Letter to the Editor
Bacteremia outbreak due to Pantoea agglomerans in hemodialysis, an infection by an unexpected guest
Brote de bacteriemia por Pantoea agglomerans en hemodiálisis. Una infección por un invitado no esperado
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Una infección por un invitado no esperado" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The comorbidity of patients on haemodialysis is directly related to the type of vascular access. The risk of complications increases with the use of central venous catheters compared to arteriovenous fistulas.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Infections are the most frequent and serious complications associated with them.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> They tend to be the cause of withdrawal and of serious events such as osteomyelitis, endocarditis, thrombophlebitis and death among between 5% and 10% of patients with catheters.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The common pathogens that cause infections in haemodialysis tend to be gram-positive cocci (<span class="elsevierStyleItalic">Staphylococcus epidermidis</span> and <span class="elsevierStyleItalic">Staphylococcus aureus)</span>.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Gram-negative organisms and fungi are less frequent. Below, we describe an epidemic outbreak in a haemodialysis centre caused by an unusual pathogen, namely <span class="elsevierStyleItalic">Pantoea agglomerans</span> (PA). Cases caused by this bacillus have been recorded in oncology units<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and in patients with chronic kidney disease on peritoneal dialysis, but not outbreaks in haemodialysis patients.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present a PA bacteraemia epidemic outbreak in a haemodialysis centre. Suspicion arose following the appearance, in the same week, of three cases of bacteraemia caused by a microorganism not described in haemodialysis, in patients from different shifts, on different dialysis machines and with different nursing staff.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Of a total of 30 patients, three people (two women and one man) were affected, with a mean age of 50 ± 15 years (clinical description of the patients in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). All of them were carriers of permanent jugular venous catheters. In view of the striking clinical symptoms, with onset during the first hour of treatment, with poor general condition, fever of up to 40 °C, severe hypertension accompanied by vomiting in two of the cases, haemodialysis was disconnected and vancomycin 1 g and gentamicin (3−5 mg/kg/post-session) were administered empirically and intravenously. In view of the lack of clinical improvement, the patients were transferred to the referral hospital.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Peripheral blood cultures were taken from the catheters, as was a sample from the vascular access orifice, pharyngeal and perianal exudates, growing only in peripheral blood cultures of all the PA cases, replacing the empirical antibiotic therapy given to the patients with meropenem 1 g post-dialysis for a total of 10 days, with resolution of the infectious symptoms and no complications during hospitalisation. The cases were reported to the healthcare authorities. An epidemiological investigation and microbiological study were undertaken of the unit, cultures of treated waters for haemodialysis, dialysis liquid, bicarbonate buffer, dialyser and vascular line connections, of the connections between these and the drainage tubes (hansens), of the drainage tubes and the anti-reflux valves of the dialysis machines, as well as of the mains water drains, the last link in the chain, where PA was ultimately found to be growing. The hypothesis was that nursing staff were the vector of the pathogenic microorganism, after being in contact with the mains water and then handling the vascular accesses. In view of the results obtained, and following a proper disinfection of the unit’s entire haemodialysis circuit and water drains, and after the nursing protocols for the handling of venous accesses had been updated, no further cases were recorded.</p><p id="par0025" class="elsevierStylePara elsevierViewall">PA is a gram-negative bacillus of the <span class="elsevierStyleItalic">Enterobacteriaceae</span> family which is normally isolated in plants, fruit, vegetables, soil and sometimes in human and animal faeces. It tends to cause nosocomial infections in immunodepressed, elderly and dialysis patients (as described hitherto, peritonitis in peritoneal dialysis and very rarely affects haemodialysis).<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Bacteraemias caused by non-conventional germs should warn us to investigate possible outbreaks. The contamination of mains water drains and contact between the latter and the nursing staff who subsequently manipulate vascular accesses provided a route for the bacteraemia. The general recommendation for catheter-related bacteraemia is the removal of the catheter, although in dialysis conservative treatment is initially acceptable to attempt to maintain venous access if there are no signs of infection. In our experience, the early detection of PA, the focal point of the pathogen, the proper disinfection of mains water and the haemodialysis circuit, together with an update of adequate asepsis measures among nursing staff in the handling of the catheters and correct antibiotic treatment enabled an excellent outcome for patients, averting the need to change the jugular venous catheters, with no further cases detected.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Borrego Garcia E, Ruiz Sancho AL, Plaza Lara E, Díaz Gómez L, Delgado Ureña A. Brote de bacteriemia por <span class="elsevierStyleItalic">Pantoea agglomerans</span> en hemodiálisis. Una infección por un invitado no esperado. Nefrologia. 2020;40:573–575.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">TCVT: tunnelled central venous catheter.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patients \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Chronic kidney disease aetiology \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Time on dialysis \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vascular access \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Immunodepression status \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 1, woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 years old \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic pyelonephritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TCVT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 2, woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">84 years old \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Angiosclerosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TCVT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case 3, man \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70 years old \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Angiosclerosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TCVT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2457455.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical description of the patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vascular access morbidity and mortality: trends of the last decade" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.E. 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