Several cases of infections have been reported in immunocompromised patients since the 1980s and, more recently, in immunocompetent patients with certain risk factors. In spite of reports from Japan, Europe and the USA, there are currently no guidelines for identification, susceptibility testing or treatment of these infections. This is particularly challenging for rural clinics, which are already limited by available diagnostic modalities and therapeutic approaches. We present a case of infection in a rural clinic that exposes these challenges and provides an argument for the establishment of guidelines.

Case presentation:

A 64-year-old immunocompetent bisexual male with a history of recent orthopaedic surgery presented to our rural clinic with left lower leg cellulitis, bacteraemia, fever and chills. The causative organism could not be definitively identified in the clinic. Cultures were sent to the state laboratory for identification. Empiric treatment with cephalexin and ceftriaxone showed no improvement in cellulitis. The patient was transferred to a tertiary-care facility where vancomycin and ciproflxacin were moderately successful. Several days later, cultures identified and the patient was treated with carbapenem and doxycycline to complete resolution of symptoms.


Although infections by are rare, they are not uncommon. Identification by culture may not always be definitive, so a high degree of suspicion and access to other diagnostic modalities is essential. Empiric treatment with certain antibiotics is usually successful and may be an acceptable therapeutic approach considering the lack of guidelines.


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