Persistent infection with metallo-beta-lactamase and extended spectrum β-lactamase producer Morganella morganii in a patient with urinary tract infection after kidney transplantation.

Organ transplant recipients under immunosuppressive therapy have a highly increased risk of acquiring unusual opportunistic infections. Diagnosis of the etiology of infection may be difficult in clinical manifestations, which need further histological and biological investigations. Here in we report, for the 1(st) time in the Iran, a Morganella morganii isolate harboring blaVIM, blaCTX-M, and blaSHV genes after kidney transplantation with persistent urinary infections.

INTRODUCTION

Morganella morganii is a Gram-negative facultative anaerobe that is commonly found in the environment and in the intestinal tracts of humans as normal flora and belongs to the family of Enterobacteriaceae. Despite its wide distribution, it has been considered a rare cause of human infections.[1] M. morganii is naturally resistant to tetracyclines, tigecycline, polymyxins, and nitrofurantoin.[2] Moreover, by chromosomally encoded AmpC beta-lactamases and possesses the ability to develop resistance on exposure to broad-spectrum cephalosporins.[3]

Urinary tract infection (UTI) after kidney transplantation is a common cause of patient morbidity and represents a potential risk factor for poorer graft and recipient outcome.[4] Several species of bacteria that cause UTI in kidney transplant patients have been isolated from Enterobacteriaceae family have been reported as the main isolates in UTI among transplant patients.[5] However, there is an emerging evidence suggesting that M. morganii may become an important opportunistic pathogen in several infections but UTI is probably the most common infection caused by M. morganii in humans and it was first described in the late 1930s as a pathogen of urinary infections.[67] Patients with kidney recipient are at high risk of UTI. Here, we describe a rare case of UTI caused by M. morganii in a patient with a kidney transplant.

CASE REPORT

A 53-year-old male with a history of received kidney in early 2006 and after 5 years he had chronic renal failure. He had been on hemodialysis from 2010 until 2014 years and in 2014, the patient received the second kidney transplant. Before kidney transplant surgery, the initial immunosuppressive therapy was with antithymocyte globulin (ATG) and this person received ganciclovir. Due to leak of the site of graft, duration of hospitalization was extended to 24 day. His posttransplantation course was uneventful until he presented to us with the above-mentioned complaints. One month after, the placement chest radiography was normal but computed tomography of abdomen and pelvis showed in the upper left kidney stone and calcification around double-J stent (DJS). Three times attempted for removed the DJS and in the 2nd time, the patient received ATG that reduced level of red blood cell in this person. After removed the DJS, three times consecutively (7, 13, and 24 days after of removed DJS), the urine cultures revealed M. morganii and these isolated were susceptible to amikacin and trimethoprim - sulfamethoxazole only and resistant to cefotaxime, cefotaxime, cefazolin, ceftizoxime, gentamicin, imipenem, nitrofurantoin by disc diffusion method, but testing of susceptibility to colistin and ciprofloxacin was not done. Patient received trimethoprim-sulfamethoxazole 160 mg-800 mg (1 double-strength tablet) orally every 12 h for 14 days and was treated which a follow-up urine culture on 1 week after discontinuation of treatment was negative. Unfortunately, 28 days after discontinuation of treatment patient presented with symptoms of dysuria and urine culture after 48 h, again the isolated was M. morganii and isolate was resistant to trimethoprim - sulfamethoxazole, cefotaxime, cefotaxime, cefazolin, ceftizoxime, gentamicin, imipenem, nitrofurantoin, and only susceptible to ciprofloxacin and colistin that was started with a dose of ciprofloxacin 500 mg/day and was continued for 7 days and a follow-up urine culture 9 days later no growth of M. morganii.

A genetic analysis using enterobacterial repetitive intergenic consensus polymerase chain reaction (PCR) revealed that all four M. morganii isolated from urine culture were identical and M. morganii in this patient was stable [Figure 1] that initial treatment with trimethoprim-sulfamethoxazole was ineffective, but the patient UTI was successfully treated by ciprofloxacin. Detection of β-lactamase resistance genes (blaCTX-M, blaSHV, blaTEM, blaOXA, and blaCMY) and carbapenemases such as the blaSIM, blaSPM, blaGIM, blaVIM, blaKPC, and blaNDM was determined using PCR and sequencing was performed using consensus primers and amplification conditions as described[89] that M. morganii was positive for blaVIM, blaCTX-M, and blaSHV but was negative for other β-lactamase and carbapenemases genes.

Figure 1

Enterobacterial repetitive intergenic consensus polymerase chain reaction pattern of Morganella morganii in four clinical isolates with 100% identity

DISCUSSION

M. morganii has recently become an important opportunistic pathogen that being frequently in immunocompromised individuals and also because of various invasive procedures.[10] Majority of M. morganii infections are related to postoperative wound and UTI and several study showed.

M. morganii is known to cause opportunistic infection, especially in the immune-compromised host.[11] In this case, the patients were immunocompromised due to immunosuppressive therapy that had a highly increased risk of acquiring unusual opportunistic infections. This patient had UTI with blaVIM and blaCTX-M and blaSHV-producing M. morganii that was permanent for a long time.

Carbapenemases, such VIM, are the most powerful β-lactamase, being able to hydrolyze nearly all β-lactamase.[12] VIM-producing Enterobacteriaceae have been isolated in several countries with high prevalence noted in the Mediterranean and Middle East region.[1314] Seija et al. in a study reported a case of blood and urine cultures grew an M. morganii isolate with harboring NDM-1 and qnrD1 that the patient was treated successfully with fosfomycin and double doses of meropenem.[15] In Greece, the first report chromosomal location of blaVIM-1 was confirmed after hybridization of the chromosomal band with the blaVIM-1 probe.[16] To our knowledge, this is the first clinical report of a carbapenem-resistant M. morganii case in immunocompromised kidney transplant in Iran. It is probable that the blaVIM carbapenemase has arisen within our hospitals where the spread of this strain and its resistance elements are of great concern for public health. Therefore, early detection, characterization, and surveillance of these resistance elements are extremely important in future for prevention and treatment.

Financial support and sponsorship

We thank staves of Microbiology Laboratory in Imam Reza Educational Hospital and Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran for their supports and collaboration. The present study was done in support of Drug Applied Research Center.

Conflicts of interest

There are no conflicts of interest.