Abscesses represent a prevalent clinical presentation stemming from bacterial infections, necessitating prompt surgical intervention and tailored antimicrobial therapy, as untreated abscesses, especially perianal abscesses, can lead to complications such as fistula formation and, rarely, sepsis. However, with further progression, the risk of developing from an encapsulated localized process [1] to non-encapsulated phlegmons increase the likelihood of systemic complications, such as sepsis, and the risk of fatal outcomes [2]. This underscores the importance of expeditiously identifying and characterizing the bacterial pathogen along with its susceptibility profile. However, the specific identification of uncommon or atypical pathogens poses challenges due to the need for specialized laboratory techniques and comprehensive databases for their discernment, compounded by limited clinical familiarity with such pathogens. A considerable proportion of abscesses are attributed to Staphylococcus aureus [3], thus prompting the selection of empirical therapy tailored to this bacterial spectrum. We present a case of abscess formation correlated with the isolation of Butyricimonas faecihominis exhibiting uncommon antibiotic resistance in blood cultures. To the best of our knowledge, this is the first described case of Butyricimonas faecihominis causing a bloodstream infection in which antibiotic resistance has been detected.
In January 2024, a 50-year-old man with a history of cocaine abuse and bilateral hip prostheses was admitted to the anaesthetic intensive care unit of the University Hospital Cologne, Cologne, Germany, with a seven-day history of pain in the perianal region progressing into general lower abdominal and testicular pain. Apart from being an active drug user, no other risk factors for abscess development, such as obesity, diabetes mellitus, or trauma to the perianal region, were present. Initial imaging revealed a perianal abscess extending into the ischioanal fossa with scrotal involvement. The patient deteriorated rapidly, developing septic shock with multi-organ failure, necessitating intensive care unit (ICU) admission. Multi-organ failure presented with prerenal kidney failure with severely elevated retention parameters (Creatinine 6.3 mg/dL [reference R: 0.50–1.10 mg/dL], Potassium 6.1mmol/L [R: 3.6–4.8 mmol/L]), markedly elevated inflammatory markers (CRP 526 mg/L [R: 9/L [R: 4.40–11.30 × 109/L]), elevated transaminases (ASAT 117 U/L [R:
After admission to the ICU two sets of peripheral blood cultures were collected. Surgical drainage of the abscess was promptly performed. A protective tranversostoma to safeguard the perianal wound was established. Piperacillin-tazobactam was selected as empirical antibiotic therapy. Retroperitoneal abscesses diagnosed in subsequent CT-Scans followed by interventions and surgery. Vacuum-assisted closure (VAC) therapy was initiated for the management of the wound. Upon admittance, two sets of blood cultures, comprising of one aerobic and anaerobic bottle each, were taken. Within just three days, we were able to detect an unusual growth of Butyricimonas spp. that was resistant to penicillin and piperacillin-tazobactam. The microbiologists reacted immediately and informed the attending physicians directly about these significant results and an interdisciplinary assessment of the patient’s clinical situation was carried out. A joint decision was made to switch the anti-infective therapy from piperacillin-tazobactam to meropenem. The patient quickly benefited from the change in antibiotic therapy. Catecholamine support was swiftly tapered and discontinued, alongside a decrease in fluid requirement. Within 24 h of initiating therapy, both inflammatory and renal function parameters exhibited a significant reduction, facilitating the patient’s transfer from the ICU to the general ward. Two further sets of blood cultures taken, remained sterile. Procalcitonin (0.50 µg/L [R:
Blood cultures were automated incubated with the Bactec FX Blood Culture system (Beckton Dickinson, Heidelberg, Germany). After 47 h of incubation one anaerobic bottle became positive, while the other bottles of the initially taken blood cultures – including the second anaerobic bottle – remained sterile. Fine, Gram-negative rods were visible in the subsequently performed Gram stain (Fig. 1). All other blood culture bottles remained negative throughout the incubation period of six days.
Material from the positive bottle was then streaked on Sheep Blood agar, MacConkey agar, Chocolate agar, Columbia agar, as well as on the two anaerobic agar plates – Schaedler and Schaedler KV agar. While no growth occurred on the aerobic plates, colonies were visible on both anaerobic agar after another incubation of two days (Fig. 2).
Growth of Butyricimonas faecihominis on both anaerobic plates – Schaedler (left) and Schaedler KV (right)
The growing organism could be identified as Butyricimonas virosa via Matrix-Assisted Laser Desorption/Ionization Time-of-Flight (MALDI-ToF). However, later genome sequencing revealed it to be Butyricimonas faecihominis. So far, Butyricimonas virosa, albeit rarely, has been reported as the main species of Butyricimonas spp. to cause blood stream infections [4]. Yet, our findings suggest that the two species might be prone to be misidentified by mass spectroscopy.
Antimicrobial susceptibility testing was performed in accordance with the standards provided by the European Committee of Antimicrobial Susceptibility Testing (EUCAST). Unexpectedly, the strain was resistant to both, Penicillin (MIC: > 256 mg/L) and piperacillin-tazobactam (MIC: 128 mg/L) (Fig. 3). Therefore, antimicrobial therapy was adapted from piperacillin-tazobactam to meropenem.
Etest (Epsilometer tests) of penicillin, piperacillin-tazobactam, meropenem, clindamycin, metronidazole (left to right) performed for Butyricimonas faecihominis
In addition, swabs and biopsies of the abscess were sent for further microbiological investigation. Although anaerobes were cultivated in several samples, Butyricimonas faecihominis could not be identified in either of them. This is most likely due to two main reasons. First of all, in several of the samples a high number of anaerobes were found, rendering it impossible to obtain a pure culture of each of them. Secondly, anaerobic bacteria often are highly vulnerable to higher oxygen levels. Hence, not all strains might have remained viable during the transport to the laboratory. Still, the extended perianal abscess has to be considered as the origin of the described bacteremia.
This also emphasizes the importance of rapid transport of critical patient samples to the microbiological laboratory in order to ensure optimum cultural diagnostics.
