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Catheter-Related Fungemia Caused by Saccharomyces cerevisiae in a Newborn

2005; Lippincott Williams & Wilkins; Volume: 24; Issue: 12 Linguagem: Inglês

10.1097/01.inf.0000189984.51944.cd

1532-0987

Nurşen Belet, Nazan Dalg, Selim ncel, Ergin Cift i, Erdal nce, Haluk G riz, Meral Barlas, lker Do ru,

Actinomycetales infections and treatment

To the Editors: Catheter-related bloodstream infections are most commonly caused by coagulase-negative staphylococci, Staphylococcus aureus, aerobic Gram-negative bacilli and Candida albicans.1 Infections caused by new or unusual agents have increased worldwide. Saccharomyces cerevisiae is considered a nonpathogenic yeast, but it can cause invasive infections in immunocompromised patients who had central venous catheters.2 We report catheter-related fungemia caused by S. cerevisiae in a newborn despite amphotericin B therapy. A term female baby was admitted to the pediatric surgery department with the presumptive diagnosis of esophageal atresia. On postnatal day 2, esophageal atresia and distal tracheoesophageal fistula were detected, the fistula was closed and end-to-end esophageal anastomosis was performed. On the follow-up, Klebsiella spp. septicemia developed and ciprofloxacin was started. On hospitalization day 32, because the general condition of the patient worsened and clinical findings of sepsis appeared, vancomycin and amphotericin B were added to the treatment. This led to a rapid alleviation of clinical and laboratory signs. Reopening of the fistula was detected on the 35th day of hospitalization. Gastrostomy and Nissen fundoplication for reflux were performed on the following day. Because of the difficulties in establishing venous access, an umbilical venous catheter (CVC) was placed. Ten days later, she developed fever with a C-reactive protein elevation to 12.9 mg/dL. S. cerevisiae was isolated from peripheral vein and from the umbilical venous catheter. The strain was susceptible to amphotericin B. Analysis of urine and cerebrospinal fluid did not reveal any abnormality. An echocardiogram and ultrasonography of the abdomen showed no evidence of localized infection. Because fungemia persisted during amphotericin B treatment, the umbilical catheter was removed. The CVC tip culture was positive for S. cerevisiae. After removal of the umbilical venous catheter, all subsequent blood cultures were negative, and symptoms resolved promptly. Amphotericin B treatment was continued for 3 weeks. Saccharomyces boulardii is a strain of S. cerevisiae used as a biotherapeutic agent to prevent antibiotic-induced diarrhea. Recently several reports of S. cerevisiae fungemia associated with the use of S. boulardii have been published.2–4 In addition, fungemia by S. cerevisiae can occur in patients who are not treated with a probiotic preparation of this organism or who share a room with treated patients.5 Hennequin et al4 have demonstrated that, after a package of probiotic agent is opened, viable cells persist on room surfaces after 2 hours at a 1-m distance and may persist on the bare hands of operators even after vigorous hand washing. There was no history of S. boulardii use in our patient, but S. boulardii was given to a patient who shared the same room with our patient. The S. boulardii infection in our case may be caused by dissemination of S. boulardii to the hands when the package is opened, followed by direct contamination of venous catheters with this yeast as suggested by Hennequin et al.4 The role of CVC in the pathogenesis of the infection has been demonstrated by CVC tip culture. Optimal management of S. cerevisiae infections includes drainage of identified foci, administration of antifungal agents and removal of infected foreign bodies, especially indwelling venous catheters.2 Catheter withdrawal is more important for patients such as our case. Cesaro et al3 reported Saccharomyces fungemia in an 8-month-old infant with acute myeloid leukemia during intensive chemotherapy and prophylaxis with S. boulardii capsule. Although that patient received antifungal prophylaxis with fluconazole, S. cerevisiae grew in blood culture and the patient recovered with amphotericin B treatment and removal of the central venous catheter. In our patient likewise, amphotericin B could not prevent development of Saccharomyces fungemia, which ended with the removal of the umbilical catheter. In the medical literature, there is no report of a Saccharomyces fungemia in a person receiving amphotericin B. In conclusion, because contamination of central venous catheter can be the cause of the infection, we recommend that preparations containing S. boulardii be prepared wearing gloves and outside the patient's room. Documented fungemia necessitates the cessation of S. boulardii administration, removal of central venous catheters and search for a roommate who is receiving S. boulardii. Nursen Belet, MD Nazan Dalgıç, MD Selim Öncel, MD Ergin Ciftçi, MD Erdal İnce, MD Section of Infectious Diseases Department of Pediatrics Haluk Güriz, MD Department of Microbiology Meral Barlas, MD Section of Pediatric Surgery Department of Surgery Ülker Doğru, MD Section of Infectious Diseases Department of Pediatrics Ankara University Medical School Ankara, Turkey