in march 2014 , a 47-year - old woman was hospitalized at the bernhard nocht clinic ( hamburg , germany ) with chills , nausea , and fever ( temperature < 40c ) .
the patient had a history of intravenous drug use ( cocaine and benzodiazepines ) and was currently enrolled in a methadone substitution program .
she also had chronic hepatitis c virus infection that was successfully treated with pegylated interferon- , ribavirin , and boceprevir .
the patient had a sustained virologic response and negative results for hepatitis c virus rna at follow - up without progression to liver fibrosis or cirrhosis . at admission ,
her peripheral blood leukocyte count was 6.6  10 cells/l , and her c - reactive protein level was increased ( 29 mg / l [ reference value < 5 mg / l ] ) .
soft tissue abscess was not observed , but the patient admitted having injected cocaine and unknown crushed tablets intravenously the day before admission .
toxicologic screening showed highly increased levels of benzodiazepine ( > 5,000 ng / ml ) and cocaine ( > 1,000 ng / ml ) ( reference values < 20 ng / ml for both substances ) .
three blood cultures were collected before empiric antimicrobial therapy with intravenous ceftriaxone ( 2 g 1/d ) was given on day 1 .
her leukocyte count increased to 27.6 10 cells/l , and c - reactive protein level increased to 112 mg / l .
she was highly febrile and became hypotensive and tachycardic , which are compatible with severe sepsis .
the patient responded rapidly to fluid substitution , became hemodynamically stable , and did not need vasopressors .
antimicrobial therapy was changed empirically to meropenem ( 1,000 mg 3/d ) on day 2 .
after 18 h of culture incubation , microbial growth was detected in 3 aerobic blood culture bottles inoculated at admission .
gram staining showed gram - negative rods , and matrix - assisted laser desorption ionization / time - of - flight mass spectrometry fingerprinting with direct sample deposition without extraction ( bruker daltonim gmbh , bremen , germany ) identified a. ursingii ( score 2.19 ) .
a blast search ( http://www.ncbi.nlm.nih.gov/blast ) of partial 16s rrna gene sequence was performed by using a taxonomy browser ( http://www.ncbi.nlm.nih.gov ) and showed 99% identity with the a. ursingii type strain nbrc110605 ( genbank accession no .
antimicrobial susceptibility testing was performed by using vitek 2 ( biomrieux , nrtingen , germany ) .
results showed susceptibility to imipenem ( mic < 0.25 mg / ml ) , meropenem ( < 0.25 mg / ml ) , gentamicin ( < 1 mg / ml ) , and ciprofloxacin ( < 0.25 mg / ml ) and resistance to ceftriaxone ( 32 mg / ml ) . the patient became afebrile the next day , her clinical symptoms improved , and laboratory parameters of inflammation returned to reference values .
2 months later , the patient had no symptoms and was attending group - counseling sessions to maintain drug abstinence .
after the first description of a. ursingii as a new species ( 2 ) , for which 13 of 29 a. ursingii isolates were obtained from patients with nosocomial bloodstream infections , few cases of a. ursingii bloodstream infections have been reported ( table ) .
we were not able to identify cases of community - acquired a. ursingii bloodstream infections in the literature .
reported a case of a. ursingii bloodstream infection in a severely immunocompromised patient with pulmonary adenocarcinoma who received chemotherapy and corticosteroids ( 3 ) . in that study ,
a. ursingii was associated with an implanted port device and considered of low pathogenic potential .
however , in the past few years , there have been reports of serious a. ursingii bloodstream infections in immunocompromised and immunocompetent patients .
reported nosocomial a. ursingii bloodstream infections in 2 pregnant women who had no concurrent illnesses ( 4 ) , but the route of transmission was not elucidated .
the authors hypothesized that infections might have been acquired from intravenous catheters from the ward shower bath , where a. ursingii and 2 different strains of a. junii were found .
a. ursingii was also found associated with nosocomial bloodstream infections among newborns , as demonstrated by 2 outbreaks in neonatal intensive care units that had high mortality rates . in both outbreaks , the source of infection
( 5 ) and mder et al . ( 6 ) , catheter - related infections were assumed .
dortet et al . ( 8) reported 10 a. ursingii infections , which included 3 cases of nosocomial bloodstream infections ,
although severe infections with a. ursingii are rare , identification of a. ursingii by molecular methods , such as 16s rrna gene sequencing , rpob gene sequence cluster analysis , and amplified fragment length polymorphism fingerprinting , indicates a relatively high prevalence of a. ursingii ( range 2.6%4.5% ) among clinical acinetobacter spp . isolates ( 1013 ) . in a study from the united kingdom ,
isolates collected over a 20-month period during 20082009 ; a total of 17 ( 71% ) of 24 a. ursingii isolates were recovered from blood cultures , but clinical details were not reported ( 12 ) .
bloodstream infections in norway ; 3 ( 2.6% ) were with a. ursingii , but clinical details of these patients were not provided .
this relatively high incidence is consistent with results from the netherlands ( 10 ) and northern ireland ( 11 ) . in most reports
, a. ursingii isolates were more susceptible to antimicrobial drugs than a. baumannii isolates ( 4,6,8,12,13 ) .
however , endo et al . ( 9 ) reported an imp-1producing , carbapenem - resistant a. ursingii isolate from a patient in japan with a nosocomial bloodstream infection .
a. ursingii isolates are usually resistant to cephalosporins ( 3,5,8 ) , as was the isolate from the patient we report , which explains the progression from severe sepsis when she was empirically given ceftriaxone to rapid clinical improvement after administration of meropenem .
( 6 ) reported a premature infant with an a. ursingii bloodstream infection also given a cephalosporin ( ceftazidime ) .
these findings suggest that a. ursingii is an emerging and serious clinical pathogen that is often involved in nosocomial bloodstream infections and associated with use of intravascular catheters .
its natural habitat remains unclear , but so far , it has only been isolated from human clinical sources .
the frequency and clinical role of a. ursingii might have been underestimated because species identification by phenotypic and semiautomated identification methods is unreliable .
for example , vitek 2 has misidentified a. ursingii as bordetella bronchiseptica ( 6,8 ) .
the most recent software version for vitek 2 enabled unambiguous identification of a. ursingii ( h. seifert , pers .
we report a case of community - acquired bloodstream infection and severe sepsis caused by a. ursingii that was probably associated with intravenous drug use in an immunocompetent patient .
this report also highlights the usefulness of matrix - assisted laser desorption / ionization time - of - flight mass spectrometry for identification of acinetobacter spp .
, including a. ursingii , in routine clinical practice and help elucidate the prevalence and clinical role of this emerging pathogen .
 we report a community - acquired bloodstream infection with acinteobacter ursingii in an hiv - negative woman who injected drugs . 
 the infection was successfully treated with meropenem . 
 species identification was performed by using matrix - assisted laser desorption / ionization time - of - flight mass spectrometry . 
 improved identification of acinetobacter spp . by using this method will help identify clinical effects of this underdiagnosed pathogen . 
The Case-Patient
Conclusions