title: Infection of a ventriculoatrial shunt with phenotypically variable Staphylococcus epidermidis masquerading as polymicrobial bacteremia due to various coagulase-negative Staphylococci and Kocuria varians.
abstract: The diagnosis of bloodstream infection with coagulase-negative staphylococci is frequently based on the isolation of the same organism from more than one blood culture. Phenotypic variation is a common characteristic of pathogenic strains of Staphylococcus epidermidis which may affect species identification by the microbiology laboratory. We describe a patient with a new onset of nephritis and gram-positive bacteremia. Gram-positive cocci grew in multiple blood cultures and were identified by the Vitek 2 system as Kocuria varians, Staphylococcus hyicus, and S. epidermidis. Bacterial isolates grew on blood agar and Congo red agar plates as two distinct morphotypes and exhibited phenotypic variation. Neither morphotype could be identified by the API-Staph assay. Cellular fatty acid analysis identified one of the morphotypes as S. epidermidis but could not identify the other morphotype. All isolates were found to be identical by pulsed-field gel electrophoresis, and both colonial morphotypes were identified as S. epidermidis by 16S ribosomal gene sequencing. Phenotypic variation of S. epidermidis may affect identification to the species level by phenotype-based identification systems. Caution should be exercised when differentiating between true infection and contamination based on strain identification.
authors.affiliation: Infectious Diseases Unit, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
authors.forename: Ronen
authors.initials: R
authors.lastname: Ben-Ami
authors.forename: Shiri
authors.initials: S
authors.lastname: Navon-Venezia
authors.forename: David
authors.initials: D
authors.lastname: Schwartz
authors.forename: Yehuda
authors.initials: Y
authors.lastname: Carmeli
mesh_terms: D000192:Actinomycetales / Q000145:classification / Q000302:isolation & purification; D000193:Actinomycetales Infections / Q000175:diagnosis / Q000382:microbiology; D016470:Bacteremia / Q000175:diagnosis* / Q000382:microbiology; D015373:Bacterial Typing Techniques; D002557:Cerebrospinal Fluid Shunts; D003030:Coagulase / Q000378:metabolism; D016172:DNA Fingerprinting; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D008875:Middle Aged; D010641:Phenotype; D013203:Staphylococcal Infections / Q000175:diagnosis* / Q000382:microbiology; D013210:Staphylococcus / Q000145:classification / Q000201:enzymology / Q000302:isolation & purification; D013212:Staphylococcus epidermidis / Q000145:classification* / Q000302:isolation & purification*
chemical_list: D003030:Coagulase