancer, respectively. Table 2.　Clinical features of patients with  Moraxella catarrhalis infection (community-acquired pneumonia)Patients Age(years) GenderUnderlyingdiseases SeveritySusceptibility M. catarrhalis to antibiotics ConcurrentisolatedbacteriaTreatment ClinicalefficacyBacteriologicalefficacyABPC CEZ CTM CTX IPM/CS MINO LVFX ST1 58 M Bronchial asthma mild Ⓡ S S S S S S S (-) SBT/ABPC Good Eradicated2 73 M Chronic renal failure moderate Ⓘ S S S S S S Ⓘ (-) CFPM Good Eradicated3 73 M Mitral regurgitation moderate Ⓡ Ⓡ Ⓘ S S Ⓘ S S (-) GRNX Good Eradicated4 74 M COPD moderate Ⓡ S S S S S S Ⓘ (-) LVFX Good Eradicated5 75 M Hypertension moderate Ⓡ S S S S S S Ⓘ (-) LVFX Good Eradicated6 77 F Gastric ca moderate S S S S S S S S (-) MEPM Good Eradicated7 77 M COPD severe Ⓡ S S S S S S S PSSP CZOP Good Eradicated8 80 M COPD severe Ⓡ S S S S S S S (-) MEPM Good Eradicated9 82 M COPD moderate S S S S S S S S (-) IPM/CS Good Eradicated10 82 Ｍ Lung ca moderate Ⓡ S S S S S S Ⓘ (-) CPR Good Eradicated11 83 Ｆ Bronchial asthma moderate S S S S S S S S H. influenzae MEPM Good Eradicated12 83 Ｍ Old tuberculosis moderate Ⓡ S S S S S S S (-) LVFX Good Eradicated13 84 Ｍ Diabetes mellitus moderate Ⓡ S S S S S S S (-) CPEX Good Eradicated14 84 Ｆ Parkinson's dis moderate Ⓡ S S S S S S Ⓡ (-) CPR Good Eradicated15 87 Ｆ COPD moderate Ⓡ S S S S S S Ⓘ (-) CPFX Good Eradicated16 88 M Lung ca moderate Ⓘ S S S S S S S H. influenzae CTM Good Eradicated17 90 M Diabetes mellitus moderate S S S S S S S S (-) MEPM Good Eradicated18 91 Ｆ Darmatomyositis moderate Ⓘ S S S S S S S (-) MEPM Good EradicatedTable 3.　Clinical features of patients with Moraxella catarrhalis infection (hospital-acquired pneumonia)Patients Age(years) GenderUnderlyingdiseases SeveritySusceptibility M. catarrhalis to antibiotics ConcurrentisolatedbacteriaTreatment Clinical efficacyBacteriologicalefficacyABPC CEZ CTM CTX IPM/CS MINO LVFX ST1 65 Ｍ IIPs mild Ⓡ S S S S S S S (-) CAZ Good Eradicated2 80 Ｍ Malignantmelanoma mild Ⓡ S S S S S S Ⓘ (-) CAZ Good Eradicated3 89 Ｆ Gastric ca mild Ⓡ S S S S S S Ⓘ (-) MEPM Good Eradicated60 Kawasaki Medical Journal   Severity was mild in all patients.    With regard to sensitivity to various type of antibacterial drug, 3 (100 percent) of 3 strains were resistant to ABPC, 2 (67 percent) of 3 strains were resistant to ST, while all the strains were sensitive to CEZ, CTM, CTX, IPM/CS, MINO, and LVFX.    As treatment, ceftazidime (CAZ) was administered to 2 patients, and MEPM to 1.   Clinical efficacy was good in all patients, and all strains were eradicated. DISCUSSION   M. catarrhlis is said to hold an important position as the causative organism for acute exacerbation of chronic lower respiratory tract infection and community-acquired pneumonia. This study revealed that acute exacerbation of chronic lower respiratory tract infection occurred in 11 patients, while community-acquired pneumonia occurred in 18 patients and hospital-acquired pneumonia occurred in 3 patients, thus the number of patients with pneumonia was larger than that with acute exacerbation of chronic lower respiratory tract infection. This suggests that M. catarrhlis is also the causative organism of hospital-acquired pneumonia. Verducin et al.6) also reported that it is not only the causative organism for respiratory infection which occurs out of hospital but also the causative organism of respiratory infection which occurs in hospital.   Acute exacerbation of chronic lower respiratory tract infection occurred in 4 males and 7 females aged 53  to  89  years ,  communi ty-acquired pneumonia occurred in 13 males and 5 females aged 58 to 91 years, and hospital-acquired pneumonia occurred in 2 males and 1 female aged 65 to 89 years, showing M. catarrhalis respiratory infection occurred most frequently in elderly male patients. Babay7) and Verducin et al.6) also reported that elderly males develop it with the greatest frequency.    All 32 patients had underlying disease. In not only acute exacerbation of chronic lower respiratory tract infection, but also in community-acquired pneumonia and hospital-acquired pneumonia, most are respiratory diseases such as COPD, or bronchial asthma, and malignant tumor (lung cancer, gastric cancer, and malignant melanoma) was observed in 3 patients. Verducin et al.6) reported that chronic respiratory disease was observed the most frequently as the underlying disease, which is consistent with our findings. Nagatake et al.1) reported that with the exception of malignant tumor, cerebrovascular diseases was frequently observed. It is presumed that when cases of hospital-acquired pneumonia are observed, cerebrovascular diseases increase as the underlying disease, as was observed by Nagatake.    Therefore, it is suggested that M. catarrhlis respiratory infection occurs in elderly males with chronic respiratory disease or malignant tumor as the underlying disease.   With regard to severity, community-acquired pneumonia was mild in 1 ,  moderate in 15 , and severe in 2 patients, and hospital-acquired pneumonia was mild in 3 patients. This suggests that M. catarrhlis pneumonia occurs mildly or moderately and less frequently severely. Past studies6,8) have also reported frequent mild or moderate severity, and the invasiveness was weaker than S.pneumoniae. However, sepsis has been reported to occur rarely in immunocompromised patients9,10,11,).    With regard to sensitivity to various types of antibacterial drugs, 25 (78 percent) of 32 strains were resistant to ABPC, 14 (44 percent) of 32 strains were resistant to ST, 3 (9 percent) of 32 strains were resistant to CEZ, and 2 (6 percent) of 32 strains was resistant to CTM, and 1 (3 percent) of 32 strains were resistant to MINO. It was concluded that third- and fourth-generation cephem, carbapenem, and new quinolone should be selected for M. catarrhlis pneumonia or respiratory infection rather than ABPC, ST, first- and second-generation 61Okimoto N, et al. : Moraxella catarrhalis respiratory infectionscephem, or MINO. Several studies6,7,8,12,13) have reported that many bacteria are resistant to ABPC or first-generation cephem antibiotics, and cephem of third-generation or later, carbapenem, and that new quinolone are effective in treatment, which is consistent with our findings.    Four (13 percent) of 32 patients had mixed infection, 2 were infected with S. pneumoniae (PSSP 1 and PISP 1) and 2 were infected with H. influenzae. Although the number of patients is small, attention should be paid to the fact that mixed infection with the 3 major causative organisms was found. In the literature, complications are seen not only with S.pneumniae or H.influezae1,8) but also with Mycoplasma pneumoniae14).    As treatment, new quinolone were administered to 13 patients, including LVFX to 8, CPFX to 3, and GRNX to 2. Third- and fourth-generation cephem were administered to 9 patients, including CDTR to 2, CFPM to 2, CPR to 2, CAZ to 2, and CZOP to 2, carbapenem were administered to 8 patients, including MEPM to 6, PAPM / BP to 1, and IPM / CS to 1. These choices were considered valid in terms of the guidelines2,4,5) regarding respiratory infection as well as in terms of sensitivity. As a result, clinical efficacy was 100 percent and eradication rate was 100 percent. Therefore M. catarrhalis respiratory infection may have a good prognosis when treated appropriately.  It is concluded as follows: (1) M. catarrhalis respiratory infection which we have experienced included not only acute exacerbation of chronic lower respiratory tract infection and community-acquired pneumonia, but also hospital-acquired pneumonia; (2) It occurs in elderly male patients with chronic respiratory disease or malignant tumor as an underlying disease; (3) Many cases are mild or moderate, and severe cases are rare; (4) Although there are many bacteria resistant to ABPC and ST, sensitivity remains to third- and fourth-generation cephem, carbapenem, and new quinolone; (5) Mixed infections with S. pneumoniae, or H. influenzae were observed; (6) Prognosis is good when the third- or fourth-generation cephem, carbapenem, or new quinolone are administered (clinical efficacy rate 100 percent, and eradication rate 100 percent). REFERENCES１） Nagatake T:  Respiratory infect ions caused by Branhamella catarrhalis: Clinical analysis concerning its pathogenicity. 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Clin Microbiol Rev 15:125-144,2002７） Babay HA:, Isolation of Moraxella catarrhalis in patients at King Khalid University Hospital,Riyadh. Saudi Med J 21:860-863,2000.８） Nagatake T. Moraxella catarrhalis pneumonia. In Respiration syndrome (Kudoh S, eds). Osaka, Japan, Nihon Rinshosya Press.2008,pp51-54９） Westendrop IC, Tiemessen MA, de Jong M, Soomers A, Wakelkamp IM, Boersma WG: Moraxella catarrhalis sepsis in a patient with juvenile spinal muscle atrophy. Neth J Med 63:227-29,200510） Sugiyama H, Ogata E, Shimamoto Y, et al.:Bacteremic Moraxella catarrhalis pneumonia in a patients with immunoglobulin deficiency. J Infect Chemother 6:61-62,200011） Balkhy HH, Memish ZA, Shibl A, Elbashier A, Osoba A: In vitro activity of quinolones against S.pneumoniae, 62 Kawasaki Medical JournalH.influenzae and M.catarrhalis in Saudi Arabia. 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Clinical features of Moraxella catarrhalis respiratory infections

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Clinical features of Moraxella catarrhalis respiratory infections

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