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      Ralstonia pickettii Bacteremia: An Emerging Infection in a Tertiary Care Hospital Setting

      case-report
      1 , , 1 , 1
      ,
      Cureus
      Cureus
      emerging, bacteremia, ralstonia

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          Abstract

          Ralstonia species are Gram-negative bacilli that have increasingly been recognized as emerging nosocomial pathogens, particularly in immunocompromised hosts. Ralstonia pickettii is the most clinically important pathogen from the Ralstonia genus. Nosocomial outbreaks of Ralstonia pickettii infections brought about by the use of contaminated medical solutions, including saline, sterile water, as well as disinfectants, have been reported. There have been case reports of invasive infections with variable presentations.

          Here, we describe three cases of Ralstonia pickettii bacteremia during a period of one year in a tertiary care hospital in Karachi, Pakistan. The first case was a 76-year-old male, known case of type 2 diabetes mellitus (DM), hypertension, and amyotrophic lateral sclerosis, who presented with complaints of burning micturition, hematuria, and fever. The patient had a history of multiple hospital admissions in the recent past. His blood culture was found to be positive for Ralstonia pickettii. A computed tomography scan of the kidneys, ureter, and bladder (CT KUB) was suggestive of pyelonephritis. The patient improved on intravenous meropenem. The second case was a 47-year-old man, who was admitted with a gunshot injury to the neck, resulting in complete cervical cord resection and mild hydrocephalus with intraventricular hemorrhage. The patient had a prolonged intensive care unit (ICU) stay, which was complicated by ventilator-associated pneumonia with Acinetobacter and central line-associated bloodstream infection (CLABSI) with Ralstonia pickettii. He was treated with meropenem and colistin but continued to deteriorate and expired. The third case was a 46-year-old lady, known case of end-stage renal disease (ESRD), who was admitted with prosthetic valve endocarditis. She had a prolonged hospital stay complicated by CLABSI with Ralstonia pickettii, improved on meropenem, but later died due to fungemia. Ralstonia pickettii is an emerging cause of nosocomial infection in patients, particularly those with a prolonged hospital stay, and can cause invasive and severe infections.

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          Most cited references15

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          Ralstonia spp.: emerging global opportunistic pathogens.

          The bacterial genus Ralstonia (Gram-negative non-fermenters) is becoming more prevalent in cases of infection with three bacterial species, Ralstonia pickettii, Ralstonia insidiosa and Ralstonia mannitolilytica, making up all cases reported (in the literature) to date. These organisms are prevalent in many different types of water supplies (including hospital water supplies), being well adapted to survive in low-nutrient conditions. They have been shown to cause infections, sometimes serious, such as osteomyelitis and meningitis, in hospital settings. Seventy cases of R. pickettii, 13 cases of R. mannitolilytica and three cases of R. insidiosa infection have been identified from the literature. Insight is given into the types of infections that are caused by these bacteria, the underlying conditions that are associated with these infections and potential treatments.
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            Ralstonia pickettii: a persistent gram-negative nosocomial infectious organism.

            Non-fermenting Gram-negative bacilli create a significant problem in clinical settings, being a widespread cause of nosocomial infections. They are opportunistic pathogens that take advantage of underlying conditions and diseases. Ralstonia pickettii, a non-fermenting Gram-negative bacillus, is regarded as being of minor clinical significance; however, many instances of infections with this organism are reported in the literature. Infections can include bacteraemia/septicaemia caused by contaminated solutions, e.g. distilled water, water for injection and aqueous chlorhexidine solutions. Cases of pseudobacteraemia have been recorded in association with R. pickettii, as have many cases of unusual infections, some of which were very invasive and severe, e.g. meningitis, septic arthritis and osteomyelitis. Six cases of death in four separate instances have also been recorded related to R. pickettii. This review illustrates that R. pickettii is a more important pathogen than was thought previously.
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              The antibiotic susceptibility of water-based bacteria Ralstonia pickettii and Ralstonia insidiosa.

              Ralstonia pickettii and Ralstonia insidiosa are waterborne bacteria that can survive and grow in various water sources, and that are emerging pathogens in hospital settings. Not much is known about the antibiotic resistance of these bacteria. Previous reports of antimicrobial susceptibility have been largely limited to a few clinical strains with no accounting for genotypic or phenotypic diversity or that these species could vary from the set breakpoints. Etests and disc diffusion tests were carried out to compare the antimicrobial susceptibilities to 12 different antibiotics of 68 different isolates of R. pickettii (53) and R. insidiosa (15) from varying environments, which have previously been well characterized both phenotypically and genetically. The majority of the R. pickettii and R. insidiosa isolates showed susceptibility to most of the antibiotics tested in this study. The most effective were found to be the quinolones and sulfamethoxazole/trimethoprim. Antibiotic susceptibility was also found not to vary between environmental niches for R. pickettii and R. insidiosa isolates.
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                Author and article information

                Journal
                Cureus
                Cureus
                2168-8184
                Cureus
                Cureus (Palo Alto (CA) )
                2168-8184
                5 July 2019
                July 2019
                : 11
                : 7
                : e5084
                Affiliations
                [1 ] Internal Medicine, Aga Khan University Hospital, Karachi, PAK
                Author notes
                Article
                10.7759/cureus.5084
                6721917
                31516793
                2330caa0-2ce7-4cac-8709-f021b2499036
                Copyright © 2019, Nasir et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 16 January 2019
                : 5 July 2019
                Categories
                Internal Medicine
                Infectious Disease

                emerging,bacteremia,ralstonia
                emerging, bacteremia, ralstonia

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