Bacteremia due to
CASE REPORTAn 83-year-old woman was admitted because of fever and chills. She had a history of type II diabetes and hypertension. Three months before, the patient had undergone a total hip replacement. At the time of admission to the hospital she was febrile, with mild dehydration, and she appeared chronically ill with multiple decubitus ulcers (grade IV in the sacral region and grade II in the lower extremities).Laboratory tests disclosed the following values: hematocrit, 26%; white blood cell count, 22,300 (70% neutrophils); glucose, 131 mg %; Na ϩ , 122 meq/ml; K ϩ , 3 meq/ml; Cl Ϫ , 96 meq/ml. Urinalysis indicated 50 leukocytes/field. A chest radiograph was normal.On the first day, blood (aerobic and anaerobic bottles; Bact Alert), urine, and soft-tissue cultures were performed, and a combination therapy with intravenous (i.v.) ceftriaxone, 1 g three times a day (t.i.d.), and i.v. metronidazole, 0.5 g t.i.d., was empirically administered.Debridment of the sacral decubitus scar was performed. The patient's fever resolved promptly with this regimen. Blood cultures yielded an anaerobic gram-negative rod that was identified as Fusobacterium varium (anaerobic bottle; Bact Alert) in combination with Bacteroides fragilis (anaerobic and aerobic bottles; Bact Alert). The specimen obtained from the sacral decubitus ulcer yielded Fusobacterium varium, Bacteroides fragilis, Porphyromonas endodontalis, a non-spore-forming gram-positive rod, Enterococcus faecalis, and Escherichia coli. Urine culture showed growth of Escherichia coli and Enterococcus faecalis. The antibiotic regimen was changed to ampicillin-sulbactam (1.5 g/8 h) and ciprofloxacin (200 mg/12 h). New blood culture showed no growth.Five days later the patient became febrile and severe sepsis developed. Previous cultures were repeated, and the antibiotic treatment was changed to imipenem, vancomycin, and amikacin. Blood cultures, as well as the central venous catheter, were positive for methicillin-resistant Staphylococcus aureus. The patient died on day 34 of admission secondary to multiorgan failure.Bacteriology. The initial decubitus ulcer specimen and blood were plated directly onto laked-blood brucella agar and phenylethanol agar supplemented with vitamin K 1 -hemin and incubated at 35°C in an anaerobic environment. They were also plated on Levine eosin-methylene blue agar and incubated at 35°C in an oxygen atmosphere and on 5% blood agar and