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      Community-acquired urinary tract infections caused by Burkholderia cepacia complex in patients with no underlying risk factor

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          Abstract

          Introduction. Urinary tract infections (UTIs) remain common infections diagnosed in outpatients as well as hospitalized patients. Community-acquired UTIs are generally caused by Escherichia coli and other members of the family Enterobacteriaceae. Burkholderia cepacia is an opportunistic pathogen mainly affecting immunocompromised and hospitalized patients, particularly those who have received prior broad-spectrum antibacterial therapy.

          Case presentation. Urine samples were collected from 157 outpatients clinically diagnosed with UTI and from 100 healthy control subjects. Samples were cultured on differential media and non-motile lactose-non-fermentors were identified via the Remel RapID ONE system. The isolates were tested by the disc diffusion method against 17 antimicrobial agents. Burkholderia was isolated as a single organism from four patients having uncomplicated infections, and one from recurrent infection. None of these patients had an underlying risk factor for this pathogen. Identification of these isolates by the Remel-RapID ONE system was confirmed by recA gene amplification. The four isolates were resistant to lincomycin, nalidixic acid, oxacillin and penicillin G. These cases received monotherapy of oral co-trimoxazole.

          Conclusions. Our findings alert urologists and diagnostic laboratories to the potential of B. cepacia complex infections in similar cases, and that this bacterium should not be ruled out.

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          Most cited references 20

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          Laboratory diagnosis of urinary tract infections in adult patients.

          Urinary tract infections (UTIs) are among the most common bacterial infections and account for a significant part of the workload in clinical microbiology laboratories. Enteric bacteria (in particular, Escherichia coli) remain the most frequent cause of UTIs, although the distribution of pathogens that cause UTIs is changing. More important is the increase in resistance to some antimicrobial agents, particularly the resistance to trimethoprim-sulfamethoxazole seen in E. coli. Physicians distinguish UTIs from other diseases that have similar clinical presentations with use of a small number of tests, none of which, if used individually, have adequate sensitivity and specificity. Among the diagnostic tests, urinalysis is useful mainly for excluding bacteriuria. Urine culture may not be necessary as part of the evaluation of outpatients with uncomplicated UTIs, but it is necessary for outpatients who have recurrent UTIs, experience treatment failures, or have complicated UTIs, as well as for inpatients who develop UTIs.
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            The etiology of urinary tract infection: traditional and emerging pathogens.

             Allan Ronald (2003)
            The microbial etiology of urinary infections has been regarded as well established and reasonably consistent. Escherichia coli remains the predominant uropathogen (80%) isolated in acute community-acquired uncomplicated infections, followed by Staphylococcus saprophyticus (10% to 15%). Klebsiella, Enterobacter, and Proteus species, and enterococci infrequently cause uncomplicated cystitis and pyelonephritis. The pathogens traditionally associated with UTI are changing many of their features, particularly because of antimicrobial resistance. The etiology of UTI is also affected by underlying host factors that complicate UTI, such as age, diabetes, spinal cord injury, or catheterization. Consequently, complicated UTI has a more diverse etiology than uncomplicated UTI, and organisms that rarely cause disease in healthy patients can cause significant disease in hosts with anatomic, metabolic, or immunologic underlying disease. The majority of community-acquired symptomatic UTIs in elderly women are caused by E coli. However, gram-positive organisms are common, and polymicrobial infections account for up to 1 in 3 infections in the elderly. In comparison, the most common organisms isolated in children with uncomplicated UTI are Enterobacteriaceae. Etiologic pathogens associated with UTI among patients with diabetes include Klebsiella spp., Group B streptococci, and Enterococcus spp., as well as E coli. Patients with spinal cord injuries commonly have E coli infections. Other common uropathogens include Pseudomonas and Proteus mirabilis.Recent advances in molecular biology may facilitate the identification of new etiologic agents for UTI. The need for accurate and updated population surveillance data is apparent, particularly in light of concerns regarding antimicrobial resistance. This information will directly affect selection of empiric therapy for UTI.
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              Multiple combination bactericidal antibiotic testing for patients with cystic fibrosis infected with Burkholderia cepacia.

              Most Burkholderia cepacia strains are resistant to many, or all, of the antibacterial agents commonly used in cystic fibrosis (CF), and selection of appropriate antibiotics for treatment of pulmonary exacerbations is therefore difficult. We developed a technique for rapid in vitro testing of multiple antibiotic combinations for B. cepacia isolates. For each of 119 multi-drug-resistant isolates of B. cepacia, our multiple combination bactericidal test (MCBT) studied the bactericidal activity of 10 to 15 antimicrobial agents using 225 +/- 97 single, double, and triple antibiotic combinations. Of the 119 isolates, 50% were resistant to all single antibiotics tested, 8% were resistant to all two-drug antibiotic combinations, but all were inhibited by at least one bactericidal triple-drug combination. When used alone, meropenem, ceftazidime and high-dose tobramycin (200 microg/ml) were bactericidal against only 47, 15, and 14% of in vitro isolates, respectively. Using a double antibiotic combination improved bactericidal activity; meropenem-minocycline, meropenem-amikacin, and meropenem-ceftazidime combinations were bactericidal against 76, 73, and 73% of isolates, respectively. However, 47% of isolates demonstrated antagonism (growth of an organism when a second antibiotic was added to a bactericidal single antibiotic). Triple antibiotic combinations that contained tobramycin, meropenem, and an additional antibiotic were most effective, and were bactericidal against 81 to 93% of isolates. We conclude that triple-antibiotic combinations are more likely than double and single antibiotic combinations to be bactericidal against B. cepacia in vitro. MCBT testing is a useful technique to help clinicians decide on appropriate nonantagonistic combination antibiotic therapy for patients with CF infected with B. cepacia.
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                Author and article information

                Journal
                JMM Case Rep
                JMM Case Rep
                JMMCR
                JMM Case Reports
                Microbiology Society
                2053-3721
                January 2017
                31 January 2017
                : 4
                : 1
                Affiliations
                [ 1]Department of Laboratory Medical Sciences, Jordan University of Science and Technology , Irbid, Jordan
                [ 2]Department of General and Pediatric Surgery, Jordan University of Science and Technology , Irbid, Jordan
                Author notes
                *Correspondence: Laila Nimri, nimri@ 123456just.edu.jo
                Article
                jmmcr005081
                10.1099/jmmcr.0.005081
                5361629
                © 2017 The Authors

                This is an open access article under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.

                Product
                Funding
                Funded by: Jordan University of Science and Technology
                Award ID: 14/2014
                Categories
                Case Report
                Urinary Tract and Reproductive Organs
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