Can J Infect Dis Med Microbiol Vol 26 No 6 November/December 2015 319
AA Hashi, JA Delport, S Elsayed, MS Silverman. Staphylococcus pettenkoferi bacteremia: A case report and review of the literature. Can J Infect Dis Med Microbiol 2015;26(6):319-322.
Staphylococcus pettenkoferi is a relatively recently described coagulase-negative staphylococci species first described in 2002. Since then, nine additional cases of infection caused by this species have been reported in various countries around the world, including Germany, Belgium, France, South Korea, Italy, Brazil and Mexico. The present report describes a case of S pettenkoferi peripheral line-associated bacteremia. To our knowledge, the present report is the first description of human infection caused by S pettenkoferi in Canada. The present report also provides an overview of the laboratory detection of uncommon coagulase-negative staphylococci.
key Words: Bacteremia; Coagulase negative; MALDI-ToF; Staphylococcus pettenkoferi
La bactériémie à Staphylococcus pettenkoferi : rapport de cas et analyse bibliographique
Le Staphylococcus pettenkoferi est une espèce de staphylocoque à coagulase négative qui a été décrit pour la première fois en 2002. Depuis, neuf autres cas d’infections causées par cette espèce ont été signalés dans divers pays du monde, y compris l’Allemagne, la Belgique, la France, la Corée du Sud, l’Italie, le Brésil et le Mexique. Le présent rapport décrit un cas de bactériémie à S pettenkoferi associée à un cathéter périphérique. En autant que les auteurs le sachent, il s’agit du premier rapport d’infection humaine à S pettenkoferi au Canada, qui donne également un aperçu de la détection en laboratoire de staphylocoques à coagulase négative rares.
Staphylococcus pettenkoferi bacteremia: A case report and review of the literature
Abdulaziz Ahmed Hashi MD1, Johannes Andries Delport MBChB MMed2, Sameer Elsayed MD FRCPC FACP2,3, Michael Seth Silverman MD FRCPC FACP3
CASE PRESENTATION A 75-year-old woman presented to the emergency department after experiencing an unwitnessed fall at home. She had been experiencing symptoms consistent with vertigo for a few days before presentation. Her medical history was significant for hypertension, type 2 diabetes mellitus, psoriasis, dyslipidemia, a seizure disorder and right knee arth-roplasty. Collateral history revealed that she had been assessed one week before for a planned total left knee arthroplasty, which had sub-sequently been postponed after the patient had been found to have a truncal rash that had been present for two weeks.
Her physical examination was significant for a petechial maculo-papular rash on her chest, arms and legs, as well as a positive Dix-Hallpike test. Vitals signs were within normal parameters and she was afebrile. Initial laboratory investigations (electrolytes, urea, creatinine, glucose) were unremarkable. She had a hemoglobin level of 138 g/L, white blood cell count of 9.0×109 cells/L and a platelet count of 176×109/L. While in the emergency department, a peripheral intra-venous (IV) catheter was placed at the dorsum of her left hand for administration of fluids.
The patient was admitted for further assessment and evaluation. Twelve hours later, she became febrile, but was otherwise asymp-tomatic. Two blood samples were drawn from separate venipuncture sites and sent for culture. Both sets of blood cultures were positive for Gram-positive cocci in clusters. She was then administered empirical IV vancomycin (1 g every 12 h).
Staphylococcus pettenkoferi was isolated in both blood cultures using a 3 h short-incubation matrix-assisted laser desorption/ionization time-of-flight (MALDI-ToF) identification protocol. It was approximately 36 h from
the time of blood culture draws until preliminary results demonstrated coagulase-negative staphylococci, and 51 h for the final culture result of S pettenkoferi. The positive blood cultures were subcultured onto a Columbia blood-agar plate (Oxoid, Thermo Fisher Scientific Inc, USA) and incubated at 35°C in 5% CO2 for 3 h. Identification of the isolates was performed using the Microflex LT with FlexControl version 3.4 software (Bruker Corporation, USA) for the automatic acquisition of mass spectra in the linear positive mode within a range of 2 kDa to 20 kDa. Automated analysis of the raw spectral data was performed using the MALDI BioTyper automation version 3.1 soft-ware (Bruker Corporation, USA).
The isolate was identified as S pettenkoferi (score 1.904); the top four choices were all strains of S pettenkoferi. Staphylococcus parauberis (score 1.250) was considered to be the next most likely identification.
cAse reporT
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1Department of Medicine; 2Department of Pathology and Laboratory Medicine; 3Department of Medicine, Division of Infectious Diseases, The University of Western Ontario, London, Ontario
Correspondence: Dr Abdulaziz Ahmed Hashi, Department of Medicine, Victoria Hospital, Room E6-117, London, Ontario N6A 5A5. Telephone 519-663-3584, e-mail [email protected]
TaBLe 1Susceptibilities for isolated Staphylococcus pettenkoferi performed using aST-GP67 cards on the Vitek 2* system
S pettenkoferiDrug VMICINT VMICDIL, mg/LClindamycin Susceptible ≤0.25Erythromycin Susceptible 0.5Oxacillin/cloxacillin Susceptible 2Trimethoprim/sulfamethaoxazole Susceptible ≤10Vancomycin Susceptible 1*BioMerieux, France. VMICDIL Vitek mean inhibitory dilution interpretation; VMICINT Vitek mean inhibitory concentration interpretation
Hashi et al
Can J Infect Dis Med Microbiol Vol 26 No 6 November/December 2015320
TaB
Le 2
Patie
nt d
emog
raph
ics,
mod
e of
dia
gnos
is a
nd tr
eatm
ent
Stud
ya
ge, y
ears
/ se
xC
omor
bidi
ties
Pres
enta
tion
Cul
ture
Bio
chem
istr
y/di
agno
sis
Trea
tmen
tO
utco
me
Trül
zsch
et a
l (1)
, 20
02; G
erm
any
(stra
in B
3117
[in
dex
stra
in])
25/u
nkno
wn
Ext
rapu
lmon
ary
TBFe
ver o
f unk
now
n
orig
in, w
eigh
t los
s;
foun
d to
hav
e TB
Blo
od c
ultu
reB
ioch
emis
try: A
PI/I
D32
Sta
ph*
initi
ally
sug
gest
ed K
ocur
ia ro
sea
or
Sta
phyl
ococ
cus
capi
tis.
Dia
gnos
is: c
onfir
med
usi
ng 1
6S rR
NA
gene
seq
uenc
ing
follo
wed
by
geno
mic
DN
A pr
epar
atio
n an
d pu
lsed
-fiel
d ge
l ele
ctro
phor
esis
.
Rifa
mpi
n, p
yraz
inam
ide,
et
ham
buto
l. Sp
ecific
tre
atm
ent o
f S
pette
nkof
eri n
ot
men
tione
d.
Suc
cess
ful
(rec
over
ed)
Loïe
z et
al (
3),
2007
; Fra
nce
63/m
ale
Dia
bete
s, c
hron
ic
diab
etic
foot
in
fect
ion
Ost
eom
yelit
is
disp
laye
d in
x-r
ay
findi
ngs
follo
win
g
wor
seni
ng p
ain,
re
dnes
s an
d w
ound
ex
udat
e
Bon
e bi
opsy
(4
of 6
sp
ecim
ens
prod
uced
b
acte
ria)
Bio
chem
istry
: API
/ID32
Sta
ph in
itial
ly s
ugge
sted
K ro
sea
and
M
icro
cocc
us ly
lae;
a s
econ
d A
PI/I
D32
Sta
ph s
trip
usin
g a
larg
er in
oc-
ulum
and
incu
batio
n pe
riod
sugg
este
d S
cap
itis
or S
taph
yloc
occu
s au
ricul
aris
.D
iagn
osis
: con
firm
ed u
sing
Mic
roS
eq 5
00†
DN
A se
quen
cing
of 1
6S
rRN
A ge
nes
with
sub
sequ
ent h
omol
ogy
sear
ch o
n N
CB
I Gen
Ban
k co
mpa
red
with
ent
ry s
train
B31
17 fr
om 2
002.
Tran
star
sal a
mpu
tatio
n,
then
pris
tinam
ycin
×1
4 w
eeks
Suc
cess
ful
(rec
over
ed)
Trül
zsch
et a
l (2)
, 20
07; G
erm
any
(stra
in K
6999
)
Unk
now
nU
nkno
wn
Unk
now
nB
lood
cul
ture
Bio
chem
istry
: AP
I/ID
32 S
taph
initi
ally
sug
gest
ed S
cap
itis
or
S a
uric
ular
is.
Dia
gnos
is: c
onfir
med
usi
ng 1
6S rR
NA
gene
seq
uenc
ing
(one
bas
e pa
ir di
ffere
nce)
, par
tial r
poB
gen
e se
quen
cing
(99.
8% s
imila
rity)
, 100
%
DN
A–D
NA
hybr
idiz
atio
n an
d R
iboP
rint‡
anal
ysis
(nea
rly id
entic
al)
com
pare
d w
ith s
train
B31
17 fr
om 2
002.
Unk
now
nU
nkno
wn
Trül
zsch
et a
l (2)
, 20
07; B
elgi
um
(isol
ate
229)
Unk
now
nU
nkno
wn
Unk
now
nB
lood
cul
ture
Bio
chem
istry
: AP
I/ID
32 S
taph
initi
ally
sug
gest
ed S
cap
itis
or
S a
uric
ular
is.
Dia
gnos
is: C
onfir
med
usi
ng 1
6S rR
NA
gene
seq
uenc
ing
(iden
tical
),
parti
al rp
oB g
ene
sequ
enci
ng (9
9.8%
sim
ilarit
y) a
nd R
iboP
rint
anal
ysis
(nea
rly id
entic
al) c
ompa
red
with
stra
in B
3117
from
200
2.
Unk
now
nU
nkno
wn
Trül
zsch
et a
l (2)
, 20
07; B
elgi
um
(isol
ate
230)
Unk
now
nU
nkno
wn
Unk
now
nB
lood
cul
ture
Bio
chem
istry
: AP
I/ID
32 S
taph
initi
ally
sug
gest
ed S
cap
itis
or
S a
uric
ular
is.
Dia
gnos
is: c
onfir
med
usi
ng 1
6S rR
NA
gene
seq
uenc
ing
(iden
tical
),
parti
al rp
oB g
ene
sequ
enci
ng (9
9.8%
sim
ilarit
y) a
nd R
iboP
rint
anal
ysis
(nea
rly id
entic
al) c
ompa
red
with
stra
in B
3117
from
200
2.
Unk
now
nU
nkno
wn
Son
g et
al (
4), 2
009;
S
outh
Kor
ea
76/m
ale
Rec
urre
nt
pulm
onar
y
TB
Adm
itted
for
recu
rrent
pu
lmon
ary
TB.
Dev
elop
ed S
teve
ns-
John
son
synd
rom
e.
Beca
me
febr
ile w
hile
be
ing
treat
ed fo
r bo
th; f
ound
to h
ave
bloo
dstre
am
infe
ctio
n
Bloo
d cu
lture
s fro
m d
iffer
ent
lum
ens
of a
ce
ntra
l lin
e
Bio
chem
istry
: Mic
roS
can
Wal
kAw
ay P
os C
ombo
Pan
el§
sugg
este
d
Sta
phyl
ococ
cus
hom
inis
(92%
) or S
aur
icul
aris
(99%
); V
ITE
K 2
Gra
m
Pos
itive
Iden
tific
atio
n sy
stem
sug
gest
ed S
aur
icul
aris
(70%
),
S c
apiti
s (5
0%),
or S
taph
yloc
occu
s w
rner
i (50
%);
AP
I/ID
32 S
taph
V
4 1
Kit
sugg
este
d S
cap
itis
(61.
5%) o
r Koc
uria
var
ians
/K ro
sea
(27.
8%).
Gen
e se
quen
cing
: gen
e se
quen
cing
of 1
6S rR
NA
usin
g th
e M
icro
Seq
M
icro
bial
Iden
tific
atio
n S
yste
m¶
and
a co
nsen
sus
sequ
ence
of 4
95
base
pai
rs s
ugge
sted
Sta
phyl
ococ
cus
capr
ae (9
9.36
%),
Sta
phyl
ococ
cus
hyic
us (9
6.94
%),
or S
taph
yloc
occu
s co
hnii
(97.
08%
).D
iagn
osis
: usi
ng a
larg
er s
eque
nce
of 1
533
base
pai
rs a
nd s
endi
ng
the
data
to G
enB
ank
sugg
este
d S
pet
tenk
ofer
i. P
hylo
gene
tic tr
ee
conf
irmed
isol
ate
to b
e m
ost c
onsi
sten
t with
S p
ette
nkof
eri.
Vanc
omyc
in 2
g IV
ev
ery
24 h
×1
wee
kSu
cces
sful
(n
egat
ive
bloo
d
cultu
res;
pat
ient
th
en tr
eate
d
for T
B)
d'A
zeve
do e
t al (
5),
2010
; Bra
zil
56/u
nkno
wn
Unk
now
nU
nkno
wn
Bloo
d cu
lture
s B
ioch
emis
try: V
ITE
K 2
* id
entif
icat
ion
syst
em s
ugge
sted
K v
aria
ns.
Dia
gnos
is: c
onfir
med
usi
ng D
NA
sequ
enci
ng o
f 16S
rRN
A an
d so
dA
gene
s w
ith s
ubse
quen
t hom
olog
y se
arch
on
Gen
Ban
k m
atch
ing
S
pet
tenk
ofer
i.
Unk
now
nU
nkno
wn
Con
tinue
d on
nex
t pag
e
Staphylococcus pettenkoferi bacteremia
Can J Infect Dis Med Microbiol Vol 26 No 6 November/December 2015 321
A score >1.700 and a differential spread of 0.654 (being greater than the recommended 0.200 spread) helped secure the identification of this organism to genus and species.
The isolate was catalase positive, with a Gram-stain consistent with a Staphylococcus species, differentiating it from the next available genus identification of Streptococcus. As part of the routine processing of positive blood cultures with Gram stain suggestive of staphylococci species, poly-merase chain reaction was performed for detection of methicillin resistance and to differentiate the strain from Staphylococcus aureus. Neither the nuc nor mecA genes were detected, therefore, confirming that this was a coagulase-negative methicillin-susceptible staphylococcal strain.
Susceptibility testing was performed using AST-GP67 cards on the Vitek 2 (BioMerieux, France) microbial identification system. The isolate had a minimum inhibitory concentration of 2 mg/L for oxacillin indicat-ing that it was susceptible. Susceptibilities are listed in Table 1.
The patient developed erythema and mild tender-ness at the site of her peripheral intravenous catheter, and was diagnosed with catheter-associated bacteremia. The IV catheter was removed and her antibiotic ther-apy was changed to 2 g IV cloxacillin every 6 h, after having received two days of IV vancomycin. A trans-thoracic echocardiogram demonstrated no evidence of valvular heart disease or vegetations. Consideration was initially given to conducting a skin biopsy to better delin-eate the cause of the patient’s rash; however, the rash resolved spontaneously. Her vertigo improved with the use of particle repositioning manoeuvres. The patient was given a prescription to complete a seven-day course of 500 mg oral cloxacillin every 6 h for six days because she had completed one day of IV cloxacillin in hospital. She was then discharged home. Repeat blood cultures taken five days after completion of antibiotic therapy were negative.
DISCUSSIONS pettenkoferi is a coagulase-negative Staphylococcus. S pettenkoferi was first described by Trülzsch et al (1) in 2002. While the authors initially reported two cases of infection with this organism (strains B3117 and A6664), subsequent investigations revealed that only one of the isolates (B3117) was S pettenkoferi (2); that strain was recovered from a blood culture sample in a patient with extra pulmonary tuberculosis. Since then, nine cases have been documented in the literature (Table 2). Trülzsch et al (2) described three more isolates of S pettenkoferi in Germany and Belgium (strain K699, isolate 229 and iso-late 230) all from blood cultures, and all displaying 100% DNA-DNA homology with strain B3117 from their 2002 study. Also in 2007, the first case of S pettenkoferi osteo-myelitis was described by Loïez et al (3) in France in a 63-year old diabetic man using bone biopsy cultures. Song et al (4) described the first case of S pettenkoferi in Asia in 2008 from central line blood cultures in a 76-year old man in South Korea with tuberculosis and Stevens-Johnson syndrome who developed bacteremia. The first South American case of S pettenkoferi was described by d’Azevedo et al (5) using blood cultures from a patient in Brazil. Other cases have also been reported including one case in Italy (6) using blood cultures and two cases in Mexico (an adult with HIV and a premature infant) using blood cultures, which were the first reported cases in North America (7).Ta
BLe
2 –
CO
NTI
NU
eDSt
udy
age
, sex
Com
orbi
ditie
sPr
esen
tatio
nC
ultu
reB
ioch
emis
try/
diag
nosi
sTr
eatm
ent
Out
com
eM
amm
ina
et a
l (6)
, 20
11; I
taly
49/m
ale
Pos
t-tra
umat
ic
hydr
ocep
halu
sS
urgi
cal t
reat
men
t of
hydr
ocep
halu
s.
Und
erw
ent p
lace
-m
ent o
f ven
tricu
lo-
perit
onea
l dra
in,
repl
aced
by
exte
rnal
ve
ntric
ular
dra
in
10 d
ays
late
r due
to
occl
usio
n of
inte
rnal
de
vice
. Ext
erna
l dr
ain
beca
me
infe
cted
. Tre
ated
, but
de
velo
ped
shoc
k
10 d
ays
late
r
Blo
od c
ultu
res
(sou
rce
of
seps
is
susp
ecte
d of
be
ing
bloo
d-st
ream
)
Bio
chem
istry
: VIT
EK
2 s
ugge
sted
S c
apiti
s; A
PI/I
D32
Sta
ph s
ugge
sted
S
cap
itis.
Dia
gnos
is: c
onfir
med
usi
ng D
NA
sequ
enci
ng o
f 16S
rRN
A ge
nes
with
ho
mol
ogy
sear
ch o
n G
enB
ank
(100
% s
imila
rity
to s
train
s B
3117
and
A
6664
).
Dap
tocy
cin
8 m
g/kg
and
P
ip-T
azo
4.5
g ×
4
dose
s, th
en
dapt
omyc
in a
lone
Uns
ucce
ssfu
l (d
ied)
Mor
fin-O
tero
, et
al (
7), 2
012;
M
exic
o
New
born
/mal
ePr
emat
ure
(3
3 w
eeks
) Fe
ver
Bloo
d cu
lture
s (1
of 3
)B
ioch
emis
try: A
PI/I
D 3
2 S
taph
sug
gest
ed K
var
ians
; Sen
sitit
re d
id n
ot
iden
tify
isol
ate.
D
iagn
osis
: con
firm
ed u
sing
DN
A se
quen
cing
of 1
6S rR
NA
, sod
A a
nd
tuf g
enes
with
sub
sequ
ent h
omol
ogy
sear
ch o
n G
enB
ank
mat
chin
g
S p
ette
nkof
eri.
Am
pici
llin
×4 d
ays,
am
ikac
in ×
4 da
ys, t
hen
ampi
cilli
n ×1
0 da
ys
Suc
cess
ful
(rec
over
ed)
Mor
fin-O
tero
, et
al (
7), 2
012;
M
exic
o
45/m
ale
AID
S, h
erpe
s zo
ster
, he
patit
is C
Cer
ebra
l to
xopl
asm
osis
Bloo
d cu
lture
s (2
of 2
)B
ioch
emis
try: A
PI/I
D32
Sta
ph s
ugge
sted
K v
aria
ns; S
ensi
titre
su
gges
ted
Sta
phyl
ococ
cus
cohn
ii ep
ider
mid
is.
Dia
gnos
is: c
onfir
med
usi
ng D
NA
sequ
enci
ng o
f 16S
rRN
A, s
odA
and
tu
f gen
es w
ith s
ubse
quen
t hom
olog
y se
arch
on
Gen
Ban
k m
atch
ing
S
pet
tenk
ofer
i.
Clin
dam
ycin
×8
days
, tri
met
hopr
im/
sulfa
met
hoxa
zole
×8
days
, azi
thro
myc
in
×8 d
ays,
am
phot
eri-
cin
B ×8
day
s
Uns
ucce
ssfu
l (di
ed)
*Bio
Mer
ieux
, Fr
ance
; † A
pplie
d B
iosy
stem
s, U
SA
; ‡ D
uPon
t, U
SA
; § B
eckm
an C
oulte
r, U
SA
; ¶ L
ife T
echn
olog
ies,
US
A.
IV I
ntra
veno
us;
NC
BI
Nat
iona
l C
ente
r fo
r B
iote
chno
logy
Inf
orm
atio
n; r
RN
A R
ibos
omal
RN
A;
TB T
uber
culo
sis
Hashi et al
Can J Infect Dis Med Microbiol Vol 26 No 6 November/December 2015322
To our knowledge, this is the first case of S pettenkoferi reported in Canada. While our patient did have a history of a maculopapular rash, the rash was deemed unlikely to be related to her infection, particu-larly because it preceded her IV catheter insertion. We were unable to perform convalescent serology for infectious causes of rash because the patient was subsequently lost to follow-up.
It is known that coagulase-negative staphylococci are associated with infections of indwelling and implanted devices (8). This is pos-sibly consistent with the present patient’s presentation, although a peripheral IV site was believed to be involved in her case. With regard to antibiotic choice, different agents have been used (see Table 2). To the best of our knowledge, our patient was the first to be treated suc-cessfully with cloxacillin, albeit having previously received a short course of vancomycin (Table 1).
We suspect that S pettenkoferi is significantly more commonly encountered than the above reports would suggest. Laboratory identi-fication can be challenging because biochemical tests may result in misidentification of S pettenkoferi as Staphylococcus hominis, Staphylococcus auricularis, Staphylococcus capitis and Kocuria varians (Table 2). In several situations, the correct identity of the bacterium was not made until molecular tests, such as 16S ribosomal RNA (rRNA) gene sequencing were performed. Notwithstanding, while genetic sequencing of 16S rRNA has been the most commonly used
method to confirm the diagnosis of S pettenkoferi, strain A6664, one of the two originally described S pettenkoferi isolates, has a slightly differ-ent rpoB gene sequence and does not have 100% DNA-DNA homol-ogy with the other strains described in 2007 by Trülzsch et al (2) compared to strain B31117. This suggests that it is a different species altogether and, therefore, 16S rRNA gene sequencing may not be suf-ficiently robust to definitively diagnose the presence of S pettenkoferi.
A limitation of our study is the lack of sequencing data because the isolate is no longer available. Nevertheless, we believe that in the present case the species diagnosis is confirmed. Our laboratory uses MALDI-ToF mass spectrometry. MALDI-ToF has been used to cor-rectly identify other coagulase-negative staphylococci that have been under-reported in the past, such as Staphylococcus lugdunensis (9). The use of MALDI-ToF may result in increased reports of S pettenkoferi infection. In studies performed at our institution, the Bruker MALDI-ToF correctly identified 485 of 485 coagulase-negative staphylococci to the species level. Included in these were 117 isolates of S capitis and S hominis species that were all identified correctly by the MALDI-ToF with none being identified as S pettenkoferi (10,11).
DISCLOSURES: The authors have no financial relationships or conflicts of interest to declare.
REFERENCES1. Trülzsch K, Rinder H, Trcek J, et al. ‘Staphylococcus pettenkoferi’, a
novel staphylococcal species isolated from clinical specimens. Diagn Microbiol Infect Dis 2002;43:175-82.
2. Trülzsch K, Grabein B, Schumann P, et al. Staphylococcus pettenkoferi sp. nov., a novel coagulase-negative staphylococcal species isolated from human clinical specimens. Int J Syst Evol Microbiol 2007;57:1543-8.
3. Loïez C, Wallet F, Pischedda P, et al. First case of osteomyelitis caused by ‘Staphylococcus pettenkoferi’. J Clinical Microbiol 2007;45:1069-71.
4. Song SH, Park JS, Kwon HR, et al. Human bloodstream infection caused by Staphylococcus pettenkoferi. J Med Microbiol 2009;58:270-2.
5. d’Azevedo PA, Comin G, Cantarelli V. Characterization of a new coagulase-negative Staphylococcus species (Staphylococcus pettenkoferi) isolated from blood cultures from a hospitalized patient in Porto Alegre, Brazil. Rev Soc Bras Med Trop 2010;43:331-2.
6. Mammina C, Bonura C, Verde MS, et al. A fatal bloodstream infection by Staphylococcus pettenkoferi in an intensive care unit patient. Case Rep Crit Care 2011;2011:612732.
7. Morfin-Otero R, Martínez-Vasquez MA, López D, et al. Isolation of rare coagulase-negative isolates in immunocompromised patients: Staphylococcus gallinarum, Staphylococcus pettenkoferi, and Staphylococcus pasteuri. Ann Clin Lab Sci 2012;42:182-5.
8. Huebner J, Goldmann DA. Coagulase-negative Staphylococci: Role as pathogens. Annu Rev Med 1999;50:223-36.
9. Szabados F, Anders A, Kaase M, et al. Late periprosthetic joint infection due to Staphylococcus lugdunensis identified by matrix-assisted laser desorption/ionisation time of fight mass spectrometry: A case report and review of the literature. Case Rep Med 2011;2011:1-4.
10. Delport J, Peters G, John M, et al. Coagulase-negative Staphylococci: Comparing MALDI-TOF to VITEK 2 and MIDI gas liquid chromatography. 2013 June 28th International Congress of Chemotherapy and Infections, Yokohama, Japan. June 5 to 8, 2013.
11. Delport J, Peters G, John M, et al. Bruker MALDI-TOF: Identification of coagulase negative staphylococci. 2013 October ID Week 2013, San Francisco, California, USA. October 2 to 6, 2013.
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