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From 1982 to 1994, 45 patients (1.22 episodes per 10,000 discharged patients) were treated for
citrobacter bacteremia at National Taiwan University Hospital (Taipei). All patients had at least one
underlying disease. Citrobacter bacteremia most commonly occurred in patients with malignancies
(48.9%) or hepatobiliary stones (22.2%). Intraabdominal tumors comprised the majority (59.1%) of
malignancies. Bacteremia commonly originated from sites such as the abdominal cavity (51.1%), urinary
tract (20%), and lung (11.1%). Polymicrobial bacteremia was diagnosed in 15 patients (33.3%);for nine
(60%) of these patients, the source of the infection was intraabdominal. Prior treatment with a thirdgeneration cephalosporin was significantly associated (P < .01) with the development of multidrug
resistance among the isolates. The mortality associated with citrobacter bacteremia was 17.8%. Poor
prognostic factors included pneumonia, altered mental status on presentation, hypothermia, oliguria,
septic shock, deterioration in mental status, hyperbilirubinemia, azotemia, and thrombocytopenia. Combination therapy, as compared with other regimens, improved the outcome of citrobacter bacteremia.
Citrobacter species are aerobic, gram-negative bacilli commonly found in water, soil, food, and the intestinal tracts of
animals and humans [I]. These organisms cause a wide spectrum of infections in the urinary tract, respiratory tract, wounds,
bone, peritoneum, endocardium, meninges, and intestines [1].
Citrobacter bacteremia is a rare infection; we are aware of
only two reported series in the English-language literature
[2, 3]. Therefore, little is known about citrobacter bacteremia
in terms of incidence, associated underlying diseases, primary
sites of infection, and outcome. Although differences between
Citrobacter freundii and Citrobacter divers us in terms of antimicrobial susceptibility have been cited [3-6], that these differences exist when these organisms are the cause of bacteremia
is unclear. Citrobacter has been reported to be frequently associated with polymicrobial bacteremia [3], but there are no data
that explain this phenomenon.
After the the third-generation cephalosporins were introduced, multidrug resistant strains of Enterobacter emerged as
a cause of bacteremia [7], but no data are available on Citrobacter species. We review our experience with citrobacter bacteremia over a B-year period and compare it with that previously reported in the literature [2, 3].
1996; 23:543-9
tures yielded Citrobacter species at the National Taiwan University Hospital (Taipei), a major teaching hospital in Taiwan;
this hospital had 1,200 beds before 1991 and 1,500 beds after
1991. The blood culture medium used to grow Citrobacter
had been changed from trypticase soy broth containing sodium
polyanetholesulfonate and modified Lombard-Dowell broth to
the Bactec 6A broth and the Bactec 7A broth (Becton Dickinson, Sparks, MD) in 1987. Citrobacter species were identified
according to standard laboratory methods. Antimicrobial susceptibility tests were done by means of the Kirby-Bauer disk
diffusion method [8, 9]. Multidrug-resistance was defined as
resistance in vitro to the extended-spectrum penicillins (ticarcillin, ticarcillinlclavulanate, and piperacillin) and the third-generation cephalosporins (cefotaxime, ceftazidime, ceftizoxime,
ceftriaxone, and cefoperazone) [7].
A patient was considered to have citrobacter bacteremia
when this organism was isolated from blood cultures on at least
one occasion. The primary site of infection was determined on
the basis of a clinical picture that was consistent with the
laboratory data and/or by a culture of tissue that was positive
for a Citrobacter species. If none of these findings was present,
the origin of the bacteremia was deemed unknown. Bacteremia
was defined as nosocomial if infections were acquired during
treatment at the study hospital, at other hospitals before transfer
to the study hospital, or during out-patient clinic visits or emergency room visits. Otherwise, the bacteremia was considered
to be community acquired.
The empirical treatment was considered appropriate if all
organisms cultured were found to be susceptible to the drug(s)
during in vitro susceptibility testing. Treatment was defined as
delayed if no appropriate treatment was begun within 48 hours
after blood for cultures was drawn. Septic shock was defined
as the septic syndrome, with a systolic blood pressure of <90
mm Hg or a drop in the mean arterial pressure of >40 mm
Hg from the baseline, in the absence of other causes of hypoten-
544
Shih et al.
em 1996;23 (September)
em
1996;23 (September)
545
Citrobacter Bacteremia
Variable
Underlying disease
Malignancy
Solid tumor
Intraabdominal tumor
Hematological tumor
Acute leukemia
Chronic leukemia
Hepatobiliary stone
Heart disease
Diabetes mellitus
Plaee of acquisition
Community
Hospital
Etiologic organism
C. jreundii
C. diversus
Intraabdominal
tissues
Urinary
tract
10
9
9
I
5
3
0
Lower
respiratory
tract
Unknown
Total
22
\6
2
I
1
3
I
13
2
I
I
0
2
2
0
4
I
49.5
37.S
a
0
1
0
0
10
2
0
I
4
0
2
0
0
0
0
0
1
0
10
1St
I
4
23
I
4
22
11
2
3
3
2
1
0
2
1
1R
5.27
6.3
19.9
26.3
I
0
7
15
NOTE. The number of patients with culture-proven primary sites of infection were as follows: intraabdominal tissues, 10 of 23; urinary tract,S of 9; lower
respiratory tract, 2 of 5; others, 2 of 5; and unknown, 0 of 3.
* Includes bone and joint infection (n = 1), CNS infection (1), and wound and soft-tissue infection (3).
I All IS patients' infections originated in the hepatobiliary tract.
em 1996; 23 (September)
Shih et al.
546
Table 2. Rates of antimicrobial resistance and significance of factors influencing the antimicrobial susceptibilities of Citrobacter species
causing bacteremia in patients in Taiwan.
Cefazolin
Cefamandole
Cefotaxime
Ciprofloxacin
Imipenem
Gentamicin
Multiple agents
C. freundii
16/18 (88.9)
13/18 (72.2)
8118 (44.4)
5/17 (29.2)
0117
3117 (17.7)
C. diversus
OR*
95% CI*
5/7 (71.1)
1/7 (l4.3)t
3.2
15.6
4.48
6.58
0.35-28.95
1.48-164.38
0.48-48.46
0.32-142.86
10/10 (100)
7110 (70)
5/7 (71.4)
2/10 (20)
3.62
0.16-76.92
0/9
2/10 (20)
1/7 (14.3)
0/7
0/7
0/7
bacter bacteremia among our patients was similar to that reported by Drelichman and Band [3].
The urinary tract was the leading site of citrobacter infection
in many previous reports [1-3, 14], including the two that
described citrobacter bacteremia [2, 3]. However, in our series,
intraabdominal tissues (mainly in hepatobiliary system) were
the most common primary sites of infection in bacteremic patients. The reason that such sites predominated in our series
was that a large portion of our patients had hepatobiliary stones
(22.2%) and intraabdominal malignancies (28.8%). Hepatobiliary infection was the most frequent (82.6% of patients) intraabdominal infection due to Citrobacter species, which is consistent with the findings of Lew et al. [15]. We emphasize that
enterococci, E. coli, and anaerobes still predominate among
patients with the pancreatic and hepatobiliary cancer and intraabdominal abscesses [16], and antimicrobial coverage for
these organisms should be considered first.
According to previous reports [1-3, 14], most citrobacter
infections have been hospital acquired. In our study, about onehalf of the cases (51.1%) were community acquired, a finding
that may be due to the predominance of cases hepatobiliary
infection (19) in our study. One large-scale study [17] showed
that hospital-acquired cases of bacteremia predominated among
patients with infections that originated from any site other than
the biliary tree and reproductive tract. Fifteen (78.9%) of the
19 patients with hepatobiliary infection in our study had community-acquired bacteremia.
In one previous report of citrobacter bacteremia in patients
with cancer [2], those with acute leukemia accounted for the
highest number with bacteremia due to Citrobacter species
alone (this number was 20 times higher than the number of
patients with solid tumors and citrobacter bacteremia). Although patients with acute leukemia still had the highest rate
of citrobacter bacteremia in our study, those with tumors of
cm
1996;23 (September)
Table 2.
(Continued)
547
Citrobacter Bacteremia
(69.7);
(35.9)
(26.9)t
(l6.1)
2/34 (5.9)
3/31 (9.7)
OR*
95% CI*
9.35
1.84
6.79
1.3
0.5-166.67
0.41-8.36
1.06-43.36
0.21-8.03
6/6
6/6
4/5
4/6
0.68
2.06
0.03-45.51
0.33-16.47
0/6
3/6 (50)
(l00)
(l00)
(80)
(66.7)
(73.0)
(52.6)t
(28.6);
(8.6)
2/37 (5.4)
2/35 (5.7);
OR*
95% CI*
4.98
11.76
10
21.33
0.26-10
0.62-250
0.96-103.78
2.69-168.94
1.09
16.5
0.05-25.48
1.93-140.85
548
Table 3.
em
Shih et al.
1996;23 (September)
Risk factor
Enrollment during first 6.5 years of study*
Occurrence of bacteremia during months
of November-February
Age ;0.65 years
Male sex
Presence of underlying condition
Malignancy
Hematologic tumor
Other conditions
Intraabdominal lesions
Diabetes mellitus
Heart disease
Delayed admission
Chemotherapy
Steroid therapy
Alcoholism
Invasive procedure
Prior antibiotic treatment
Polymicrobial bacteremia
Nosocomial acquisition of bacteremia
Primary site of bacteremia
Lung
Intraabdomina1 site
Urinary tract
Multidrug resistance
Initial clinical manifestation
Hypotension
Altered mental status
Body temperature
<37C
>38SC
Oliguria
Jaundice
Leukocytosis (WBC count, > 10,000/mm3)
Neutropenia (neutrophil count, <500/nun 3)
Complications
Septic shock
Deterioration in mental status
Bilirubin level > 1 mg/dL
Increase in creatinine level of more than twofold
Platelet count, < 100,000/nun 3
Treatment
None or delayed
Delayed
Surgical/invasive procedure
Combination therapy
aRt
CIt
P value
6/21 (28.6)
2/24 (8.3)
4.40
0.78-24.81
NS
3/14 (21.4)
2/15 (13.3)
5/22 (22.7)
5/31 (16.1)
6/30 (20)
3/23 (13.0)
1.42
0.62
1.96
0.29-6.99
0.11-3.50
0.41-9.43
NS
NS
NS
3/22 (13.6)
1/6 (16.7)
5/23 (21.7)
2/16 (12.5)
0.57
1.4
0.12-2.73
0.10-19.01
NS
NS
2/11 (18.2)
0/5
1/6 (16.7)
1/11 (9.1)
0/8
2/7 (28.6)
2/3 (66.7)
1/15 (6.7)
3/17 (17.6)
4/15 (26.7)
4/22 (18.1)
6/34
8/40
7/39
7/34
8/37
6/38
6/42
7/30
5/28
4/30
4/23
(17.6)
(20)
(17.9)
(20.6)
(21.6)
(15.8)
(14.3)
(23.3)
(17.9)
(13.3)
(17.4)
1.04
0.35
0.91
0.39
0.2
2.13
12.33
0.23
0.99
2.36
1.05
0.18-6.07
0.02-6.94
0.09-9.10
0.04-3.54
0.01-3.91
0.33-13.67
0.96-158.08
0.03-2.11
0.20-4.78
0.50-11.19
0.21-4.76
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
3/5 (60)
4/23 (17.4)
0/9
1/5 (20)
5/40
4/22
8/36
7/40
(12.5)
(18.2)
(22.2)
(17.5)
10.5
0.95
0.18
1.18
1.39-79.13
0.21-4.37
0.01-3.36
0.11-12.21
.03
NS
NS
NS
4/15 (26.7)
4/8 (50)
4/30 (13.3)
4/36 (11.1)
2.36
8
0.50-11.19
1.41-45.23
NS
.03
2/2 (100)
6/39 (15.4)
4/13 (30.8)
4/12 (33.3)
6/28 (21.4)
0/5
6/43 (14)
2/4 (50)
1/27 (3.7)
4/33 (12.1)
2/15 (13.3)
8/39 (20.5)
28.85
0.18
11.56
3.63
1.77
0.34
1.24-672.13
0.02-1.55
1.14-117.44
0.74-17.81
0.31-10.11
0.02-6.71
.03
NS
.03
7/15 (46.7)
7/12 (58.3)
6/15 (40)
7/11 (63.6)
5/7 (71.4)
1/30 (3.3)
1/33 (3.0)
1/29 (3.4)
1/34 (2.9)
1/36 (2.8)
25.38
44.8
18.67
57.75
87.5
2.71-237.58
4.50-445.75
1.97-176.45
5.57-598.44
6.65-1151.19
.0009
.0001
.003
.00005
.00013
2/9 (22.2)
1/4 (25)
1/10 (10)
1/18 (5.6)
5/35
5/35
7/35
7/27
0.27-10.74
0.17-23.25
0.05-4.12
0.02-1.51
NS
NS
NS
.11
(14.3)
(14.3)
(20)
(25.9)
1.71
2
0.44
0.17
NS
NS
NS
because of the predominance of primary infections at contaminated sites, especially the abdominal cavity. When a patient
presents with citrobacter bacteremia, a thorough search for an
intraabdominal lesion should be made. Multidrug resistance
among Citrobacter species was found to be associated with
administration of a third-generation cephalosporin before the
onset of bacteremia.
cm
1996;23 (September)
Citrobacter Bacteremia
Acknowledgment
The authors thank Professor Andrew T. F. Huang of Duke University (Durham, NC) for reviewing the manuscript.
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