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MD-CASES-D-20-00016

Clinical Case Report

OPEN

Community-acquired Acinetobacter ursingii occult

bacteremia in a healthy 9-month-old girl
A case report
Rei Yoshida, MDa, Masashi Narita, MDb,∗, Teruyuki Hachiman, BSc

Abstract
Introduction: Acinetobacter species are a diverse group of gram-negative, aerobic coccobacilli. Currently, more than 50
Acinetobacter spp. are recognized, but most are not pathogenic to humans. With respect to Acinetobacter ursingii, there have been
only a few reports about bacteremia, especially in immunocompetent patients.
Patient concerns: A 9-month-old girl presented with complex febrile seizure. She had cough and nasal discharge for 2 weeks,
Downloaded from http://journals.lww.com/md-cases by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 02/15/2021

and fever on the day of admission.

Diagnosis: The blood culture was positive for Acinetobacter ursingii.
Intervention: The patient was treated with intravenous cefotaxime for 10 days.
Outcomes: The treatment was successful, and the patient was discharged with no further complications.
Conclusion: Acinetobactor ursingii is a rare causative pathogen in immunocompetent patients and almost all of the cases are due
to nosocomial infection. Acinetobactor ursingii is usually considered as a low virulence strain with a benign clinical course. The fatality
of bacteremia depends on the host immunity. Blood cultures positive for Acinetobactor ursingii should be treated with appropriate
antibiotics to minimize the risk of complications.
Abbreviation: NICU = neonatal intensive care unit.
Keywords: Acinetobacter ursingii, community acquired bacteremia, febrile seizure, occult bacteremia

1. Introduction been recognized as opportunistic microorganisms especially in

The genus Acinetobacter comprises a heterogenous group of non-
motile, aerobic, oxidase negative Gram-negative coccobacilli.[1,2]
They are widespread in natural moist and hospital environments,
and they are associated with skin colonization of hospitalized
patients.[3] Despite their low virulence, they have increasingly
Written informed consent was obtained from the patient’s father for publication
of this case report. This case report has approved by the institutional review
board of Okinawa Chubu Hospital, Okinawa, Japan on February 5th, 2020 (IRB:
2019-65).
The authors have no funding and conflicts of interest to disclose.
Data sharing not applicable to this article as no datasets were generated or
analyzed during the current study.
a
Department of Pediatrics, b Division of Infectious Diseases, c Clinical Laboratory,
Okinawa Chubu Hospital, Okinawa, Japan.
∗
Correspondence: Masashi Narita, Division of ICorrespondence: Masashi Narita,
Division of Infectious Diseases, Department of Medicine, Okinawa Chubu
Hospital, Okinawa, Japan, 281 Miyazato, Uruma, 9042293, Okinawa, Japan
(e-mail: masashi.narita@gmail.com).
Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
How to cite this article: Yoshida R, Narita M, Hachiman T. Community-acquired
Acinetobacter ursingii occult bacteremia in a healthy 9-month-old girl: a case
report. Med Case Rep Study Protoc 2020;1:1(e0011).
Received: 21 September 2020 / Received in final form: 26 September 2020 /
Accepted: 29 September 2020
http://dx.doi.org/10.1097/MD9.0000000000000011
hospitalized and immunocompromised patients.[4] Currently, 57
genomic species of Acinetobacter are recognized.[5] Most human
infections are nosocomial and predominantly caused by A
baumanii and other members of the Acinetobacter baumanii
group, including Acinetobacter nosocomialis, Acinetobacter pittii,
and Acinetobacter seifertii.[1] Novel species such as Acinetobacter
ursingii (A ursingii) and Acinetobacter schindleri are rarely
reported as pathogens.[6–18] In addition, there have been only a
few reports of community-acquired A ursingii bacteremia.[17,18]
We report a case of community-acquired bloodstream infection
with A ursingii in an immunocompetent girl.
2. Case presentation
A 9-month-old girl visited our hospital because of 2 episodes of
seizures that lasted for a few minutes. She had cough and nasal
discharge for 2 weeks, and fever on the day of admission. She had
no history of hospitalization, and there was no developmental
delay observed. Vaccination including pneumococcal conjugate
vaccine, Haemophilus influenzae type b, hepatitis B, the
diphtheria-tetanus-acellular pertussis-inactivated polio virus
vaccine (DPT-IPV), bacille Calmette-Guerin (BCG) were cur-
rently up to date for her. Her cousin has a history of septo-optic
dysplasia and epilepsy. At the time of admission, her heart rate
was 140 to 160 beats per minute, blood pressure was 126/68 mm
Hg, and body temperature was 39.8 °C. On physical examina-
tion, she appeared weak due to the seizure episodes. Her Glasgow
Coma Scale was E3V4M5 without nuchal rigidity. The third

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seizure occurred while placing peripheral intravenous catheter,
and seizure did not stop until we gave her diazepam 0.3 mg/kg
intravenously. After performing skin preparation 3 times using
70% isopropyl alcohol, blood was taken from her left medial
cubital vein and dorsal vein of right hand in 2 bottles for blood
culture.
Blood samples were inoculated in pediatric blood culture vials
(PED PLUS/F BD BACTECTM PLUS Resin Media: BD BACTEC
FX Blood Culture Systems, BD Diagnostics, Tokyo, Japan). Her
head computed tomography scan revealed no abnormalities.
Lumbar puncture was performed followed by administration of
cefotaxime 200 mg/kg/d. Her blood leukocyte count was 12,100/
mL (normal range:3,300–8,600), and C-reactive protein level was
0.43 mg/dL. Her urine test and cerebrospinal fluid test showed no
abnormalities as well as no organism on Gram stains of both
specimens. On the second hospital day her blood culture turned
out positive for Gram-negative coccobacilli in 1 of the 2 aerobic
blood culture bottles. After 24 hours of incubation, colonies were
circular, convex and almost 1 mm in diameter. Non-fermentative,
oxidase negative gram-negative rods were found using triple
sugar iron (TSI) ager. The VITEK 2 system (bioMérieux, Japan)
identified the organism as A ursingii. During this process, Urease
test showed positive against the usual characteristics of A ursingii
and other Acinetobacter species. By way of precaution, the
organism was also identified as A ursingii by matrix-associated
laser desorption/ionization time-of-flight mass spectrometer
(MALDI-TOF MS: Bruker Japan, score 2.434). Antimicrobial
susceptibility testing performed by using broth microdilution
MIC method (Dry Plate “EIKEN”; Eiken Kagaku Co.,Tokyo,
Japan) following the Clinical and Laboratory Standards Institute
(CLSI) guideline (M-100-S-27).
The results showed susceptibility to piperacillin (minimal
inhibitory concentration mg/mL), cefotaxime (4 mg/mL), ceftazi-
dime (2 mg/mL), imipenem (≦0.25 mg/mL), amikacin (<1 mg/mL)
and resistant to aztreonam (8 mg/mL). Cefotaxime was continued
for 10 days on the basis of susceptibility results. Her urine and
cerebrospinal fluid culture showed no growth. There was no
further seizure episodes and complications, and her fever
resolved. She discharged home without further antibiotics.
3. Discussion
The genus Acinetobacter comprises a heterogenous group of non-
motile, strictly aerobic, nonfermenting, nonfastidious, catalase-
positive, oxidase negative bacteria which presents as short,
plump, gram-negative coccobaccili.[1,2] They are widespread in
natural moist and hospital environments and are associated with
skin colonization of hospitalized patients.[15]A ursingii is a novel
species, which was first identified in 2001[6] and in the past few
years there have been several case reports and series of A ursingii
bloodstream infections.[7–14,16–18]A ursingii usually causes
nosocomial infections, however, its ecological niches and
virulence have not been clarified yet.
There have been case reports and series of A ursingii
bacteremia, including 11 cases in adults (Table 1) and 11 cases
in children including the our presented case (Table 2). In the adult
cases, the average age was 51 years old (range: 26-99). The ratio
of male to female showed 3:8, and 2 cases (2/11, 18%) had septic
shock. Four cases (4/11, 36%) had malignancies, and 3 of them
received chemotherapy from central venous catheter.[7–9,14]
Seven cases (7/11, 64%) had central venous catheter, however,
there was no clear descriptions of catheter-related blood stream
infection such as culture positivity of devices or significant time to
positivity of blood cultures between device site and peripheral
vein. One case of cholecystitis[10] were found. The details of
infection focus regarding 2 obstetric cases were unknown.[13]
One case of “community acquired“ had a history of intravenous
drug use the day before admission, and after admission, she
developed septic shock.[18] There was no known fatalities,
though the outcome was unknown in 3 cases.[9] Of note, another
case series of adult A ursingii bacteremia described only 1 fatal
case without giving any details.[15]
In the cases of children, the ages of the onset of bacteremia were
not reported in the half of the cases, but there were 2 reports of

Table 1
Characteristics of adults with A ursingii bacteremia
Age Sex Clinical Susceptibility Duration Clinical
Reference (yr) presentation Background Device ABx R ABx of ABx (d) Outcome Settings
Horii et al[13] 26 F Bacteremia Pregnancy NR CAZ PIPC 14 Survived NI
Holloman et al[16] 27 F Bacteremia Pregnancy, Hyperemesis PICC GEM MEPM→CPFX 10 Survived NI
gravidarum
Horii et al[13] 30 F Bacteremia Pregnancy NR CAZ CFPM 6 Survived NI
Dortet et al[9] 38 F Bacteremia Gastric ADCA, Chemo, CV CFX NR NR NR NI
Ducasse et al[10] 47 F Cholangitis ERCP+EST for none CEZ CTX→Cefuroxime 14 Survived NI
choledocholithiasis
Salzer et al[18] 47 F Bacteremia IVDA none CTRX MEPM 10 Survived CA
Septic shock
Loubinoux et al[7] 63 M Bacteremia Lung ADCA, Chemo CV CAZ IPM+AMK+RFP 14 Survived NI
PR Gómez et al[8] 63 F Bacteremia Gastric ADCA, Chemo CV AMPC/CVA LVFX 15 Survived NI
Dortet et al[9] 67 F Septic shock CPH, MV prosthesis CV CFX NR NR NR NI
∗
Endo et al[14] NR M Bacteremia DM/HTN, CKD/HD, OPCA, CV, ETT, UC MEPM, CFPM CPFX 14 Survived NI
Infected AA TST
Dortet et al[9] 99 M Cholangitis IHD CV CFX NR NR NR NI
AA = aortic aneurysm, ABx = antibiotics, ADCA = adenocarcinoma, AMK = amikacin, AMPC/CVA = amoxicillin/clavulanate, CA = community acquired, CL = choledocholithiasis, CAZ = ceftazidime, CEZ =
cefazolin, CFPM = cefepime, CFX = cefoxitin, Chemo = chemotherapy, CKD = chronic kidney disease, CPFX = ciprofloxacin, CPH = Chronic pulmonary heart, CTRX = ceftriaxone, CTX = cefotaxime, CV = central
venous catheter, DM = diabetes mellitus, ERCP = endoscopic retrograde cholangiopancreatography, EST = endoscopic sphincterotomy, ETT = endotracheal tube, GEM = gentamicin, HD = hemodialysis, HTN =
hypertension, IHD = Ischemic heart disease, IPM = imipenem, IVDA = Intravenous drug abuse, LVFX = levofloxacin, MEPM = meropenem, MV = mitral valve, NI = nosocomial infection, NR = not reported,
OPCA = oropharyngeal carcinoma, PICC = peripherally inserted central catheter, PIPC = piperacillin, R = resistance, RFP = rifampin, SS = Septic shock, TST = thoracostomy tube, UC = ureteral catheter.
∗
IMP-1-producing carbapenem-resistant strain.

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Table 2
Characteristics of children with A ursingii bacteremia
Clinical Gestational Birth Susceptibility Duration of Clinical
Reference Age Sex presentation Background age (wk) weight (g) Device ABx R ABx Abx (d) Outcome Settings
Kilic et al[11] NR M Bacteremia Wet lung 38 3290 CV NR MEPM+AMK 7 Survived NI
Kilic et al[11] NR M NR RDS 27 580 CV, ETT NR MEPM+AMK NR Died NI
Kilic et al[11] NR F NR HIE 37 4300 CV NR MEPM+AMK 7 Survived NI
Kilic et al[11] NR F Bacteremia RDS 32 1720 CV NR MEPM+AMK 7 Survived NI
Kilic et al[11] NR M DIC RDS, IVH 25 700 CV NR MEPM+AMK NR Died NI
Máder et al[12] 7D F NEC RDS 31 1130 ETT None PIPC/TAZ+VCM NR Survived NI
Máder et al[12] 25D M NEC NR 36 900 CV None CAZ+AMK 21 Survived NI
Máder et al[12] 58D F NEC CLD 29 800 ETT None CPFX+CLDM 3 Died NI
Complete atelectasia
Yakut et al[17] 2M M Aspiration PNA TE fistula NR NR NR None ABPC/SBT NR Survived NI
Yakut et al[17] 1Y M Diarrhea / vomiting GERD NR NR none None ABPC/SBT NR Survived CA
Present case 9M F Febrile seizure none 40 3790 none AZT CTX 10 Survived CA
ABPC/SBT = ampicillin/sulbactam, ABx = antibiotics, AMK = amikacin, AZT = aztreonam, BW = birth weight, CA = community acquired, CATL = Complete atelectasia, CAZ = ceftazidime, CLD = Chronic Lung
Disease, CLDM = clindamycin, CPFX = ciprofloxacin, CV = central venous catheter, D = days, DIC = disseminated intravascular coagulation, ETT = endotracheal tube, GA = gestational age, GERD =
gastroesophageal reflux disease, HIE = Hypoxic-ischemic encephalopathy, IVH = intraventricular hemorrhage, MEPM = meropenem, NEC = Necrotizing enterocolitis, NI = nosocomial infection, NR = not reported,
PIPC/TAZ = piperacillin/tazobactam, PNA = pneumonia, R = resistance, RDS = respiratory distress syndrome, TE fistula = Tracheoesophageal fistula, VCM = vancomycin.

outbreak of A ursingii bacteremia in the neonatal intensive care
unit (NICU),[11,12] and consequently 8 (8/11, 73%) of the cases
were infants in the NICU. In addition, 6 (6/8, 75%) of the NICU
cases were premature babies, and 3 of them died; all were born at
less than 30 weeks with a birth weight less than 800 g.[11,12] These
3 babies had complications of respiratory failure, disseminated
intravascular coagulation, and necrotizing enterocolitis respec-
tively.[11,12] The ratio of male to female showed 6:5 including the
presented case. All of the NICU cases had central venous
catheters or were placed on mechanical ventilation.[11,12] These
findings suggest that A urisingii is an emerging pathogen that may
cause nosocomial bacteremia and be associated with the use of
intravascular catheters and malignancies, otherwise the focus of
infection is obscure. In addition, patients with A ursingii
bacteremia usually have a good clinical course except premature
neonates. As reported in previous studies,[11,12,18] premature
babies are immune-compromised, have dermal fragility and
devices placed for total parenteral nutrition can be risk factors for
A ursingii bacteremia. It is difficult to discern the cause of
mortality in premature babies with A.ursingii bacteremia with
less than 30 weeks of gestational age because of their complex co-
morbidities.
The susceptibility methods for isolated A ursingii were not
standardized in the previous case studies and series, using agar
dilution method, disk diffusion test, Epsilometer test or other
commercial-based automated antimicrobial susceptibility testing
system.[7–14,16,17] The susceptibilities to antibiotics for A ursingii
bacteremia were categorized into 3 types: susceptible to all class
of antibiotics, resistant to cephalosporines and multi-drug
resistant including broad spectrum antibiotics such as carbape-
nem. In adult cases (Table 1), 9 cases (9/11, 82%) were resistant
to cephalosporins, including a case with imipenemase-1 produc-
ing carbapenem resistant strain.[14] In the cases of children, the
susceptibilities were reported in over the half of cases (6/11, 55%)
including the present case. No multi-drug resistant strains were
reported despite the use of broad spectrum antibiotics for the
NICU outbreak cases.[11] Regarding diversity of antimicrobial
use in adults and pediatrics cases, initial treatment was started
with carbapenems in 36% (8/22) of the cases, fluoroquinolones in
14% (3/22) of the cases and 41% (9/22) of the cases used
combined antibiotics. The duration of the antibiotics were 7 to 21
days in previous reports.[7–14,16–18] There was no case of invasive,
continuous bloodstream infection such as endocarditis, deep-
seated abscess or osteomyelitis which needed a longer duration of
treatment. A case series revealed that about half of the cases of A.
ursingii bacteremia which received inappropriate antibiotics
within 48 hours after the onset of bacteremia had significantly
lower mortality rates compared to A.baumannii.[15]A.ursingii
may present with low virulence, however the prognosis may not
be dependent on antibiotics alone, but also on the patient medical
status, usage of intravenous devices and the immune status. It
would be appropriate to continue 7 to 10 days of broad spectrum
antibiotics, then narrow down when antimicrobial susceptibili-
ties are reported.
This 9-month-old girl who presented with febrile seizures was
found to have community-acquired A ursingii occult bacteremia.
Occult bacteremia is defined as a positive blood culture for a
pathogen in a well-appearing child without an obvious source of
infection.[19] In children vaccinated against Streptococcus
pneumoniae and Haemophilus influenzae, the prevalence of
occult bacteremia is less than 1% in those who are febrile. A high
rate of febrile seizures, especially complex seizures, has been
noted in Japanese children with occult bacteremia.[20] In
addition, febrile seizures are at similar risk for occult bacteremia
as those with fever alone, and the incidence of bacteremia may
decrease in the post-pneumococcal conjugate vaccine era.[21] The
presented case had complex febrile seizure with occult A ursingii
bacteremia without previous history of seizure disorder followed
by benign clinical course.
To our knowledge, this is the first case report of community-
acquired A ursingii occult bacteremia in a healthy child. The
ecology of most Acinetobacter species is still poorly under-
stood.[2] These strains can survive in the environment, and have
been found on equipment, and on surfaces and materials[22] close
to colonized patients. The skin and mucosae of patients can be
colonized, and that colonization may last for days to weeks.[23,24]
Community acquired infections with Acinetobacter species have
been reported in tropical and subtropical area.[25] Although there

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was a community acquired pediatric case of A ursingii bacteremia
with gastroesophageal reflex disease,[17] there has been no case
reports without underlying or previous illness. The presented case
with fever followed by seizures was investigated and treated
aggressively as a septic, medical emergency despite its obscure
focus of infection. Regarding the diagnosis of a blood stream
infection, a blood culture positive for A ursingii is difficult to
evaluate and it is difficult to differentiate true infection from
contamination or colonization. In our institute, the house staff
obtain blood cultures using 70% isopropyl alcohol for skin
preparation to avoid contamination.[26] Once Gram-negative
coccobacilli are detected by blood culture, it should be treated as
a true infection regardless whether it is nosocomial or community
acquired.
Community acquired occult bacteremia by Acinetobacter
species can be easily overlooked as it is usually a lower virulence
strain with a benign clinical course, though fatalities can occur in
immunocompromised patients with certain risk factors. Blood
cultures positive for A ursingii should be immediately treated
with appropriate antibiotics to minimize the risk for complica-
tions.
Acknowledgment
We respectfully thank Dr Saori Kinjo for taking care of this
patient, and Dr. Byron Izuka for judicious elaborating this article.
Author contributions
Rei Yoshida: Conceptualization, Writing-original draft, Investi-
gation. Masashi Narita: Investigation, Methodology, Project
administration, Supervision, Writing- review & editing. Teruyuki
Hachiman: Data curation.
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