a 52-year - old woman with granulocytic sarcoma affecting the anterior cranial fossa and frontal sinus was commenced on ade ( cytarabine , daunorubicin and etoposide ) and mylotarg ( gemtuzumab ) through a peripherally inserted central catheter ( picc ) line as part of the aml 17 trial ( http://aml17.cardiff.ac.uk/aml17/default.aspx ) .
she was known to have a beta - lactam allergy manifest as an erythematous rash . on day 9 of chemotherapy ,
her fever resolved after 48 hours and meropenem was stopped after 7 days . on day 18 of chemotherapy
she remained febrile over the next three days and caspofungin was started in view of high - resolution computed topography ( hrct ) chest findings compatible with possible fungal infection and a positive initial serum galactomannan assay ( although the repeat specimen was negative ) .
meropenem was therefore replaced with ciprofloxacin as it was thought to be responsible for the rash .
all cultures including multiple blood cultures and picc line site swabs were culture negative . on day 31 of chemotherapy she was still febrile and blood cultures from peripheral veins and the picc line taken on day 30 yielded gram - positive cocci in pairs and chains after 24 and 11 hours ' culture respectively .
the isolate was identified as leuconostoc lactis using the bd phoenix identification ( becton , dickinson and company , usa ) and api rapid i d 32 strep systems ( biomrieux , france ) .
mean inhibitory concentrations ( mics ) determined by e - test ( ab biodisk , sweden ) were : penicillin 0.5 mg / l , vancomycin > 256 mg / l , teicoplanin 256 mg / l , ciprofloxacin 1.0 mg / l , tigecycline 0.064 mg / l , linezolid 1.5 mg / l and daptomycin 0.064 mg / l . on day 32 of chemotherapy , ciprofloxacin and teicoplanin
the next day therapy was changed to tigecycline ( 50 mg iv q12h ) because of concerns over myelotoxicity ( anaemia and thrombocytopenia ) associated with linezolid .
daptomycin was unavailable in the hospital formulary and ampicillin was not used due to concerns over beta - lactam allergy and a borderline penicillin e - test mic .
the patient continued to have low - grade fevers over the next four days , despite a negative transthoracic echocardiogram . on the fourth day of treatment , however , her fever resolved and she was discharged from hospital after completing 8 days of tigecycline , to which she had no adverse effects .
leuconostoc spp . are catalase - negative , gram - positive , facultatively anaerobic coccobacilli .
they are environmental organisms often found on plants , dairy products , vegetables , wine and occasionally in human vaginal and stool samples . although an uncommon human pathogen , cases of bacteremia , endocarditis , pneumonia , meningitis , osteomyelitis , peritonitis , brain and liver abscesses have been described .
and other gram - positive antimicrobial - resistant organisms are increasingly recognised as important pathogens in neutropenic patients probably due , in addition to immunosuppression , to the use of indwelling intravascular devices , antibiotic prophylaxis and evolution of chemotherapeutic agents .
infection with leuconostoc may cause fever , intravenous catheter - related sepsis , bacteremia , abdominal pain , gastroenteritis , colitis or meningitis in this group of patients . other reported risk factors for infection
removal of intravenous catheters alone has been shown to be curative in some patients without the need for antimicrobial therapy .
are intrinsically resistant to glycopeptides , owing to the production of peptidoglycan precursors ending in d - ala - d - lac , but are usually susceptible to penicillin , ampicillin , aminoglycosides , clindamycin , minocycline and macrolides .
in addition , linezolid and daptomycin have been used successfully to treat leuconostoc bacteremia , although linezolid mics of leuconostoc spp .
although the organism has been shown to be resistant to cefoxitin , it is susceptible to cefotaxime in vitro .
tigecycline , a glycylcycline , is a broad spectrum synthetic derivative of minocycline which has a broad spectrum of activity against various gram - positive and gram - negative bacteria including multidrug - resistant strains , anaerobic bacteria and atypical organisms .
it has proven to be useful in the treatment of hospital - acquired infections caused by vancomycin - intermediate and vancomycin - resistant enterococci ( vre ) , meticillin - resistant staphylococcus aureus ( mrsa ) , extended - spectrum -lactamase ( esbl)-producing enterobacteriaceae , multidrug - resistant acinetobacter baumanii and penicillin - resistant streptococcus pneumoniae . in the uk ,
its licensed indications are complicated intra - abdominal and complicated skin and soft tissue infection .
it is also licensed for the treatment of community - acquired pneumonia in the us .
although tigecycline has been demonstrated to be a safe and effective second - line option in microbiologically documented infections in neutropenic patients , there have been no trials to determine whether tigecycline is effective in neutropenic bacteremia and there are also theoretical concerns surrounding low serum concentrations ( due to a large volume of distribution ) and its mostly bacteriostatic activity .
it is for this reason that tigecycline is not generally recommended for primary bacteremia but it is used for secondary bacteremia associated with complicated skin and soft tissue infections , intra - abdominal infections and community - acquired pneumonia . despite these concerns , here
we report the first successful use of tigecycline in the treatment of leuconostoc bacteremia in a neutropenic patient .
 leuconostoc lactis is a recognised cause of infection in immunocompromised hosts . 
 it is intrinsically resistant to multiple antibiotics and treatment options may be limited . 
 we report a case of safe and effective use of tigecycline in the treatment of leuconostoc catheter - related line sepsis in a neutropenic patient . to our knowledge 
 , this is the first reported case of successful use of tigecycline for leuconostoc bacteremia . 