Cedecea lapagei An Extremely Rare Uropathogen: A Case Report and Review of the Literature

Background: Gram-negative enterobacteria are the most common cause of urinary tract infections. Cedecea is a new separate genus in the family enterobacteriaceae, and it is a very rare pathogen that was primarily found in the respiratory tract. Cedecea lapagei is a very rare pathogen of urinary tract infections. To the best of our knowledge, this is the rst case report in the world reported in English literature. Case presentation: A 55 years old man with chronic renal failure, poorly controlled diabetes mellitus, and hypertension presented with acute exacerbations of renal failure and irritative voiding symptoms. After stabilization and empirical antibiotic therapy with Ceftriaxone, the patient’s condition was not improved and deteriorated progressively. After the request of urine culture, the culture was isolated, an extremely rare uropathogen recently recognized by the Centers for Disease Control and Prevention (CDC); the Cedecea lapagei. Cedecea lapagei identication had been done using Eosin methylene blue agar (EMB). Gram-negative lipase positive bacteria with bacillus in shape, motile in nature that is non-spore-forming, and non-encapsulated enterobacteria with the nal result of >100,000 colony-forming units per ml of Cedecea lapagei were isolated. Mueller-Hinton agar had been used to perform antimicrobial sensitivity and resistance. The pathogen was extensively resistant to the extended-spectrum beta-lactamases antibiotics and extended-spectrum beta-lactam inhibitors while carbapenems, uoroquinolones, aminoglycosides, and Trimethoprim-sulfamethoxazole showed a higher sensitivity rate. Conclusion: The treatment of Cedecea lapagei infections represents a challenging issue due to its multi-drug resistant and extensive drug resistance patterns to a variety of antimicrobial classes, such as extended-spectrum beta-lactamases, cephalosporins, and beta-lactam inhibitors. Antimicrobial treatment should be aligned with the culture ndings once available.


Introduction
Urinary tract infections (UTIs) are recognized to be the most common community and hospital-acquired bacterial infections. Chronic renal failure patients with uncontrolled diabetes mellitus are vulnerable to recurrent urinary tract infections and urosepsis caused by the usual and rare opportunistic uropathogens.
Gram-negative enterobacteria are the most common cause of urinary tract infections. Cedecea is a new separate genus in the family enterobacteriaceae, and it is a very rare pathogen that was primarily found in the respiratory tract. Its name is an abbreviation for the Centers for Disease Control (CDC) Laboratories in 1981, where the initial group isolates "Enteric Group 15". They are Gram-negative, lipase positive and non-spore-forming bacilli. Cedecea genus was isolated from human clinical specimens including sputum, blood, Ulcer, and urine (1,2). Cedecea lapagei a rare bacterial infection in humans and has an emerging antimicrobial resistance. First case of Cedecea lapagei was reported in 2006 and most of the Cedecea species have been isolated from the respiratory tract. A literature search revealed no reports of prior isolation of Cedecea lapagei from urine culture and this is the rst case of Cedecea lapagei as an uropathogen in the world reported in English literature. We report an extremely rare case of clinically signi cant urinary tract infection caused by Cedecea lapagei in a 55 years old dialysis patient with chronic renal failure and 2 years follow up for the patient did not show any recurrence of the isolate.

Case Report
A 55 years old man with chronic renal failure, uncontrolled diabetes mellitus, and hypertension presented with acute exacerbations of renal failure and irritative voiding symptoms. Laboratory investigations revealed creatinine (13.43mg/dl), urea (177mg/dl), low hemoglobin (6.9mg/dl), marked leukocytosis (WBC: 11,15), high blood sugar (436mg/dl), hyperkalemia, and metabolic acidosis. Ultrasound of the abdomen showed grade 2 parenchymal disease, and other organs were unremarkable. The patient was admitted to the intensive care unit and underwent several dialysis occasions, blood transfusions, prompt blood sugar, and blood pressure control, and adequate uid resuscitation. Empirical antibiotic therapy with ceftriaxone was initiated, but unfortunately, the patient's condition was not improved and deteriorated progressively day by day according to the general condition of the patient and laboratory investigations. A clean catch midstream urine sample was obtained from the patient and the urine culture was isolated, an extremely rare uropathogen recently recognized by the Centers for Disease Controland Prevention (CDC); the Cedecea lapagei. Cedecea lapagei identi cation had been done using eosin methylene blue agar (EMB). Gram-negative lipase positive bacteria with bacillus in shape, motile in nature that is non-spore-forming, and non-encapsulated enterobacteria with the nal result of >100,000 colonyforming units per ml of Cedecea lapagei were isolated. Mueller-Hinton agar had been used to perform antimicrobial sensitivity and resistance.Antimicrobial sensitivity and resistance pattern of the pathogens was performed under standard protocols. The antibiotic susceptibility of uropathogens was studied against imipenem 10mcg, ertapenem 10mcg, amikacin 30mcg, cefazolin 30ug, ceftazidime 30ug, trimethoprim/sulfamethoxazole 1.25/23.75 mcg, cipro oxacin 5mcg. The pathogen was extensively resistant to the extended-spectrum beta-lactamases antibiotics, and extended-spectrum beta-lactam inhibitors (Cephalosporins including ceftriaxone, cephazolin, Ceftazidime, Ce xime, and ampicillin and amoxicillin-clavulanic acid). The pathogen showed a higher sensitivity pattern against Carbapenems (imipenem and ertapenem), Fluoroquinolones (cipro oxacin, levo oxacin), aminoglycosides (amikacin and gentamicin), and Trimethoprim-sulfamethoxazole. Levo oxacin 500mg acon once daily was initiated after culture results became available. Table 1 demonstrates the antimicrobial pro le of the microorganism. The condition of the patient was improved, and the return of urine culture did not show any bacterial growth. The patient was discharged home with routine dialysis, levo oxacin tab, antihypertensive medications, and diabetic medications. The patient did not show any recurrence with this unusual uropathogen for two years following up with routine dialysis. Discussion E.coli is the most common cause of bacterial urinary tract infections in both community and hospitalacquired UTIs and both gender and age groups followed by Klebsiella pneumonia. Furthermore, rare opportunistic microorganisms included Enterobacter cloacae, Enterococcus faecium, Streptococcus species, Citrobacter freundii, Staphylococcus haemolyticus, Candida, and other rare pathogens are prevalent in immunocompromised patients as the current case demonstrated an immunocompromised patient with a very unusual case of urinary tract infection caused by Cedecea lapagei (3). In the medical literature, there are very few cases caused by different species of the Cedecea genus such as pneumonia, soft tissue infections, and sepsis. Perkins SR and colleagues reported that most of the Cedecea species have been isolated from the respiratory tract, and Cedecea davisae were the most commonly reported species caused by all of the cases (4,5). No previous reports of prior isolation of Cedecea lapagei from urine culture in the literature and this case of Cedecea lapagei as an uropathogen is documented in the world for the rst time. This case report described an extremely rare case of clinically signi cant urinary tract infections caused by Cedecea lapagei. The treatment of Cedecea species infections represents a challenging issue due to its multi-drug resistant and extensive drug resistance patterns to a variety of antimicrobial antibiotics, such as extended-spectrum beta-lactamases, cephalosporins, and beta-lactam inhibitors as the present case have been noticed (6). The patient responded well with levo oxacin after drug adjustment due to the preexisting azotemia. The antimicrobial choices of such chronic renal failure patients are debating and should be adjusted according to the renal function, the e cacy of the drug, and minimize the worsening of preexisting antimicrobial resistance.

Conclusıon
The current case recognized that Cedecea lapagei were sensitive to a variety of antimicrobial classes including carbapenems but antimicrobial sensitivity and resistance pattern differs from case to case. Antimicrobial treatment should be aligned with the culture ndings once available. Full attention should be given in immunocompromised patients not responding to the initial empirical therapy.

Declarations
Disclosure of potential con icts of interest The authors declare no con ict of interest for the study.

Funding resources
This study received no nancial support.
Ethics committee and informed consent to publish case reports are not required for any ethical approval in our institution, and the patient was received a written informed consent.
Availability of supporting data not applicable.