Kocuria kristinae is a rare microbe causing infection in children. The genus Kocuria was previously classified in the Micrococcaceae family. It has been regrouped as Kocuria recently according to chemotaxonomic and phylogenetic studies.[1] Five out of 17 species of Kocuria were reportedly causing disease in humans, and K. kristinae is one of them.[2] It is an aerobe, which is catalase(+), coagulase(-), gram-positive coccus. It is a part of the human skin and oral flora and can cause bloodstream infections in immunocompromised and in patients with indwelling catheters.[3] The documented reports on Kocuria kristinae infection were very few and it is rarely reported in pediatric age group. We, here, summarize a case of Kocuria kristinae sepsis as a sign of possibility of disease from an uncommon organism and to steer up the proper antibiotic selection based on the Review of the literature[Table 1].
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Table 1: Pediatric case details of studies included in this review
An 11-year-old male child who is a known case of Ewing's sarcoma in ethmoid sinus diagnosed at 10 years of age and had undergone 12 cycles of chemotherapy with Inj Vincristine, Inj Doxorubicin and Inj Cyclophosphamide, alternating with Inj Ifosfamide and Etoposide, according to EURO EWING 2012 protocol. Following completion of 12 cycles of chemotherapy, the child presented to casualty with the complaint of oral ulcers, throat pain, fever and pain, burning sensation during swallowing and decreased oral intake for two days. At admission, the child was pale, tired, febrile with a temperature of 102°F (38.9°C), and was tachycardic. The chemotherapy was being delivered via port-a-cath, which is an indwelling central venous catheter inserted soon after the diagnosis. Oral examination revealed curdy-white, non-scrapable deposits on the dorsum of the tongue with grade 4 mucositis. Blood samples were taken for investigations, and the child was started on empirical intravenous antibiotics – Cefoperazone-sulbactam and ciprofloxacin (for suspected febrile neutropenia), Intravenous fluids, and supportive oral care. Blood investigations showed anaemia (Hb – 8.5 gm/dl), leucopenia (Total White cell counts – 100 cells/cumm with absolute neutrophils 2 and lymphocytes 98 in number), elevated C-reactive protein (323.40 mg/l).
Blood culture was incubated in the BACTEC system, which showed growth after 11 hours. It was gram-positive cocci in clusters and tetrads irregularly. The sample was inoculated on chocolate, and blood agar showed tiny, pale, non-hemolytic, smooth, convex colonies. This organism was non-motile, catalase-positive, and coagulase-negative. Vitek2 compact automated identification system confirmed the growth as Kocuria kristinae. The modified Kirby-Bauer disc diffusion method was used to test drug sensitivity, and it was sensitive to Ampicillin, Ciprofloxacin, Ofloxacin, Clindamycin, Vancomycin, Teicoplanin, Piperacillin-Tazobactam and Ampicillin-Tazobactam.
Following the growth of Kocuria, Cefoperazone-sulbactam was discontinued, and intravenous Vancomycin 20 mg/kg/dose every 6 hours commenced and continued ciprofloxacin. He was afebrile by five days of treatment. Gradually mucositis resolved and started on the oral diet. The repeat blood investigations showed normal blood counts and repeat blood culture was negative done on the 5th day of antibiotics. The Inj Vancomycin was given for 7 days and he was discharged on oral Ciprofloxacin for 7 days with oral care.
An immunocompromised state due to chemotherapy leads to the risk of infections by organisms that are not considered primary pathogens. In these circumstances, Kocuria kristinae emerged as a new pathogen causing infections in immunocompromised patients and patients with a breach of oral or gut mucosal integrity. After discovering this organism, cases have been reported that this organism was found to be responsible for catheter-related infections in patients who were immunocompromised or on total parenteral nutrition. On literature review, so far, we found 11 case reports in which 11 pediatric patients and 8 neonatal patients were discussed. Most of the cases were catheter-related bloodstream infections. In contrast, the organism has also been detected in synovial fluid in two instances with septic arthritis,[4,5] in a throat swab in one case,[6] and pus from umbilicus in one case.[7] One child with leukaemia was reported to have Kocuria kristinae infection.[8] In all the cases organism was sensitive to Penicillin, cephalosporins, quinolones and glycopeptides except one case which reported multidrug-resistant Kocuria growth[7] (Resistant to Penicillin, Oxacillin and Ciprofloxacin but susceptible to glycopeptides and linezolid). All the patients were treated with a combination of antibiotics with intravenous Vancomycin except for two cases, who were reated with IV Levofloxacin,[6] and the other was with Cefalothin.[5] So far, no mortality has been reported in pediatric cases due to Kocuria kristinae sepsis.
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