Native Valve Endocarditis in a Dialysis Patient by Achromobacter xylosxidans, A Rare Pathogen.

Sir,

A 54-year-old male presented with generalized weakness, body ache, and fever for 2 weeks. No history of pharyngitis, dyspnea, chest pain, and bowel/bladder complaints. He was on hemodialysis for end-stage renal disease secondary to hypertension. T, 102.3 F; heart rate, 115/min; respiratory rate, 12/min; and blood pressure, 137/80 mmHg. Grade II/VI pansystolic murmur at mitral region, radiating to the left axilla was noticed. Two-dimensional Echocardiogram showed aortic and mitral vegetations with mitral regurgitation, confirmed by transesophageal echocardiography. Blood culture isolated Achromobacter xylosoxidans sensitive to piperacillin-tazobactam, ceftazidime and resistant to ampicillin, gentamicin, imipenem, and aztreonam. Accordingly, piperacillin-tazobactam was used but repeat blood cultures at 48 h grew the same pathogen. Despite 2 weeks of antibiotics, bacteremia persisted without resolution of vegetations. Cardiovascular surgery was consulted for prosthetic valve replacement. A. xylosoxidans has been cultured from indwelling catheters, endotracheal, and shunt tubings.[1] Several case reports show transmission from contaminated water and the unhygienic hands of healthcare workers.[2] It also causes bacteremia in dialysis-dependent patients.[3] Our patient was on hemodialysis and possibly infection occurred consequent to cross-contamination due to poor hygienic practices. The characteristic antimicrobial pattern of A. xylosoxidans includes resistance to aminoglycosides, narrow-spectrum penicillins, cephalosporins, and aztreonam.[45] Eradicating this bacteria is extremely difficult, especially in endocarditis where the resistant microcolonies are enmeshed with fibrin and platelet strands. In retrospect, we believe that we could have added gentamicin as some in vitro studies suggest gentamicin with beta-lactams may be synergistic, despite a high level of resistance to aminoglycosides.[3]

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