Grand Round

Pasteurella multocida infection in solid organ transplantation

Eric S Christenson, Haitham M Ahmed, Christine M Durand

We present a case of fulminant Pasteurella multocida sepsis in a 66-year-old man who had undergone a renal transplant.
Our patient lived with two dogs and a cat with which he was very close. We propose that his bacteraemia might have
resulted from direct inoculation of P multocida via his cat licking the venous stasis ulcers on his legs. The patients
clinical course was complicated by cardiopulmonary failure and he ultimately succumbed to his infection. P multocida
is a rare cause of infections in immunocompromised hosts, epidemiologically linked to exposure to cats, dogs, and
other animals. This case of P multocida shows the importance of considering this organism in immunocompromised
hosts presenting with severe infections, especially if their history shows exposure to domesticated or wild animals
known to be potential carriers of this disease. In this Grand Round, we review the clinical features, epidemiology,
treatment, and prognosis of P multocida infections with a focus on these features in patients who are immunosuppressed.

Introduction
Pet ownership oers substantial psychological benet to
patients coping with dicult medical situations.17
However, these relations pose infectious risks when they
result in exposure of patients to their pets microbiota
through direct contact, licking, faecaloral transmission,
bite wounds, inhalation, or transmission through
associated vectors such as eas or ticks.
Animal bites can result in the direct inoculation of microbiota from the pets mouth into the patients subcutaneous
tissues.8 Every year, several million Americans are bitten by
animals, resulting in 300 000 emergency department visits;
one of every two Americans will be bitten by an animal or
by another person at some point in their lives.913
About 90% of animal bites are from cats and dogs;
318% of dog bites and 2880% of cat bites become
infected.6,9,12,14,15 Pasteurella multocida is the most common
causative organism isolated from dog-bite and cat-bite
wounds and is identied in 50% of dog bites and 75% of
cat bites.810,16
After contact with the animals saliva, patients usually
develop evidence of infection within the rst 24 h of
exposure.8 In immunocompetent hosts, these bites
typically result in cellulitis, lymphangitis, or abscess
formation.8 However, when these zoonotic organisms
infect immunocompromised hosts, the outcomes can be
fatal.1 In this Grand Round we describe a case of
fulminant P multocida sepsis and provide a review of
P multocida infections in immunocompromised hosts.

Case presentation
A 66-year-old man who had undergone a renal transplant
presented to the emergency department of our
community hospital reporting 1 week of increasing
dyspnoea. His wife reported that he began to complain of
fatigue with decreased oral intake and shortness of
breath in the week before admission, which became
progressively worse with time. On the morning of
presentation, the patient developed nausea, diarrhoea,
fevers, and diaphoresis. His wife stated that he felt
clammy to the touch and seemed to be very short of
breath, which prompted her to take him to the nearest
emergency department.
www.thelancet.com/infection Vol 15 February 2015

The patients past medical history showed that he had

been a recipient of a living-donor renal transplant from
his stepson 10 years previously (donor and recipient were
both seropositive for cytomegalovirus), and that he had
diabetes (haemoglobin A1c of 68% [508 mmol/mol]),
obesity, chronic venous stasis ulcers, and enterococcal
aortic-valve endocarditis needing bioprosthetic valve
replacement 9 years previously.
The patient was receiving prednisone (25 mg once
daily), mycophenolate mofetil (500 mg twice daily), and
tacrolimus (05 mg twice daily). The patient had no
history of rejection episodes, opportunistic infections, or
drug changes. The patient lived at home with his wife,
two dogs, and a cat. The patients wife reported that the
cat spent most of its time with the patient in his bedroom.
On arrival to the outside hospital, the patient was
diaphoretic and dyspnoeic. He had a temperature of
359C, heart rate of 124 beats per min, blood pressure of
100/62 mm Hg, respiratory rate of 34 breaths per min
with an oxygen saturation of 89% on room air, and
weight of 1673 kg. Clinically signicant ndings on
physical examination included a new III/VI systolic
ejection murmur, loudest at the right upper sternal
border, coarse rales; wheezing throughout all lung elds;
3+ symmetric, bilateral lower extremity oedema, with
overlying brawny changes; and shallow, leaking
ulcerations.
In the emergency department, the patient became
increasingly hypoxic, needing mechanical ventilation,
and developed bradycardia with a heart rate of 20 beats
per min, leading to the administration of epinephrine
and atropine. His bradycardia was complicated by
subsequent ventricular tachycardia with several
debrillations for a total code time of 7 min. A chest
radiograph showed bibasilar inltrates; prompting the
patient to be empirically initiated on broad spectrum
intravenous antibiotics with cefepime 1 g intravenous
every 8 h and transferred to the cardiac intensive care
unit at our hospital for further management.
On arrival at the intensive care unit, the patients heart
rate was 106 beats per min and blood pressure was
104/56 mm Hg on 03 L/kg per min of norepinephrine.
He was intubated with an oxygen saturation of 95% on

Lancet Infect Dis 2015;

15: 23540
Published Online
November 21, 2014
http://dx.doi.org/10.1016/
S1473-3099(14)70895-3
Johns Hopkins University,
Department of Medicine,
Baltimore, MD, USA
(E S Christenson MD,
H M Ahmed MD,
C M Durand MD)
Correspondence to:
Dr Eric S Christenson,
601 North Caroline Street,
Baltimore, MD 21287, USA
echris14@jhmi.edu

235

Grand Round

fractional inspiration of 100% oxygen. Electrocardiography showed a left bundle branch block with
T-wave inversions in leads 1 and V4V6. An arterial
blood gas assessment showed a pH of 787 kPa oxygen,
880 kPa carbon dioxide, and 18 mmol/L HCO3 with
plasma lactate 47 mmol/L; white blood cell count was
15 200 cells per L, international normalised ratio was
41, and troponin I was 40 ng/mL. Repeat chest
radiography showed cardiomegaly, mediastinal enlargement, and cephalisation of the pulmonary vasculature.
The patient continued to deteriorate clinically with
worsening hypoxia. We changed the antibiotics regimen
from intravenous cefepime to intravenous meropenem
1 g every 12 h and intravenous vancomycin 15 g every
24 h.
Transthoracic and transesophageal echocardiograms
showed mid-to-distal anterior wall, anteroseptal wall,
and anterolateral wall akinesis with global hypokinesis
and an ejection fraction of 3035% with severe aortic
stenosis of his bioprosthetic valve. No vegetations or
masses were noted. Coronary angiography showed no
obstructive lesions. The patient needed increasing
doses of norepinephrine for the next 48 h and had nonsustained runs of ventricular tachycardia. Blood
cultures sent to the laboratory in the emergency
department of the initial hospital grew Gram-negative
rods in two of two sets on the Bactec Plus blood culture
media (Becton, Dickinson and Company, Franklin
Lakes, NJ, USA), which were later identied as
P multocida via the RapID NH System (Thermo Fisher
Scientic, Lenxa, KS, USA).
Later that day, the family met and decided to transition
the patient to comfort care in accordance with his
preferences. The patient was extubated and died with his
family at his bedside.

P multocida

See Online for appendix

236

P multocida is a Gram-negative coccobacillus reported as

part of the oral microbiota in 66% of dogs, 7090% of
cats, and in several other domesticated and wild
animals.1620 P multocida also colonises the nasopharynx
in human beings after exposure to infected animals.21,22
This bacterium rst gained recognition as a pathogen in
1881 when it was described as the causative organism of
fowl cholera by Louis Pasteur.20,23
P multocida is the most common species of the Pasteurella
genus to cause infection in human beings, although other
species including Pasteurella canis and Pasteurella dagmatis
have occasionally been implicated in severe human
infections.24,25 P multocida can be further separated into
four subspecies (multocida, gallicida, septica, and tigris) on
the basis of its capsule and ve serogroups and 16 serotypes
on the basis of its heat-stable O antigen.20,23 This organism
grows well on blood or chocolate agar culture but not on
MacConkeys agar.19,26 Staining of the organism typically
reveals single cells showing bipolar staining, but might
also show pairs or chains.19

P multocidas capsule and lipopolysaccharide layer lead

to two key virulence factors that act to inhibit
phagocytosis and resist complement-mediated lysis.23,27
The importance of these virulence factors is supported
by the fact that serotypes missing these features do not
lead to infection.13
P multocida produces several enzymes that boost its
virulence by impairing host-defence responses;
hyaluronidase and neuraminidase assist P multocidas
invasion through the extracellular matrix and help it
scavenge necessary nutrients.13 Many serotype D isolates
produce P multocida toxin that accelerates the maturation
of macrophages to dendritic cells, inhibiting their
migration through the lymphatic system and preventing
the development of a robust adaptive immune response.23
On the basis of animal vaccination studies, the humoural
immune response seems crucial to the clearance of
P multocida infections probably because of the propensity
of encapsulated organisms to resist complement-mediated
lysis and phagocytosis in the absence of opsonisation.27,28
P multocida is usually transmitted to human beings
from their pets in association with dog and cat bites,
licks, and scratches.17 Cat bites, independent of the
slightly increased carriage rates in cats, are deemed to be
more dangerous for P multocida infection than are dog
bites because they tend to produce deeper puncture
injuries as opposed to the tearing wounds common with
dog bites.10,15,24 P multocida infections typically occur
through the transfer of saliva in bite wounds.25 Various
disease processes can result once P multocida penetrates
the skin, including cellulitis, osteomyelitis, and septic
arthritis. In rare cases, other sites of entry have been
described, causing urinary tract infections and
pulmonary infections.17,24,2932
In immunocompetent hosts, the rst signs of a
P multocida infection are pain and swelling at the
inoculation point, with the presence of purulent
drainage.33 These signs are typically followed by the rapid
progression of spreading erythema and pain in the rst
24 h after an animal bite.26,25 Infections can lead to the
formation of osteomyelitis or tenosynovitis depending
on the location and depth of the initial injury.26
We did not identify a denitive route of infection, but we
believe that our patients P multocida infection was
probably acquired by direct inoculation through his cat
licking his leg wounds. Another route of entry that cannot
be ruled out in this patient is his respiratory tract, in view
of the patients constellation of symptoms and the
propensity of P multocida to colonise this tissue. The
appendix reviews cases of P multocida sepsis and infections
of immunocompromised patients from 2004 to 2014.

P multocida infections in immunocompromised

hosts
In immunocompetent patients, Pasteurella infections are
typically controlled through a combination of innate and
adaptive immune systems restricting infections to the
www.thelancet.com/infection Vol 15 February 2015

Grand Round

soft tissue. By contrast, in immunocompromised hosts,

P multocida can lead to more fulminant infections,
including sepsis, endocarditis, peritonitis, septic arthritis,
and meningitis, and are associated with mortality rates of
2831%.34,35
In reports of endocarditis caused by P multocida,
patients present acutely with high fevers and systemic
signs of infection. This infection can be dicult to treat
and needed valvular replacement in six of 13 surviving
patients in one series.36 Pre-existing valvular lesions or
articial valves increase the risk of endocarditis.36
Septic arthritis is another potential feature of
P multocida reported in immunocompromised patients
that presents as acute swelling and pain in aected joints.
This outcome is more often noted in the setting of
adjacent soft tissue infection, previously damaged joint,
articial joints, or surgical manipulation.19,37 If this infection is not treated with early, aggressive therapy, it will
usually result in severe joint impairment.19
Meningitis is a particularly serious presentation of
P multocida, especially in infants (appendix). Such infection
is usually associated with contact between the infant and
domesticated animals within the household, but intrauterine exposure of the fetus to maternal P multocida
infection has also been reported.38,39
P multocida peritonitis typically presents as diuse
abdominal pain or altered mental status in patients with
cirrhosis or indwelling peritoneal catheters.19 These cases
have also been associated with reports of household pets
licking catheters.19 Individuals with cirrhosis seem to be
at especially high risk for severe P multocida infections,
presenting as a risk factor in 77% of patients with
P multocida bacteraemia in a case series of 13 patients
from France.34,4043

Immunocompromise in renal transplant patients

As the repertoire of immunosuppressive drugs has
expanded, the frequency of rejection episodes has
decreased substantially, leading to improved quality and
length of life for many patients.44,45 Unfortunately, this
immunosuppression puts patients at increased risk for
both typical and opportunistic infections.46 More than
50% of renal transplant recipients are estimated to have
infectious complications within the rst year of receipt of
their new organ.47 Infectious complications account for
1535% of deaths in patients with functional renal
grafts.4851
Calcineurin and mechanistic target of rapamycin
(mTOR) inhibitors are often used in the transplantation
setting to attenuate the immune systems response to
foreign antigens present on the transplanted organ.
The calcineurin inhibitor acts through suppression of
the NFAT/NOD1 pathway and mTOR inhibitor through
the suppression of the interleukin 2 induction pathway.52,53
This suppression prevents the immune system from
responding to transplant antigens but also impairs the
bodys ability to rapidly respond to bacterial infections via
the adaptive immune system.52 A meta-analysis54
comparing the use of calcineurin inhibitors and mTOR
inhibitors showed no signicant dierence in bacterial
infections between the two groups.

P multocida in end-stage renal disease and renal

transplantation
In end-stage renal disease, P multocida has been noted as
the causative organism in several reported cases of
overwhelming sepsis.17,55,56 Most of these infections have
been reported in individuals with dogs or cats in the
household, with contact with dialysis equipment being

Age
(years)

Sex

Site of
infection

Exposure

Our patient

66

Male

Systemic

Probably cat
Diabetes, AVR,
licking wounds obesity

Satta et al, 201257

38

Male

Endocarditis,
cellulitis

Two cats,
contact with
dogs

Schmulewitz
et al, 200858

31

Female

Left maxillary
sinus

Ali et al, 200760

67

Male

Female

Steiner et al,
198759

Comorbidities

Immunosuppression

Treatment

Outcome

Tacrolimus,
mycophenolate,
prednisone

Meropenem plus
vancomycin

Died

Marfans syndrome,
AVR

Tacrolimus, steroids

Ertapenem then
ceftriaxone
sodium

Full recovery

Dog licking
face

Systemic lupus
erythematous

Sirolimus,
mycophenolate,
prednisolone

Amoxicillin/
clavulanic acid
then doxycycline

Clinically
improved

Perinephritic
abscess

Cat scratch

Goodpastures
syndrome

Mycophenolate,
Piperacillin/
ciclosporin, prednisone tazobactam plus
ciprooxacin
then ceftriaxone
sodium plus
ciprooxacin

Full recovery

Psoas muscle
abscess

Cat and dog

Meningomyelocele,
neurogenic bladder

Azathioprine,
prednisone

Gait
abnormality

Ampicillin plus
gentamicin
sulphate then
penicillin

AVR=aortic valve replacement.

Table: Cases of Pasteurella multocida infections in renal transplant patients

www.thelancet.com/infection Vol 15 February 2015

237

Grand Round

an important risk factor in the case of home peritoneal

dialysis.56 Reviews of published work showed that
P multocida seems to be a rare cause of severe disease
after renal transplantation (table).5760

Treatment
Because of the high morbidity of P multocida infections,
all individuals bitten by cats are advised to receive prompt
medical attention.25 If untreated, infection is thought to
occur in 2880% of cat bites, although this gure is
probably biased by the increased tendency of patients
experiencing sequelae from an animal bite to present to
their physician.10,6163 Empirical treatment is recommended
because this approach substantially decreases the risk of
symptomatic infection.25,64,65
Amoxicillin/clavulanic is the preferred choice for initial
therapy because it displays excellent eectiveness in the
treatment of P multocida and other causative organisms of
bite infections, including Streptococcus spp, some species
of Staphylococcus and oral anaerobic microbiota.61 Although
Panel: General guidelines for pet ownership in immunosuppressed individuals
Pet hygiene and maintenance
Wash hands carefully after handling pets
Keep pets healthy by feeding them food that is not contaminated or spoiled, and seek
veterinary help at the rst signs of illness
Avoid contact with animals that have diarrhoea
Avoid cleaning birdcages, birdfeeders, litter boxes, and handling animal faeces; use of
disposable gloves and a standard surgical mask is advised if avoidance is not possible
Wear gloves to clean aquariums or have someone else in the household do the cleaning
Prevent contact of pet oral secretions with open wounds and catheters
Pet selection
Consider waiting to acquire a new pet until a time when the patient is on stable
immunosuppression (at least 612 months after transplantation)
Avoid stray animals
Avoid contact with non-human primates
Avoid animal bites and scratches (do not pet stray animals)
Consider the type of pet and specic risks for infections:
Reptiles (snakes, iguanas, lizards, and turtles) have a high risk of salmonella
infection and should be avoided
Rodents have a risk of transmitting lymphocytic choriomeningitis virus
Young cats have risk of transmitting Bartonella henselae
Cats have a risk of transmitting Toxoplasma gondii
Puppies, kittens, and chicks have a risk of transmitting campylobacter infections
Adapted with permission from Avery and Michaels (Avery RK, Michaels MG, Practice AIDC. Strategies for safe living after solid
organ transplantation. Am J Transplant 2013; 13: 30410).

Search strategy and selection criteria

We identied data by searching PubMed for articles published in English
between Jan 1, 2004, and July 22, 2014, with the terms Pasteurella AND sepsis,
Pasteurella AND immunopromise, Pasteurella AND transplant, and Pasteurella AND
renal. We reviewed identied articles and other relevant references from hand-searching
of records. Articles not available online were obtained in printed form through searches in
the University of Maryland library.

238

P multocida is typically very sensitive to penicillin, some

-lactamase-producing isolates have been reported.20
A systematic analysis19 of in-vitro antibiotic
susceptibility for P multocida has shown that the antibiotics with the best activity are the penicillins and
second-generation and third-generation cephalosporins,
tetracyclines, chloramphenicol, co-trimoxazole, and
uoroquinolones.25,66,67 Although rst-generation cephalosporins and clindamycin are usually used for soft tissue
infections, they have poor activity against P multocida
and should be avoided if this organism is suspected.25,26,
Macrolides are also noted to have poor activity against
P multocida and should be avoided.25
Optimum treatment duration has not been delineated
by any randomised controlled trials but based on case
reports, P multocida infections in immunocompromised
patients with soft tissue infections should be treated for
at least 14 days, with longer courses for patients with
severe infections.19 In patients presenting with deep soft
tissue or articular infections, early debridement of
wound sites and surgical management are crucial.68
Co-trimoxazole is used to prevent several opportunistic
infections after solid organ transplantation (ie, Pneumocystis jirovecii and toxoplasmosis), and has activity
against P multocida. These patients might derive additional
benet in prevention of this zoonotic infection. This
attribute deserves consideration in calculation of the risk
benet of continuing prophylactic co-trimoxazole therapy
in patients at high risk for exposure to P multocida.
Vaccination eorts have thus far focused on the highdisease burden of P multocida infections in agriculturally
important species, but these experiences might help to
inform eorts aimed at the development of human
vaccinations.26,69 Inactivated, live, and subunit-based formulations have been produced and have substantially reduced
the frequency of symptomatic infections in a wide range of
animal species.26,69 These eorts have led to the production
of several commercially available vaccines for livestock.26

Prognosis
In immunocompetent patients, P multocida infections
are typically localised and resolve with antibiotics or
minor surgical intervention. However, in immunocompromised hosts, decreased humoural and cellmediated responses allow P multocida to evade host
defences and spread to distant sites via the bloodstream
with severe consequences, shown by an increased risk
for peritonitis, endocarditis, and meningitis.26 Mortality
in these cases is reportedly 2530%, although some
reporting bias might be present.26,70,71

Prevention
Although some risk of zoonotic infection is inherent with
the ownership of pets, general guidelines exist to minimise
this danger (panel).5,72 The acquisition of new pets should
be avoided for the 6 months after transplantation and after
receipt of high-dose immunosuppression, such as after
www.thelancet.com/infection Vol 15 February 2015

Grand Round

treatment for an episode of rejection.44 To optimise the

health of pets and therefore diminish disease transmission
to their owners, pets should be kept clean, taken to a
veterinarian regularly, and prevented from hunting
outside. After contact with pets, patients should wash their
hands thoroughly.72,73 As highlighted by our case, patients
should avoid letting pets lick any open wounds or catheters.
For pet maintenance, proper disposal of animal waste is
key; contact with animals experiencing diarrhoea or other
illness should be avoided.5,72,74 When obtaining new pets,
the facilities from which animals are acquired should be
examined, because the hygienic and sanitary conditions in
facilities of pet breeders, pet stores, and animal shelters are
highly variable.74 Patients should avoid the adoption of
young or stray pets because these are at increased risk both
for colonisation with potentially dangerous organisms and
for animal scratches and bites.5,74

Conclusion
More than 60% of Americans have at least one pet, with
dogs and cats representing the most popular choices.26
Pets have the potential to bring psychological benets to
patients with chronic illness but can also be vectors for
life-threatening infections.73 Bite wounds from animals
and people account for roughly 1% of emergency room
admissions.64,75
Renal transplant recipients are at increased risk for
both typical and opportunistic infections. Clinicians and
patients should be vigilant, especially in the rst few
months after transplantation, and maintain an increased
index of suspicion for infections from various sources,
including domesticated animals. Patients need to be
counselled on the importance of avoiding contact with
animals oral secretions, especially at any potential entry
points for infection.
Contributors
ESC did the scientic literature search and developed the tables. ESC,
HMA, and CD participated in the patients care during admission to
hospital. ESC followed up with the patients outpatient providers and
outside hospitals to collect additional medical information and
documentation. ESC, HMA, and CD all participated in writing and
editing of the report.
Declaration of interests
We declare no competing interests.
Acknowledgments
We thank Robin Avery for reviewing the report and being an invaluable
educational resource, and our patients family for allowing us to share
his case with the medical community.
References
1
Elad D. Immunocompromised patients and their pets: still best
friends? Vet J 2013; 197: 66269.
2
Braun C, Stangler T, Narveson J, Pettingell S. Animal-assisted
therapy as a pain relief intervention for children.
Complement Ther Clin Pract 2009; 15: 10509.
3
Friedmann E, Katcher AH, Lynch JJ, Thomas SA. Animal
companions and one-year survival of patients after discharge from a
coronary care unit. Public Health Rep 1980; 95: 30712.
4
Friedmann E, Thomas SA. Pet ownership, social support, and oneyear survival after acute myocardial infarction in the Cardiac
Arrhythmia Suppression Trial (CAST). Am J Cardiol 1995;
76: 121317.

www.thelancet.com/infection Vol 15 February 2015

6
7
8
9

10
11
12
13

14
15

16

17

18

19

20

21

22

23
24

25

26
27

28

29

30

Hemsworth S, Pizer B. Pet ownership in immunocompromised

childrena review of the literature and survey of existing
guidelines. Eur J Oncol Nurs 2006; 10: 11727.
Steele RW. Should immunocompromised patients have pets?
Ochsner J 2008; 8: 13439.
Serpell J. Benecial eects of pet ownership on some aspects of
human health and behaviour. J R Soc Med 1991; 84: 71720.
Abrahamian FM, Goldstein EJ. Microbiology of animal bite wound
infections. Clin Microbiol Rev 2011; 24: 23146.
Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ.
Bacteriologic analysis of infected dog and cat bites. Emergency
Medicine Animal Bite Infection Study Group. N Engl J Med 1999;
340: 8592.
Goldstein EJ. Bite wounds and infection. Clin Infect Dis 1992;
14: 63338.
Beck AM, Jones BA. Unreported dog bites in children.
Public Health Rep 1985; 100: 31521.
Elliot DL, Tolle SW, Goldberg L, Miller JB. Pet-associated illness.
N Engl J Med 1985; 313: 98595.
Crowther MA, Ginsberg JS, Julian J, et al. A comparison of two
intensities of warfarin for the prevention of recurrent thrombosis in
patients with the antiphospholipid antibody syndrome.
N Engl J Med 2003; 349: 113338.
Thomas PR, Buntine JA. Mans best friend?: a review of the Austin
Hospitals experience with dog bites. Med J Aust 1987; 147: 53640.
Elenbaas RM, McNabney WK, Robinson WA. Evaluation of
prophylactic oxacillin in cat bite wounds. Ann Emerg Med 1984;
13: 15557.
Bailie WE, Stowe EC, Schmitt AM. Aerobic bacterial ora of oral
and nasal uids of canines with reference to bacteria associated
with bites. J Clin Microbiol 1978; 7: 22331.
Mugambi SM, Ullian ME. Bacteremia, sepsis, and peritonitis with
Pasteurella multocida in a peritoneal dialysis patient. Perit Dial Int
2010; 30: 38183.
Guillet C, Join-Lambert O, Carbonnelle E, Ferroni A, Vachee A.
Pasteurella multocida sepsis and meningitis in 2-month-old twin
infants after household exposure to a slaughtered sheep.
Clin Infect Dis 2007; 45: e8081.
Weber DJ, Wolfson JS, Swartz MN, Hooper DC. Pasteurella
multocida infections. Report of 34 cases and review of the literature.
Medicine (Baltimore) 1984; 63: 13354.
Migliore E, Serraino C, Brignone C, et al. Pasteurella multocida
infection in a cirrhotic patient: case report, microbiological aspects
and a review of literature. Ad Med Sci 2009; 54: 10912.
Avril JL, Donnio PY, Pouedras P. Selective medium for Pasteurella
multocida and its use to detect oropharyngeal carriage in pig
breeders. J Clin Microbiol 1990; 28: 143840.
Siahanidou T, Gika G, Skiathitou AV, et al. Pasteurella multocida
Infection in a neonate: evidence for a human-to-human horizontal
transmission. Pediatr Infect Dis J 2012; 31: 53637.
Harper M, Boyce JD, Adler B. Pasteurella multocida pathogenesis:
125 years after Pasteur. FEMS Microbiol Lett 2006; 265: 110.
Cohen-Adam D, Marcus N, Scheuerman O, Hoer V, Garty BZ.
Pasteurella multocida septicemia in a newborn without scratches,
licks or bites. IMAJ 2006; 8: 65758.
Freshwater A. Why your housecats trite little bite could cause you
quite a fright: a study of domestic felines on the occurrence and
antibiotic susceptibility of Pasteurella multocida.
Zoonoses Public Health 2008; 55: 50713.
Wilson BA, Ho M. Pasteurella multocida: from zoonosis to cellular
microbiology. Clin Microbiol Rev 2013; 26: 63155.
Boyce JD, Adler B. The capsule is a virulence determinant in the
pathogenesis of Pasteurella multocida M1404 (B:2). Infect Immun
2000; 68: 346368.
Gong Q, Qu N, Niu M, et al. Immune responses and protective
ecacy of a novel DNA vaccine encoding outer membrane protein
of avian Pasteurella multocida. Vet Immunol Immunopathol 2013;
152: 31724.
Van Langenhove G, Daelemans R, Zachee P, Lins RL. Pasteurella
multocida as a rare cause of peritonitis in peritoneal dialysis.
Nephron 2000; 85: 28384.
Dixon JM, Keresteci AG. Renal infection with
Pasteurella multocida. Can Med Assoc J 1967; 97: 2829.

239

Grand Round

31
32
33
34

35

36
37
38

39

40

41

42

43

44
45

46
47

48

49

50

51
52

53

240

Tattevin P, Souala F, Gautier AL, et al. Diabetes in patients with

pasteurellosis. Scand J Infect Dis 2005; 37: 73133.
Warren JS, Smith JW. Pasteurella multocida urinary tract infection.
Arch Pathol Lab Med 1984; 108: 40102.
Mitnovetski S, Kimble F. Cat bites of the hand. ANZ J Surg 2004;
74: 85962.
Ra F, Barrier J, Baron D, Drugeon HB, Nicolas F, Courtieu AL.
Pasteurella multocida bacteremia: report of thirteen cases over twelve
years and review of the literature. Scand J Infect Dis 1987; 19: 38593.
Chang K, Siu LK, Chen YH, et al. Fatal Pasteurella multocida
septicemia and necrotizing fasciitis related with wound licked by a
domestic dog. Scand J Infect Dis 2007; 39: 16770.
Khan MF, Movahed MR, Jung J. Pasteurella multocida endocarditis.
J Heart Valve Dis 2012; 21: 26062.
Stiehl JB, Sterkin LA, Brummitt CF. Acute Pasteurella multocida in
total knee arthroplasty. J Arthroplasty 2004; 19: 24447.
Pace D, Attard-Montalto S. Quest for the diagnosis. Case 1: a
neonatal zoonosis. Neonatal Pasteurella multocida septicaemia.
Acta Paediatrica 2008; 97: 25052.
Hirsh D, Farrell K, Reilly C, Dobson S. Pasteurella multocida
meningitis and cervical spine osteomyelitis in a neonate.
Pediatr Infect Dis J 2004; 23: 106365.
Koch CA, Mabee CL, Robyn JA, Koletar SL, Metz EN. Exposure to
domestic cats: risk factor for Pasteurella multocida peritonitis in liver
cirrhosis? Am J Gastroenterol 1996; 91: 144749.
Fayad G, Modine T, Mokhtari S, et al. Pasteurella multocida aortic
valve endocarditis: case report and literature review.
J Heart Valve Dis 2003; 12: 26163.
Tseng HK, Su SC, Liu CP, Lee CM. Pasteurella multocida bacteremia
due to non-bite animal exposure in cirrhotic patients: report of two
cases. J Microbiol Immunol Infect 2001; 34: 29396.
Adler AC, Cestero C, Brown RB. Septic shock from Pasturella
multocida following a cat bite: case report and review of literature.
Conn Med 2011; 75: 60305.
Kotton CN. Zoonoses in solid-organ and hematopoietic stem cell
transplant recipients. Clin Infect Dis 2007; 44: 85766.
Ducloux D, Carron PL, Racadot E, et al. CD4 lymphocytopenia in
long-term renal transplant recipients. Transplant Proc 1998;
30: 285960.
Fishman JA. Infection in solid-organ transplant recipients.
N Engl J Med 2007; 357: 260114.
Alangaden GJ, Thyagarajan R, Gruber SA, et al. Infectious
complications after kidney transplantation: current epidemiology
and associated risk factors. Clin Transplant 2006; 20: 40109.
Parasuraman R, Samarapungavan D, Venkat KK. Updated
principles and clinical caveats in the management of infection in
renal transplant recipients. Transplant Rev (Orlando) 2010;
24: 4351.
Prakash J, Ghosh B, Singh S, Soni A, Rathore SS. Causes of death
in renal transplant recipients with functioning allograft.
Indian J Nephrol 2012; 22: 26468.
West M, Sutherland DER, Matas AJ. Kidney transplant recipients
who die with functioning grafts - Serum creatinine level and cause
of death. Transplantation 1996; 62: 102930.
Briggs JD. Causes of death after renal transplantation.
Nephrol Dial Transpl 2001; 16: 154549.
Vandewalle A, Tourneur E, Bens M, Chassin C, Werts C.
Calcineurin/NFAT signaling and innate host defence: a role for
NOD1-mediated phagocytic functions. Cell Commun Signal 2014;
12: 8.
Fingar DC, Richardson CJ, Tee AR, Cheatham L, Tsou C, Blenis J.
mTOR controls cell cycle progression through its cell growth
eectors S6K1 and 4E-BP1/eukaryotic translation initiation factor
4E. Mol Cell Biol 2004; 24: 20016.

54

55

56

57

58

59
60

61
62

63
64

65

66

67

68

69

70

71

72
73
74

75

Almeida CC, Silveira MR, de Araujo VE, et al. Safety of

immunosuppressive drugs used as maintenance therapy in kidney
transplantation: a systematic review and meta-analysis.
Pharmaceuticals 2013; 6: 117094.
Boinett C, Gonzalez A. Pasteurella multocida septicaemia in a
patient on haemodialysis. BMJ Case Rep; 2009; published online
April 7. DOI:10.1136/bcr.01.2009.1492.
Sol PM, van de Kar NC, Schreuder MF. Cat induced Pasteurella
multocida peritonitis in peritoneal dialysis: a case report and review
of the literature. Int J Hyg Environ Health 2013; 216: 21113.
Satta G, Gorton RL, Kandil H. Prosthetic valve endocarditis caused
by Pasteurella in a penicillin allergic patient: challenges in
diagnosis and treatment Infect Dis Rep 2012; 4: e32.
Schmulewitz L, Chandesris MO, Mainardi JL, et al. Invasive
Pasteurella multocida sinusitis in a renal transplant patient.
Transpl Infect Dis 2008; 10: 20608.
Steiner FT, Brem AS, Peter G. Psoas muscle abscess due to
Pasteurella multocida. J Urol 1987; 137: 48788.
Ali A, LaRocco A, Mooney M, et al. Pasteurella multocida Perinephric
Abscess After Renal Transplantation. Infect Dis Clin Prac 2007;
15: 19698.
Israeli E, Attali M, Kraco OH, Polevshikov M, Malnick SD.
Smitten by a kitten. South Med J 1999; 92: 90911.
Esposito S, Picciolli I, Semino M, Principi N. Dog and cat biteassociated infections in children. Eur J Clin Microbiol Infect Dis
2013; 32: 97176.
Kizer KW. Epidemiologic and clinical aspects of animal bite
injuries. JACEP 1979; 8: 13441.
Henton J, Jain A. Cochrane corner: antibiotic prophylaxis for
mammalian bites (intervention review). J Hand Surg Eur Vol 2012;
37: 80406.
Brakenbury PH, Muwanga C. A comparative double blind study of
amoxycillin/clavulanate vs placebo in the prevention of infection
after animal bites. Arch Emerg Med 1989; 6: 25156.
Sands M, Ashley R, Brown R. Trimethoprim/sulfamethoxazole
therapy of Pasteurella multocida infection. J Infect Dis 1989;
160: 35354.
Goldstein EJ, Citron DM. Comparative activities of cefuroxime,
amoxicillin-clavulanic acid, ciprooxacin, enoxacin, and ooxacin
against aerobic and anaerobic bacteria isolated from bite wounds.
Antimicrob Agents Chemother 1988; 32: 114348.
Kadakia AP, Langkamer VG. Sepsis of total knee arthroplasty after
domestic cat bite: should we warn patients? Am J Orthopedics 2008;
37: 37071.
Ahmad TA, Rammah SS, Sheweita SA, Haroun M, El-Sayed LH.
Development of immunization trials against Pasteurella multocida.
Vaccine 2014; 32: 90917.
Velez M, Casanasa B, Greene JN, Morey J, Mastroianni D, Oehler R.
Pasteurella multocida infections in cancer patients. Asian Biomed
2010; 4: 44955.
Al-Sabah S, Goldberg P, Qureshi ST. Pasteurella multocida septic
shock following liver transplantation treated with drotrecogin alpha
(activated). Transpl Infect Dis 2007; 9: 23336.
Rabinowitz PM, Gordon Z, Odon L. Pet-related infections.
Am Fam Physician 2007; 76: 131422.
Avery RK, Michaels MG, Practice AIDC. Strategies for safe living
after solid organ transplantation. Am J Transplant 2013; 13: 30410.
Angulo FJ, Glaser CA, Juranek DD, Lappin MR, Regnery RL.
Caring for pets of immunocompromised persons.
J Am Vet Med Assoc 1994; 205: 171118.
Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries
treated in emergency departments. JAMA 1998; 279: 5153.

www.thelancet.com/infection Vol 15 February 2015