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Sahuquillo-Arce J, Suárez-Urquiza P, Hernández-Cabezas A, Tofan L, Chouman-Arcas R, García-Hita M, Sabalza-Baztán O, Sellés-Sánchez A, Lozano-Rodríguez N, Martí-Cuñat J, López-Hontangas J. Actinotignum schaalii infection: Challenges in diagnosis and treatment. Heliyon 2024; 10:e28589. [PMID: 38590897 PMCID: PMC10999919 DOI: 10.1016/j.heliyon.2024.e28589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/10/2024] Open
Abstract
Actinotignum schaalii affects elderly people and is associated with individuals with urological-related predispositions, but can be found in a variety of locations, such as cutaneous, intraabdominal, genitourinary and surgical infections. Disseminated infections occur less frequently and are by and large related to urinary tract colonisation. This pathogen is often neglected due to growth requirements, especially in urinary tract infections. We present 107 Actinotignum schaalii isolated from genitourinary samples (80.4%), from skin and soft tissue infections (13.1%), from bone and deep tissue infection (4.7%) and from blood cultures (1.9%). The automated system Alfred 60/AST was paramount for the isolation of 77.6% of the UTI. All the isolates tested were susceptible to penicillin, ampicillin, linezolid, vancomycin, teicoplanin, rifampicin and tetracycline. In conclusion, we present a large series of Actinotignum schaalii infections. This pathogen is hard to isolate, and is resistant to commonly used empirical antimicrobials.
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Affiliation(s)
- J.M. Sahuquillo-Arce
- Servicio de Microbiología, Hospital Doctor Moliner, Serra, Spain
- Grupo de Investigación de Infecciones Respiratorias, IIS La Fe, Valencia, Spain
| | - P. Suárez-Urquiza
- Servicio de Microbiología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - A. Hernández-Cabezas
- Servicio de Microbiología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - L. Tofan
- Servicio de Análisis Clínicos, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - R. Chouman-Arcas
- Servicio de Microbiología, Hospital Francesc de Borja, Gandia, Spain
| | - M. García-Hita
- Servicio de Microbiología, Hospital de la Vega Lorenzo Guirao, Cieza, Spain
| | - O. Sabalza-Baztán
- Servicio de Microbiología, Hospital General Universitari de Castelló, Castellón de la Plana, Spain
| | | | - N. Lozano-Rodríguez
- Servicio de Microbiología, Hospital General Universitari de Castelló, Castellón de la Plana, Spain
| | - J. Martí-Cuñat
- Servicio de Microbiología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - J.L. López-Hontangas
- Servicio de Microbiología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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2
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Morawiec E, Czerwiński M, Czerwińska AB, Wiczkowski A. Semen dysbiosis—just a male problem? Front Cell Infect Microbiol 2022; 12:815786. [PMID: 36176582 PMCID: PMC9514095 DOI: 10.3389/fcimb.2022.815786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Seminal microflora is crucial to male fertility. Dysbiosis—disturbance of quantitative ratios of individual bacteria or appearance of pathogenic species—rarely results in symptomatic disease. Inflammation results in decreased sperm production, lower motility, or morphological changes and, in the long term, can cause ejaculatory duct obstruction, leading to infertility. Moreover, it may cause infection of the partner’s female genital tract. Dysbiosis in both partners results in fertility problems, disorders in embryo implantation, or miscarriages. In addition, chronic inflammation of the male genitourinary system may accelerate the appearance of antisperm antibodies. A comprehensive examination of seminal microflora can clarify the causes of infertility or prevent pathological conditions that affect seminal parameters. Seminal microflora as a direct impact on fertility problems as well as a decrease in the effectiveness of assisted reproduction methods, insemination, or in vitro procedures.
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Affiliation(s)
- Emilia Morawiec
- Department of Microbiology, Faculty of Medicine, University of Technology in Katowice, Katowice, Poland
- Gyncentrum Sp. z o.o. Laboratory of Molecular Biology and Virology, Katowice, Poland
- Department of Histology, Cytophysiology and Embryology, Faculty of Medicine, University of Technology in Katowice, Katowice, Poland
- *Correspondence: Emilia Morawiec,
| | - Michał Czerwiński
- Gyncentrum Sp. z o.o. Laboratory of Molecular Biology and Virology, Katowice, Poland
- American Medical Clinic, Katowice, Poland
| | - Anna Bednarska- Czerwińska
- Gyncentrum Sp. z o.o. Laboratory of Molecular Biology and Virology, Katowice, Poland
- Faculty of Medicine, University of Technology in Katowice, Katowice, Poland
| | - Andrzej Wiczkowski
- Department of Microbiology, Faculty of Medicine, University of Technology in Katowice, Katowice, Poland
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A 2-Year Retrospective Case Series on Isolates of the Emerging Pathogen Actinotignum schaalii from a Canadian Tertiary Care Hospital. Microorganisms 2022; 10:microorganisms10081608. [PMID: 36014029 PMCID: PMC9412865 DOI: 10.3390/microorganisms10081608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 07/29/2022] [Accepted: 08/03/2022] [Indexed: 11/21/2022] Open
Abstract
(1) Background: Actinotignum schaalii is an emerging, opportunistic pathogen often linked with UTIs but can extend beyond the urogenital system. Data on the clinical significance of A. schaalii are still emerging. (2) Methods: A retrospective review of A. schaalii isolates in a Canadian tertiary care hospital was conducted. The clinical data of patients that grew A. schaalii from January 2020 to 2022 were documented. Demographics, site, management, and microbiological parameters surrounding culture and sensitivities were recorded. (3) Results: A total of 43 cases of A. schaalii were identified. Actinotignum schaalii was primarily involved in UTIs (n = 17), abscesses (n = 9), bacteremia (n = 6), septic arthritis (n = 5), and ulcers (n = 5). A. schaalii had a slight predilection for polymicrobial infections (51.1%, n = 22 out of 43), with Aerococcus urinae (n = 5) being the most common coisolate. Susceptibility testing was only performed in two cases that showed sensitivity to beta-lactam antibiotics and resistance to metronidazole and ciprofloxacin. Amoxicillin–clavulanate (n = 5) is the most frequently prescribed antibiotic. (4) Conclusions: The non-urogenic clinical significance of A. schaalii remains undervalued. The management of A. schaalii infection is multimodal, consisting predominantly of antimicrobials and surgical procedures specific to the etiology. Clinicians should request sensitivities for A. schaalii so that appropriate antimicrobial coverage can be provided.
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4
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Gajdács M, Urbán E. The Pathogenic Role of Actinomyces spp. and Related Organisms in Genitourinary Infections: Discoveries in the New, Modern Diagnostic Era. Antibiotics (Basel) 2020; 9:E524. [PMID: 32824418 PMCID: PMC7459602 DOI: 10.3390/antibiotics9080524] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/14/2020] [Accepted: 08/15/2020] [Indexed: 12/16/2022] Open
Abstract
Actinomycosis is a chronic, suppurative, granulomatous infectious disease, caused by different species of Actinomyces bacteria. To date, 26 validly published Actinomyces species have been described as part of a normal human microbiota or from human clinical specimens. Due to the rapid spread of new, modern diagnostic procedures, 13 of 26 of these species have been described in this century and the Actinomycetaceae family has undergone several taxonomic revisions, including the introduction of many novel species termed Actinomyces-like organisms (ALOs). There is scarce data available on the role of these novel bacterial species in various infectious processes in human medicine. The aim of this review is to provide a comprehensive overview of Actinomyces and closely related organisms involved in human diseases-with a special focus on newly described species-in particular their role in genitourinary tract infections in females and males.
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Affiliation(s)
- Márió Gajdács
- Department of Pharmacodynamics and Biopharmacy, Faculty of Pharmacy, University of Szeged, 6720 Szeged, Hungary;
- Institute of Medical Microbiology, Faculty of Medicine, Semmelweis University, 1089 Budapest, Hungary
| | - Edit Urbán
- Institute of Translational Medicine, Faculty of Medicine, University of Pécs, 7624 Pécs, Hungary
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5
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Hidrocele infectado. Enferm Infecc Microbiol Clin 2019; 37:341-343. [DOI: 10.1016/j.eimc.2018.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 11/22/2022]
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6
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Hemenway AN, Christensen A, Schriever C. Treatment considerations for potential uropathogens detected by precision microbiological testing. Am J Health Syst Pharm 2018; 75:1775-1782. [PMID: 30404894 DOI: 10.2146/ajhp180208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The clinical and microbiological data for urinary tract infections (UTIs) for 6 organisms detected by matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) at community health systems were examined. SUMMARY The use of precision microbiological diagnostic testing such as MALDI-TOF and real-time quantitative polymerase chain reaction has increased the ability to detect a wider spectrum of organisms. This has raised questions of the clinical relevance of infrequently encountered organisms, especially when cultured from urine. This article reviews clinical and microbiological data for UTIs for 6 organisms detected by MALDI-TOF at community health systems (Actinotignum schaalii, Chryseobacterium indologenes, Aerococcus urinae, Aerococcus sanguinicola, Corynebacterium riegelii, and Corynebacterium urealyticum). Since little information currently exists, most of the data associating the aforementioned organisms with UTIs were derived from case reports. Although these organisms are more readily identified using precision microbiological diagnostic testing methods, infection should not be assumed based on culture results alone since asymptomatic bacteriuria has been reported. Similar to more common urinary pathogens, clinical correlation is essential. To facilitate treatment, we provide a table of empirical options likely to achieve clinical success based on in vivo and in vitro data. If available, pathogen-specific susceptibility data should be used to direct therapy. CONCLUSION Clinical and microbiological data and potential treatment options were presented for 6 traditionally underrecognized organisms that are increasingly being found from urinary specimens. The treatment recommendations should be interpreted cautiously as they were devised through the use of very limited data.
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Affiliation(s)
- Alice N Hemenway
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Rockford, IL
| | - Alyssa Christensen
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Rockford, IL
| | - Christopher Schriever
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Rockford, IL
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7
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Gram-Positive Uropathogens, Polymicrobial Urinary Tract Infection, and the Emerging Microbiota of the Urinary Tract. Microbiol Spectr 2017; 4. [PMID: 27227294 DOI: 10.1128/microbiolspec.uti-0012-2012] [Citation(s) in RCA: 200] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Gram-positive bacteria are a common cause of urinary-tract infection (UTI), particularly among individuals who are elderly, pregnant, or who have other risk factors for UTI. Here we review the epidemiology, virulence mechanisms, and host response to the most frequently isolated Gram-positive uropathogens: Staphylococcus saprophyticus, Enterococcus faecalis, and Streptococcus agalactiae. We also review several emerging, rare, misclassified, and otherwise underreported Gram-positive pathogens of the urinary tract including Aerococcus, Corynebacterium, Actinobaculum, and Gardnerella. The literature strongly suggests that urologic diseases involving Gram-positive bacteria may be easily overlooked due to limited culture-based assays typically utilized for urine in hospital microbiology laboratories. Some UTIs are polymicrobial in nature, often involving one or more Gram-positive bacteria. We herein review the risk factors and recent evidence for mechanisms of bacterial synergy in experimental models of polymicrobial UTI. Recent experimental data has demonstrated that, despite being cleared quickly from the bladder, some Gram-positive bacteria can impact pathogenic outcomes of co-infecting organisms. When taken together, the available evidence argues that Gram-positive bacteria are important uropathogens in their own right, but that some can be easily overlooked because they are missed by routine diagnostic methods. Finally, a growing body of evidence demonstrates that a surprising variety of fastidious Gram-positive bacteria may either reside in or be regularly exposed to the urinary tract and further suggests that their presence is widespread among women, as well as men. Experimental studies in this area are needed; however, there is a growing appreciation that the composition of bacteria found in the bladder could be a potentially important determinant in urologic disease, including susceptibility to UTI.
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8
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Janda JM. Taxonomic update on proposed nomenclature and classification changes for bacteria of medical importance, 2015. Diagn Microbiol Infect Dis 2016; 86:123-7. [DOI: 10.1016/j.diagmicrobio.2016.06.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 06/28/2016] [Accepted: 06/30/2016] [Indexed: 12/23/2022]
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Actinotignum (formerly Actinobaculum) schaalii: a review of MALDI-TOF for identification of clinical isolates, and a proposed method for presumptive phenotypic identification. Pathology 2016; 48:367-71. [PMID: 27131934 DOI: 10.1016/j.pathol.2016.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 03/12/2016] [Accepted: 03/21/2016] [Indexed: 12/21/2022]
Abstract
Actinotignum schaalii is a recognised cause of urinary tract infection. Following a case of urosepsis, 20 isolates of A. schaalii were collected over an initial 18 month period from urine and blood culture. An additional 25 isolates were collected over the following 13 months. Actinotignum schaalii had likely been overlooked or dismissed as a contaminant in our laboratory prior to this study period. It grows slowly on blood agar with supplemental CO2 or anaerobically. It may not grow on MacConkey agar or chromogenic agars used for routine urine culture. Repeated attempts at identification by matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS) may be required as the optimal age of cultures for testing is unclear. Utilising its characteristic antibiogram may assist phenotypic identification of this organism which is otherwise difficult to distinguish from other actinomycetes.
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10
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Prigent G, Perillaud C, Amara M, Coutard A, Blanc C, Pangon B. Actinobaculum schaalii: A truly emerging pathogen?: Actinobaculum schaalii: un pathogène réellement émergent? New Microbes New Infect 2016; 11:8-16. [PMID: 27014462 PMCID: PMC4789325 DOI: 10.1016/j.nmni.2015.10.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/25/2015] [Accepted: 10/26/2015] [Indexed: 10/31/2022] Open
Abstract
Actinobaculum schaalii is a Gram-positive facultative anaerobe bacillus. It is a commensal organism of the genitourinary tract. Its morphology is nonspecific. Aerobic culture is tedious, and identification techniques have long been inadequate. Thus, A. schaalii has often been considered as a nonpathogen bacterium or a contaminant. Its pathogenicity is now well described in urinary tract infections, and infections in other sites have been reported. This pathogen is considered as an emerging one following the growing use of mass spectrometry identification. In this context, the aim of our study was to evaluate the number of isolations of A. schaalii before and after the introduction of mass spectrometry in our hospital and to study the clinical circumstances in which isolates were found.
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Affiliation(s)
- G Prigent
- Service de biologie, Unité de microbiologie, Le Chesnay, France
| | - C Perillaud
- Service de biologie, Unité de microbiologie, Le Chesnay, France
| | - M Amara
- Service de biologie, Unité de microbiologie, Le Chesnay, France
| | - A Coutard
- Service de biologie, Unité de microbiologie, Le Chesnay, France
| | - C Blanc
- Service de médecine interne, maladies infectieuses et tropicales, Centre Hospitalier de Versailles, Le Chesnay, France
| | - B Pangon
- Service de biologie, Unité de microbiologie, Le Chesnay, France
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11
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Lotte R, Lotte L, Ruimy R. Actinotignum schaalii (formerly Actinobaculum schaalii): a newly recognized pathogen-review of the literature. Clin Microbiol Infect 2015; 22:28-36. [PMID: 26577137 DOI: 10.1016/j.cmi.2015.10.038] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 10/14/2015] [Accepted: 10/29/2015] [Indexed: 11/19/2022]
Abstract
The genus Actinotignum contains three species, Actinotignum schaalii (formerly Actinobaculum schaalii), Actinotignum urinale and Actinotignum sanguinis. A. schaalii is the species most frequently involved in human infections, with 172 cases, mostly urinary tract infections (UTIs), reported so far. Invasive infections have also been described. This facultative anaerobic Gram-positive rod is part of the urinary microbiota of healthy patients. It is responsible for UTIs, particularly in elderly men and young children. A. schaalii is an underestimated cause of UTIs because of its fastidious growth on usual media and difficulties associated with its identification using phenotypic methods. Indeed, this slow-growth bacterium requires blood-enriched media and an incubation time of 48 hours under anaerobic or 5% CO2 atmosphere. Furthermore, only matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF) or molecular-based methods allow the accurate identification of this bacteria. MALDI-TOF using Microflex LT with the Biotyper database (Bruker Daltonics, Bremen, Germany) is the most reliable technology for the routine identification of A. schaalii. The identification of this uropathogen is all the more important because it is resistant to trimethoprim/sulfamethoxazole and second-generation quinolones that are widely used in the treatment of UTIs. Antimicrobial therapy using β-lactams prolonged for up to 2 weeks is the most efficient treatment and should be recommended. Microbiologists should assess the presence of A. schaalii in urine using appropriate culture and identification methods in the case of a direct examination that is positive for small coccoid rods, a negative nitrite urinary stick associated with leukocyturia, treatment failure with trimethoprim/sulfamethoxazole or fluoroquinolones, or undocumented, repeated UTIs.
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Affiliation(s)
- R Lotte
- Department of Bacteriology at Nice Academic Hospital, Nice, France; Nice Medical University, Nice-Sophia Antipolis University, Nice, France; INSERM U1065 (C3M), Bacterial Toxins in Host Pathogen Interactions, C3M, Bâtiment Universitaire Archimed, Nice, France.
| | - L Lotte
- Department of Bacteriology at Nice Academic Hospital, Nice, France; Nice Medical University, Nice-Sophia Antipolis University, Nice, France
| | - R Ruimy
- Department of Bacteriology at Nice Academic Hospital, Nice, France; Nice Medical University, Nice-Sophia Antipolis University, Nice, France; INSERM U1065 (C3M), Bacterial Toxins in Host Pathogen Interactions, C3M, Bâtiment Universitaire Archimed, Nice, France
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Abstract
Actinomyces israelii has long been recognized as a causative agent of actinomycosis. During the past 3 decades, a large number of novel Actinomyces species have been described. Their detection and identification in clinical microbiology laboratories and recognition as pathogens in clinical settings can be challenging. With the introduction of advanced molecular methods, knowledge about their clinical relevance is gradually increasing, and the spectrum of diseases associated with Actinomyces and Actinomyces-like organisms is widening accordingly; for example, Actinomyces meyeri, Actinomyces neuii, and Actinomyces turicensis as well as Actinotignum (formerly Actinobaculum) schaalii are emerging as important causes of specific infections at various body sites. In the present review, we have gathered this information to provide a comprehensive and microbiologically consistent overview of the significance of Actinomyces and some closely related taxa in human infections.
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13
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Hays C, Lienhard R, Auzou M, Barraud O, Guérin F, Ploy MC, Cattoir V. Erm(X)-mediated resistance to macrolides, lincosamides and streptogramins in Actinobaculum schaalii. J Antimicrob Chemother 2014; 69:2056-60. [PMID: 24710027 DOI: 10.1093/jac/dku099] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Actinobaculum schaalii is a Gram-positive bacillus increasingly reported as a causative agent of urinary tract infections as well as invasive infections, mainly in the elderly and patients with underlying urological conditions. Since little is known about the molecular basis of antimicrobial resistance in A. schaalii, the aim of this study was to investigate resistance to macrolides, lincosamides and streptogramins (MLS) in this emerging pathogen. METHODS A total of 32 A. schaalii clinical isolates from France and Switzerland were studied. MICs of erythromycin, spiramycin, lincomycin, clindamycin and quinupristin/dalfopristin were determined by the agar dilution method. Resistance genes erm(A), erm(B), erm(C), erm(F), erm(G), erm(X), msr(A) and mef(A) were screened by PCR. The genetic environment was determined by random cloning and PCR mapping. RESULTS Out of 32 isolates tested, 21 were highly resistant to erythromycin, spiramycin, lincomycin and clindamycin (MICs >256 mg/L), whereas 11 exhibited low MICs (MICs < 0.12 mg/L). On the other hand, quinupristin/dalfopristin remained active against all the isolates. An inducible MLSB resistance phenotype was noted in all cases. The erm(X) gene was detected among all resistant strains, whereas none was detected in susceptible strains. Analysis of genetic support and environment revealed that erm(X) was probably part of the chromosome of A. schaalii. CONCLUSIONS This study is the first molecular characterization of MLS resistance in A. schaalii. In all cases, it was due to the presence of erm(X), a methylase gene previously identified in other clinically relevant Gram-positive bacilli.
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Affiliation(s)
| | | | - Michel Auzou
- CHU de Caen, Service de Microbiologie, Caen, France
| | - Olivier Barraud
- CHU de Limoges, Service de Bactériologie-Virologie-Hygiène, Limoges, France INSERM U1092, Limoges, France Université de Limoges, UMR-S1092, Limoges, France
| | - François Guérin
- CHU de Caen, Service de Microbiologie, Caen, France Université de Caen Basse-Normandie, EA4655 (équipe 'Antibio-résistance'), Caen, France
| | - Marie-Cécile Ploy
- CHU de Limoges, Service de Bactériologie-Virologie-Hygiène, Limoges, France INSERM U1092, Limoges, France Université de Limoges, UMR-S1092, Limoges, France
| | - Vincent Cattoir
- CHU de Caen, Service de Microbiologie, Caen, France Université de Caen Basse-Normandie, EA4655 (équipe 'Antibio-résistance'), Caen, France
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14
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Tuuminen T, Suomala P, Harju I. Actinobaculum schaalii: identification with MALDI-TOF. New Microbes New Infect 2014; 2:38-41. [PMID: 25356339 PMCID: PMC4184588 DOI: 10.1002/2052-2975.32] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/02/2013] [Accepted: 12/04/2013] [Indexed: 11/30/2022] Open
Abstract
Actinobaculum schaalii is an emerging uropathogen. So far, its identification has been performed with 16S rRNA gene sequencing or PCR. The diagnosis has often been delayed due to fastidious growth and identification problems. Eleven clinical isolates of A. schaalii from bloodstream infections that were initially identified with 16S rRNA sequencing analysis were recovered and later identified with matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF). We present a review of bacteriological data of these patients, an algorithm for fast laboratory work-up and advocate the use of sensitized culture of urine to allow better recovery of A. schaalii in susceptible patients.
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Affiliation(s)
- T Tuuminen
- Department of Bacteriology and Immunology, Haartman Institute, University of Helsinki Helsinki, Finland ; Eastern Finland Laboratory Centre Joint Authority Enterprise, Mikkeli District Laboratory Finland
| | - P Suomala
- Eastern Finland Laboratory Centre Joint Authority Enterprise, Mikkeli District Laboratory Finland
| | - I Harju
- Clinical Microbiology Laboratory, Turku University Hospital Turku, Finland
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15
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Torres-Sangiao E, Lissarrague-Sanz A, Cañizares-Castellanos A, Bou G. Prostatitis bacteriana. Enferm Infecc Microbiol Clin 2013; 31:344-6. [DOI: 10.1016/j.eimc.2012.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Revised: 09/25/2012] [Accepted: 09/25/2012] [Indexed: 11/26/2022]
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16
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Zimmermann P, Berlinger L, Liniger B, Grunt S, Agyeman P, Ritz N. Actinobaculum schaalii an emerging pediatric pathogen? BMC Infect Dis 2012; 12:201. [PMID: 22928807 PMCID: PMC3457841 DOI: 10.1186/1471-2334-12-201] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Accepted: 08/15/2012] [Indexed: 11/24/2022] Open
Abstract
Background Actinobaculum schaalii was first described as a causative agent for human infection in 1997. Since then it has mainly been reported causing urinary tract infections (UTI) in elderly individuals with underlying urological diseases. Isolation and identification is challenging and often needs molecular techniques. A. schaalii is increasingly reported as a cause of infection in humans, however data in children is very limited. Case presentation We present the case of an 8-month-old Caucasian boy suffering from myelomeningocele and neurogenic bladder who presented with a UTI. An ultrasound of the urinary tract was unremarkable. Urinalysis and microscopy showed an elevated leukocyte esterase test, pyuria and a high number of bacteria. Empiric treatment with oral co-trimoxazole was started. Growth of small colonies of Gram-positive rods was observed after 48 h. Sequencing of the 16S rRNA gene confirmed an A. schaalii infection 9 days later. Treatment was changed to oral amoxicillin for 14 days. On follow-up urinalysis was normal and urine cultures were negative. Conclusions A.schaalii is an emerging pathogen in adults and children. Colonization and subsequent infection seem to be influenced by the age of the patient. In young children with high suspicion of UTI who use diapers or in children who have known abnormalities of their urogenital tract, infection with A. schaalii should be considered and empiric antimicrobial therapy chosen accordingly.
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Affiliation(s)
- Petra Zimmermann
- Department of Paediatrics, University Children's Hospital, Berne, Switzerland
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Salvadó M, Plasencia V, Segura C, Gómez J, Medina MJ, Sáez-Nieto JA, Castellanos S, Horcajada JP. Infection due to Actinobaculum spp: report of 12 patients in Spain. J Infect 2012; 66:107-9. [PMID: 22750149 DOI: 10.1016/j.jinf.2012.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 06/22/2012] [Accepted: 06/23/2012] [Indexed: 11/27/2022]
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Andersen LB, Bank S, Hertz B, Søby KM, Prag J. Actinobaculum schaalii, a cause of urinary tract infections in children? Acta Paediatr 2012; 101:e232-4. [PMID: 22211919 DOI: 10.1111/j.1651-2227.2011.02586.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To inform that Actinobaculum schaalii can colonize the urine and cause urinary tract infection in children. METHODS Urine samples were examined by wet smear microscopy, incubated in 5% CO(2) for 1-2 days, and species-specific real-time polymerase chain reaction (PCR) for A. schaalii was performed. RESULTS In 5 of the 29 screened urines, A. schaalii was found only by real-time PCR in quantities equivalent to ≥ 10(4) -10(5) CFU/mL. In addition, A. schaalii was found in quantities equivalent to ≥ 10(6) CFU/mL by both culture and PCR in two children with a urinary tract infection and large numbers of leucocytes in the urine. CONCLUSION Actinobaculum schaalii is CO(2)-dependent. Therefore, if there are clinical symptoms and/or a negative culture despite the presence of leucocytes in the urine, Gram staining and incubation in 5% CO(2) or species-specific real-time PCR should be performed to identify A. schaalii.
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Actinobaculum schaalii: An Emerging Uropathogen? Case Rep Urol 2012; 2012:468516. [PMID: 22606634 PMCID: PMC3350018 DOI: 10.1155/2012/468516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 02/26/2012] [Indexed: 11/17/2022] Open
Abstract
A. schaalii is a rare uropathogen. We report urosepsis with Actinobaculum schaalii detected serendipitously in blood and urine culture in a 79-year-old with urinary tract obstruction. This paper illuminates the flaws in our current system in detecting A. schaalii and raises awareness among clinicians and laboratory teams.
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20
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Cattoir V. Actinobaculum schaalii: review of an emerging uropathogen. J Infect 2011; 64:260-7. [PMID: 22209960 DOI: 10.1016/j.jinf.2011.12.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 12/05/2011] [Accepted: 12/17/2011] [Indexed: 10/14/2022]
Abstract
Actinobaculum schaalii is a facultative anaerobic, Gram-positive rod-shaped species phylogenetically related to Actinomyces that is likely part of the commensal flora of the human genitourinary tract. Because of its fastidious growth under aerobic conditions and its resemblance to bacteria of the resident flora, A. schaalii is frequently overlooked or considered as a contaminant. It is also difficult to identify phenotypically, still requiring molecular identification. Note that the recent technology of matrix-assisted laser desorption/ionisation time-of-flight-mass spectrometry could be a promising tool for its identification. Recent studies using sensitive PCR assays showed that its clinical significance was largely underestimated. Since its first description in 1997, A. schaalii has been responsible for numerous urinary tract infections (UTIs), mainly in elderly (usually >60 years) and patients with underlying urological conditions. Infected urines usually show many Gram-positive rods with significant leukocyturia and a negative test for nitrites. Numerous cases of severe infections have also been described, such as urosepsis, bacteremia, cellulitis, spondylodiscitis, and endocarditis. In vitro, A. schaalii is highly susceptible to β-lactams but it is resistant to ciprofloxacin and cotrimoxazole, first-choice antimicrobials for the oral treatment of UTIs. A penicillin (e.g. amoxicillin) or a cephalosporin (e.g. cefuroxime, ceftriaxone) should be the preferred treatment.
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Affiliation(s)
- Vincent Cattoir
- Centre National de Référence de la Résistance aux Antibiotiques, Laboratoire associé Entérocoques, Service de Microbiologie, CHU Côte de Nacre, Av. Côte de Nacre, 14033 Caen Cedex 9, France.
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21
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Tschudin-Sutter S, Frei R, Weisser M, Goldenberger D, Widmer AF. Actinobaculum schaalii - invasive pathogen or innocent bystander? A retrospective observational study. BMC Infect Dis 2011; 11:289. [PMID: 22029906 PMCID: PMC3252262 DOI: 10.1186/1471-2334-11-289] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 10/26/2011] [Indexed: 11/21/2022] Open
Abstract
Background Actinobaculum schaalii is a Gram-positive, facultative anaerobic coccoid rod, classified as a new genus in 1997. It grows slowly and therefore is easily overgrown by other pathogens, which are often found concomitantly. Since 1999, Actinobaculum schaalii is routinely investigated at our hospital, whenever its presence is suspected due to the detection of minute grey colonies on blood agar plates and negative reactions for catalase. The objective of this study was to determine the clinical significance of Actinobaculum schaalii, identified in our microbiology laboratory over the last 11 years. Methods All consecutive isolates with Actinobaculum schaalii were obtained from the computerized database of the clinical microbiology laboratory and patients whose cultures from any body site yielded this pathogen were analyzed. Observation of tiny colonies of Gram-positive, catalase-negative coccoid rods triggered molecular identification based on 16S rRNA gene sequencing. Results 40 isolates were obtained from 27 patients during the last 11 years. The patient's median age was 81 (19-101) years, 25 (92.6%) had underlying diseases and 12 (44.4%) had a genitourinary tract pathology. Actinobaculum schaalii was isolated in 12 urine cultures, 21 blood cultures, and 7 deep tissue biopsies. Twenty-five (62.5%) specimens were monobacterial, the remaining 15 (37.5%) were polybacterial 7/7 deep tissue samples (three bloodcultures and five urine cultures). Recovery from urine was interpreted as colonization in 5 (18.6%) cases (41.6% of all urine samples). Six (22.2%) suffered from urinary tract infections, six (22.2%) from abscesses (skin, intraabdominal, genitourinary tract, and surgical site infections) and 10 (37.0%) from bacteremia. Conclusions In this largest case series so far, detection of Actinobaculum schaalii was associated with an infection - primarily sepsis and abscesses - in 81.5% of our patients. Since this pathogen is frequently part of polymicrobial cultures (42.5%) it is often overlooked or considered a contaminant. Detection of Actinobaculum schaalii in clinical isolates mainly reflects infection indicating that this Gram-positive rod is not an innocent bystander.
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Affiliation(s)
- Sarah Tschudin-Sutter
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital, Basel, Switzerland
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22
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Abstract
Actinobaculum species are anaerobic Gram-positive rods that have previously been associated with urinary tract infection (UTI) in the elderly. We report 12 patients with Actinobaculum bacteremia. Only 40% of blood cultures were clinically considered significant by the treating physicians, but most patients were treated for UTI, suggesting a possible urinary source of bacteremia. Clinicians should be aware of the pathogenic potential of Actinobaculum spp.
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Bank S, Hansen TM, Søby KM, Lund L, Prag J. Actinobaculum schaalii in urological patients, screened with real-time polymerase chain reaction. ACTA ACUST UNITED AC 2011; 45:406-10. [PMID: 21767246 DOI: 10.3109/00365599.2011.599333] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Actinobaculum schaalii can cause urinary tract infections (UTIs) and occasionally septic complications. It is a carbon dioxide-requiring Gram-positive rod which is overlooked if urine is cultured in ambient air or if there is growth of conventional species. This study aimed to find the frequency of A. schaalii in consecutive cohorts of patients with kidney stones, children with suspected UTI and patients with indwelling catheters. MATERIAL AND METHODS A quantitative real-time polymerase chain reaction (PCR) assay was used to screen consecutive urine samples from of 76 patients with kidney stones, 29 children and 37 with different indwelling catheters. RESULTS In patients with kidney stones, A. schaalii was found in seven (29%) of the 24 leucocyte esterase stix-positive urines, which was twice as often as in the stix-negative urines (p = 0.22), and in five (36%) of 14 children less than 3 years old but not in 15 children 3?15 years old (p = 0.02). The eight catheterized patients with A. schaalii (22%) were elderly and half had comorbidities. In the patients where A. schaalii was found, other uropathogens were found from five of the 15 patients with kidney stones, one of the five children and seven of the eight with an indwelling catheter. CONCLUSION Actinobaculum schaalii is common among elderly people with suspected UTI and may be clinically significant, when found alone or together with other bacteria, among children and patients treated for kidney stones.
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Affiliation(s)
- Steffen Bank
- Departments of Clinical Microbiology, Viborg Hospital, Denmark.
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Beguelin C, Genne D, Varca A, Tritten ML, Siegrist HH, Jaton K, Lienhard R. Actinobaculum schaalii: clinical observation of 20 cases. Clin Microbiol Infect 2010; 17:1027-31. [PMID: 20854424 DOI: 10.1111/j.1469-0691.2010.03370.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Actinobaculum schaalii is a new species that has so far been isolated from human blood, urine and pus. Its importance has probably been underestimated and other Actinobaculum spp. may also have been underdiagnosed. This retrospective study comprises all known cases of A. schaalii infections identified since 2004 in the canton of Neuchâtel (170,000 inhabitants), Switzerland. Strains were cultivated and isolated in the bacteriology laboratory using its routine procedure. Identification included a Rapid ID 32 A strip (bioMérieux) and 16S rRNA gene sequencing. Twenty-one positive samples were found in 19 patients (11 male, 8 female) of all ages (range 16-91 years): 10 from urine (50%), six from blood (30%), one from both blood and urine (5%), and three from pus (15%). Thirteen out of 17 (76%) cases with either blood or urine specimens had underlying genitourinary tract pathologies. When urine cultures were positive for A. schaalii, leucocytes were found in all samples (10/10, 100%) but all nitrite tests were negative (10/10, 100%). The onset of appropriate treatment was delayed due to the diminished sensitivity of A. schaalii to the antibiotics commonly used for UTIs (i.e. ciprofloxacin and trimethoprim/sulfamethoxazole) and to the delay in microbiological diagnosis. A. schaalii should specifically be searched in all cases of leukocyturia with a negative nitrite test but with Gram-positive rods in the Gram stain, in patients with underlying genitourinary tract pathology, instead of dismissing these findings as clinically irrelevant colonization by coryneform bacteria. This infection may be much more common than previously thought.
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Affiliation(s)
- C Beguelin
- Department of Internal Medicine, HNE Community Hospital, Lausanne, Switzerland
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25
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First report of Actinobaculum schaalii urinary tract infection in North America. Diagn Microbiol Infect Dis 2010; 67:282-5. [DOI: 10.1016/j.diagmicrobio.2010.02.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Revised: 02/23/2010] [Accepted: 02/26/2010] [Indexed: 11/20/2022]
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Nielsen HL, Søby KM, Christensen JJ, Prag J. Actinobaculum schaalii: a common cause of urinary tract infection in the elderly population. Bacteriological and clinical characteristics. ACTA ACUST UNITED AC 2010; 42:43-7. [PMID: 19883165 DOI: 10.3109/00365540903289662] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To-date only 21 clinical cases of Actinobaculum schaalii infection have been published, and A. schaalii has been considered a rare cause of urinary tract infection (UTI) and urosepsis. Between y 2005 and 2008, we isolated A. schaalii from 55 predisposed elderly patients. In these cases, microscopic findings of coccoid rods in wet smears of urine gave rise to clinical suspicion and subsequently to its isolation from urine. Typically only scant growth of A. schaalii occurred after incubation of the urine for 24 h, but it became visible after 2 days of incubation in 5% CO(2). Preliminary biochemical identification was carried out by combining the API Coryne and Rapid ID32A test systems, and the identification was later confirmed by partial 16S rDNA gene sequencing. During the 4-y period, A. schaalii caused septicaemia, UTIs and asymptomatic bacteriuria. One patient was later infected with Actinobaculum massiliense. The incidence of A. schaalii infections is much higher than previously reported. We present numerous case reports and describe the bacteriological and clinical characteristics of this overlooked uropathogen.
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Affiliation(s)
- Hans Linde Nielsen
- Department of Clinical Microbiology, Viborg Hospital, Heibergs Allé 4, Viborg, Denmark
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27
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Bank S, Jensen A, Hansen TM, Søby KM, Prag J. Actinobaculum schaalii, a common uropathogen in elderly patients, Denmark. Emerg Infect Dis 2010; 16:76-80. [PMID: 20031046 PMCID: PMC2874361 DOI: 10.3201/eid1601.090761] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
This organism is identified more often by PCR than by cultivation. Actinobaculum schaalii can cause urinary tract infections and septicemia but is difficult to identify by cultivation. To obtain a fast diagnosis and identify A. schaalii, we developed a TaqMan real-time quantitative PCR. Routine urine samples were obtained from 177 hospitalized patients and 75 outpatients in Viborg County, Denmark, in 2008–2009. The PCR detected A. schaalii in 22% of samples from patients >60 years of age. This assay showed that A. schaalii is more common than implied by routine cultivation. In 90% of PCR-positive urine samples, other common uropathogens were identified. This finding suggests that A. schaalii is a common, undetected, bacterial pathogen. Our results suggest that A. schaalii may be a more common pathogen than previously thought, especially in patients with unexplained chronic urinary tract infections, who are often treated with trimethoprim or ciprofloxacin, to which A. schaalii is resistant.
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Affiliation(s)
- Steffen Bank
- Department of Clinical Microbiology, Viborg Hospital, Heibergs Allé 4, DK-8800 Viborg, Denmark.
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Hesstvedt L, Hasseltvedt V, Aandahl E, Caugant D, Høiby EA. Septicaemia due to Actinobaculum schalii. ACTA ACUST UNITED AC 2009; 38:735-7. [PMID: 16857631 DOI: 10.1080/00365540500540467] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We report a case of septicaemia caused by Actinobaculum schalii, an Actinomyces-like bacterium, a gram-positive, non-sporulating rod. The search for the bacterium is relevant in cases with unexplained pyuri and septicaemia, because it may cause severe infection in predisposed humans. The bacterium is susceptible to a wide range of antibiotics.
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Affiliation(s)
- Liv Hesstvedt
- Department of Microbiology, Sykehuset Innlandet, Lillehammer, Norway
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29
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Hall V. Actinomyces--gathering evidence of human colonization and infection. Anaerobe 2007; 14:1-7. [PMID: 18222714 DOI: 10.1016/j.anaerobe.2007.12.001] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Accepted: 12/01/2007] [Indexed: 10/22/2022]
Abstract
The roles of the 'classical'Actinomyces spp. as colonizers of oral cavities of man and animals, in development of intra-oral infections and as agents of actinomycosis have been well documented. This mini-review focuses on perceptions of human colonization and infection that have emerged in the past decade, largely as a result of advances in classification, identification and direct detection from clinical material. Arguably, of the greatest importance is the recognition of actinomycosis as a major factor and indicator of poor prognosis in both infected osteoradionecrosis and bisphosphonate-associated osteonecrosis of the jaws. Among recently described species, Actinomyces graevenitzii has been isolated almost exclusively from oral and respiratory sites and may be a causative agent of actinomycosis. Conversely, several other Actinomyces spp. are isolated commonly from superficial soft tissue infections. Members of the genus Actinobaculum, which is closely related to Actinomyces, are strongly associated with urosepsis. Isolation and identification of Actinomyces and related genera by conventional methods remain difficult. Diagnosis is commonly belated and based solely upon histological findings. Development of direct detection methods may aid patient management and further elucidate clinical associations.
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Affiliation(s)
- Val Hall
- Anaerobe Reference Unit, NPHS Microbiology Cardiff, University Hospital of Wales, Cardiff CF14 4XW, UK.
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30
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Haller P, Bruderer T, Schaeren S, Laifer G, Frei R, Battegay M, Flückiger U, Bassetti S. Vertebral osteomyelitis caused by Actinobaculum schaalii: a difficult-to-diagnose and potentially invasive uropathogen. Eur J Clin Microbiol Infect Dis 2007; 26:667-70. [PMID: 17618471 DOI: 10.1007/s10096-007-0345-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We report the first case of vertebral osteomyelitis caused by Actinobaculum schaalii and review all cases of A. schaalii identified at our institution between 2002 and 2005. A. schaalii causes urinary tract infections - especially in elderly people - occasionally with septic complications.
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Affiliation(s)
- P Haller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland
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31
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Sturm PDJ, Van Eijk J, Veltman S, Meuleman E, Schülin T. Urosepsis with Actinobaculum schaalii and Aerococcus urinae. J Clin Microbiol 2006; 44:652-4. [PMID: 16455938 PMCID: PMC1392690 DOI: 10.1128/jcm.44.2.652-654.2006] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Actinobaculum was isolated from urine only after prolonged incubation in 5% CO(2) after discrepancy between urine Gram stain and initial culture results was observed. Additional patients were diagnosed using this method. The prevalence of Actinobaculum species in urinary tract infections is underestimated since it is not isolated by routine urine culture procedures.
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Affiliation(s)
- P D J Sturm
- Department of Medical Microbiology, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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32
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R1885 – R2270. Clin Microbiol Infect 2006. [DOI: 10.1111/j.1470-9465.2006.12_4_1432.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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