The Open Microbiology Journal




ISSN: 1874-2858 ― Volume 13, 2019

Aerococcus christensenii as Part of Severe Polymicrobial Chorioamnionitis in a Pregnant Woman



Catrine Carlstein1, Lillian Marie Søes2, Jens Jørgen Christensen2, *
1 Department of Gynaecology and Obstetrics, Næstved Hospital, Ringstedgade 61, 4700 Næstved, Denmark
2 Department of Clinical Microbiology, Slagelse Hospital, Ingemannsvej 18, 4200 Slagelse, Denmark

Abstract

Chorioamnionitis is a potentially life threatening infection of the fetal membranes, commonly caused by ascending bacteria from the vagina and cervix. In our case, a healthy nullipara with a term pregnancy presented clinical signs of infection after induced labour with an intracervical balloon. Thick green and foul smelling amniotic fluid was observed and culture showed massive growth of Aerococcus christensenii, a facultative anaerob species found in the human vagina, previously only rarely alleged to cause invasive infection. Additional testing with 16S rRNA gene analysis also identified the presence of Gemella asaccharolytica, Snethia sanguinegens, Parvimonas micra and Streptobacillus moniliformis. The patient was treated with cefuroxime and metronidazole and recovered quickly. The newborn showed no signs of infection. This case points at the possible role of these pathogens in female genital tract infections. The case also underlines the importance of the combination of culture and culture independent diagnostic approaches to reveal possible polymicrobial natures of selected infections, in this case chorioamnionitis.

Keywords: Aerococcus christensenii, gemella assacharolytica, parvimonas micra, polymicrobial chorioamnionitis, pregnancy, snethia sanguinegens, streptobacillus moniliformis.


Article Information


Identifiers and Pagination:

Year: 2016
Volume: 10
First Page: 27
Last Page: 31
Publisher Id: TOMICROJ-10-27
DOI: 10.2174/1874285801610010027

Article History:

Received Date: 20/11/2014
Revision Received Date: 3/1/2015
Acceptance Date: 23/2/2015
Electronic publication date: 10/3/2016
Collection year: 2016

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© Carlstein et al. ; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution-Non-Commercial 4.0 International Public License (CC BY-NC 4.0) (https://creativecommons.org/licenses/by-nc/4.0/legalcode), which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to this author at the Department of Clinical Microbiology, Slagelse Hospital, Ingemannsvej 18, 4200 Slagelse, Denmark; Tel: +45 58 55 94 04; E-mail: jejc@regionsjaelland.dk




INTRODUCTION

Chorioamnionitis is an infection of the fetal membranes, thought to affect as many as 10 % of all labouring women [1Hastings-Tolsma M, Bernard R, Brody MG, Hensley J, Koschoreck K, Patterson E. Chorioamnionitis: prevention and management. MCN Am J Matern Child Nurs 2013; 38(4): 206-12.
[http://dx.doi.org/10.1097/NMC.0b013e3182836bb7] [PMID: 23579417]
] and it is a major challenge with regard to secure the mother as well as the foetus from life threatening complications. In term pregnancies it is thought to be caused primarily by ascending infections from the vagina and cervix, causing an inflammatory response in the decidua followed by a chorionitis [2Riggs JW, Blanco JD. Pathophysiology, diagnosis, and management of intraamniotic infection. Semin Perinatol 1998; 22(4): 251-9.
[http://dx.doi.org/10.1016/S0146-0005(98)80013-X] [PMID: 9738989]
].

In most healthy women, one or two species of Lactobacillus dominates the vaginal flora [3Lamont RF, Sobel JD, Akins RA, et al. The vaginal microbiome: new information about genital tract flora using molecular based techniques. BJOG 2011; 118(5): 533-49.
[http://dx.doi.org/10.1111/j.1471-0528.2010.02840.x] [PMID: 21251190]
]. Yet, in up to one third of healthy women, the Lactobacillus species lack in appreciable numbers and may be replaced by several other species, e.g. Atopobium, Megasphaera and Leptotrichia species [3Lamont RF, Sobel JD, Akins RA, et al. The vaginal microbiome: new information about genital tract flora using molecular based techniques. BJOG 2011; 118(5): 533-49.
[http://dx.doi.org/10.1111/j.1471-0528.2010.02840.x] [PMID: 21251190]
]. Aerococcus christensenii has been isolated from the human vagina too [4Collins MD, Jovita MR, Hutson RA, Ohlén M, Falsen E. Aerococcus christensenii sp. nov., from the human vagina. Int J Syst Bacteriol 1999; 49(Pt 3): 1125-8.
[http://dx.doi.org/10.1099/00207713-49-3-1125] [PMID: 10425770]
]. A. christensenii,Gemella asaccharolytica and Snethia (Leptotrichia) sanguinegens [5De Martino SJ, Mahoudeau I, Brettes JP, Piemont Y, Monteil H, Jaulhac B. Peripartum bacteremias due to Leptotrichia amnionii and Sneathia sanguinegens, rare causes of fever during and after delivery. J Clin Microbiol 2004; 42(12): 5940-3.
[http://dx.doi.org/10.1128/JCM.42.12.5940-5943.2004] [PMID: 15583348]
, 6Ulger-Toprak N, Summanen PH, Liu C, Rowlinson MC, Finegold SM. Gemella asaccharolytica sp. nov., isolated from human clinical specimens. Int J Syst Evol Microbiol 2010; 60(Pt 5): 1023-6.
[http://dx.doi.org/10.1099/ijs.0.001966-0] [PMID: 19666813]
] are relatively newly established taxons and have only rarely to very rarely been alleged to cause invasive infections. During labour, increased vaginal secretions are common, creating a favourable medium for growth of bacteria, which can ascend and stimulate maternal and foetal inflammatory responses with the release of cytokines, prostaglandins and endotoxins [1Hastings-Tolsma M, Bernard R, Brody MG, Hensley J, Koschoreck K, Patterson E. Chorioamnionitis: prevention and management. MCN Am J Matern Child Nurs 2013; 38(4): 206-12.
[http://dx.doi.org/10.1097/NMC.0b013e3182836bb7] [PMID: 23579417]
]. Applicating molecular laboratory methods may contribute considerably in diagnostic outlining of these organisms [7Jensen KH, Dargis R, Christensen JJ, Kemp M. Ribosomal PCR and DNA sequencing for detection and identification of bacteria: experience from 6 years of routine analyses of patient samples. APMIS 2014; 122(3): 248-55.
[http://dx.doi.org/10.1111/apm.12139] [PMID: 23879657]
].

In this case, we describe a healthy woman with a singleton term pregnancy, whom after iatrogenic initiation of labour developed high fever, vomiting and tachycardia. Routine culture methodology, 16S rRNA gene analysis and amended interpretation of mixed chromatograms each contributed importantly to the detection and final understanding of the polymicrobial infectious episode. These revealed to be A. christensenii, G. asaccharolytica, S. sanguinegens/Leptotrichia amnionii, Parvimonas micra and Streptobacillus moniliformis.

Case story

A 33-year old healthy nullipara with an intrauterine singleton normal pregnancy of 42 weeks and 0 days’ gestational age was admitted to the maternity ward for inducing labour due to gravida prolongata.

An intracervical balloon was placed for ripening the cervix. Fourteen hours later, artificial rupture of membranes was performed, but amniotic fluid was never surely identified. Furthermore, accelerated stimulation with synthetic oxytocin was initiated. The foetus was constantly monitored with cardiotocography (CTG).

The patient began to feel unwell, having nausea and vertigo, twelve hours after artificial rupture of membranes. The CTG was normal (Appendix Fig. 1). The oxytocin stimulation was paused and the patient rested for the night. During the next day, the patient got increasingly ill, with high fever (39.2 °C), shivering, vomiting and tachycardia. The CTG also showed fetal tachycardia (FHR 160-170) and several episodes of bradycardia lasting between one and one and a half minute (Appendix Fig. 2). A fetal scalp-pH was 7, 34 (7, 25-7, 35).

The patient had 3g intravenous benzylpenicillin, due to prolonged prelabour rupture of membranes (PROM). Thin, green amniotic fluid flowed from the vagina twenty-nine hours after artificial rupture of membranes. Because of high maternal temperature, fetal tachycardia combined with decelerations on the CTG (suggesting fetal distress), green amniotic fluid and poor progress of labour, an acute caesarean section was performed with finding of bad smelling, thick, green amniotic fluid. The newborn cried spontaneously with Apgar score 10/1, 10/5.

At surgery, a swab of the amniotic fluid was submitted for microbiological analysis.

After the caesarean section, the patient was treated with intravenous cefuroxime and metronidazole for three days and peroral amoxicillin for another five days. The patient recovered rapidly. The newborn showed no signs of infection and sepsis. Both mother and newborn were discharged wellbeing.

Microbiology

The Stuart charcoal swab with amniotic fluid taken at caesarian section was plated on 5% Danish horse blood agar for incubation in ambient air supplemented with 5% CO2 at 35°C. Furthermore on blue agar (optimized for growth of gram-negative rods, especially Enterobacteriaceae), tellurite agar, and on β-glucuronidase test agar (for demonstration of β-glucuronidase activity) for incubation in ambient air at 35°C, plus on anaerobic agar for anaerobic incubation at 37°C (Concept 400 chamber from Ruskinn Technology Ltd; gas mixture: 80% nitrogen, 10% hydrogen, 10% CO2/pure nitrogen).

All plates including Mueller Hinton plates were from SSI Diagnostica, Statens Serum Institut, Hillerød, Denmark. A. christensenii grew massively together with two other bacterial colonies, which could not be cultured further in preparation for identification. A. christensenii was identified by MALDI-TOF MS (Compass 1.4, Version 3.4, Build 3.4.76.0 by Bruker Daltonics) with a score value of 2.09, four identical hits and a distance to next taxon match of > 0.7. No anaerobic growth was noticed. In order to confirm the finding, partial 16S rRNA gene analysis was performed using the Select NA™ assay by Molzym (http://www. molzym.com/). By application of the Gram-positive primer set, a mixed chromatogram was found. By applicating the Gram-negative primer set, S. sanguinegens (sequence identity: 387 of 392 base pair) was identified in addition to a mixed chromatogram.

The mixed chromatograms were examined using the Isentio RipSeq website (http:// www.isentio.com/) confirming the presence of A. christensenii, but additionally detecting G. asaccharolytica and also revealing the presence of S. sanguinegens, P. micra and S. moniliformis.

A. christensenii and G. asaacharolytica are facultative anaerobic species, S. Sanguinegens/L. amnionii and P. micra are anaerobic gram negative rods and gram positive cocci, respectively. S. moniliformis is a fastidious facultatively anaerob gram negative rod.

By Oxoid disc susceptibility testing on Mueller Hinton 5% blood agar with NAD and incubated in ambient air supplemented with 5% CO2 at 35°C, the A. christensenii strain was found sensitive to penicillin.

DISCUSSION

Prompt action was taken in this severe chorioamnionitis episode, which surely influenced the positive outcome regarding both mother and newborn. Despite benzylpenicillin treatment, the patient developed high fever and illness twenty-four hours after artificial rupture of membranes and CTG indicated fetal distress. In addition, green and foul-smelling amniotic fluid was observed together with badly smelling pus at caesarean section, which is characteristic for infections involving anaerobic bacteria [8Morita M, Wang HL. Association between oral malodor and adult periodontitis: a review. J Clin Periodontol 2001; 28(9): 813-9.
[http://dx.doi.org/10.1034/j.1600-051x.2001.028009813.x] [PMID: 11493349]
]. The patient recovered quickly after intravenously administering of cefuroxime and metronidazole.

Nulliparity, obesity, genetic factors and the time interval from premature rupture of membranes (PROM) to birth are factors that influence the risk of an ascending bacterial infection [9Cabrera IB, Quinones JN, Durie DE, et al. Intracervical balloon placement and the risk of chorioamnionitis in term rupture of membranes. Obstet Gynecol 2014; 123(Suppl. 1): 43S.
[http://dx.doi.org/10.1097/01.AOG.0000447324.05518.6e]
]. An intracervical balloon can theoretically increase the risk of infection, although a recent study showed no significantly higher risk of chorioamnionitis after placement of an intracervical balloon when adjusted for nulliparity [9Cabrera IB, Quinones JN, Durie DE, et al. Intracervical balloon placement and the risk of chorioamnionitis in term rupture of membranes. Obstet Gynecol 2014; 123(Suppl. 1): 43S.
[http://dx.doi.org/10.1097/01.AOG.0000447324.05518.6e]
]. The number of sterile vaginal explorations in term labour has not been found to be an independent risk factor for intrapartum fever [10Cahill AG, Duffy CR, Odibo AO, Roehl KA, Zhao Q, Macones GA. Number of cervical examinations and risk of intrapartum maternal fever. Obstet Gynecol 2012; 119(6): 1096-101.
[http://dx.doi.org/10.1097/AOG.0b013e318256ce3f] [PMID: 22617572]
].

Chorioamnionitis is often polymicrobiol. A variety of bacteria, including miscellaneous anaerobes, Streptococcus agalactiae (Group B haemolytic streptococci), Gardnerella vaginalis, Mycoplasma and Ureaplasma,Escherichia coli, S. sanguinegens and Leptotrichia species may be identified by culture and/or culture-independent methods, such as 16S rRNA gene analysis [11DiGiulio DB. Diversity of microbes in amniotic fluid. Semin Fetal Neonatal Med 2012; 17(1): 2-11.
[http://dx.doi.org/10.1016/j.siny.2011.10.001] [PMID: 22137615]
, 12Wang X, Buhimschi CS, Temoin S, Bhandari V, Han YW, Buhimschi IA. Comparative microbial analysis of paired amniotic fluid and cord blood from pregnancies complicated by preterm birth and early-onset neonatal sepsis. PLoS One 2013; 8(2): e56131.
[http://dx.doi.org/10.1371/journal.pone.0056131] [PMID: 23437088]
].

A. christensenii has formerly only rarely been described. It was primarily isolated from the human vagina [4Collins MD, Jovita MR, Hutson RA, Ohlén M, Falsen E. Aerococcus christensenii sp. nov., from the human vagina. Int J Syst Bacteriol 1999; 49(Pt 3): 1125-8.
[http://dx.doi.org/10.1099/00207713-49-3-1125] [PMID: 10425770]
] and has recently been found in subacute bacterial endocarditis [13Jose A, Cunha BA, Klein NC, Schoch PE. Aerococcus christensenii native aortic valve subacute bacterial endocarditis (SBE) presenting as culture negative endocarditis (CNE) mimicking marantic endocarditis. Heart Lung 2014; 43(2): 161-3.
[http://dx.doi.org/10.1016/j.hrtlng.2013.11.005] [PMID: 24341951]
]. To our knowledge, this is the first case to describe A. christensenii in chorioamnionitis. Hence, our finding corresponds well with the previous observations by Collins and colleagues [4Collins MD, Jovita MR, Hutson RA, Ohlén M, Falsen E. Aerococcus christensenii sp. nov., from the human vagina. Int J Syst Bacteriol 1999; 49(Pt 3): 1125-8.
[http://dx.doi.org/10.1099/00207713-49-3-1125] [PMID: 10425770]
].

As described by DiGiulio, we also found S. sanguinegens and Leptotrichia species only by PCR and not by culture [11DiGiulio DB. Diversity of microbes in amniotic fluid. Semin Fetal Neonatal Med 2012; 17(1): 2-11.
[http://dx.doi.org/10.1016/j.siny.2011.10.001] [PMID: 22137615]
]. These pathogens have previously been described in infections in pregnancy and postpartum women [5De Martino SJ, Mahoudeau I, Brettes JP, Piemont Y, Monteil H, Jaulhac B. Peripartum bacteremias due to Leptotrichia amnionii and Sneathia sanguinegens, rare causes of fever during and after delivery. J Clin Microbiol 2004; 42(12): 5940-3.
[http://dx.doi.org/10.1128/JCM.42.12.5940-5943.2004] [PMID: 15583348]
, 14Boennelycke M, Christensen JJ, Arpi M, Krause S. Leptotrichia amnionii found in septic abortion in Denmark. Scand J Infect Dis 2007; 39(4): 382-3.
[http://dx.doi.org/10.1080/00365540601053022] [PMID: 17454911]
]. They appear more commonly in amnionitic fluid after the introduction of molecular methods [11DiGiulio DB. Diversity of microbes in amniotic fluid. Semin Fetal Neonatal Med 2012; 17(1): 2-11.
[http://dx.doi.org/10.1016/j.siny.2011.10.001] [PMID: 22137615]
].

The molecular analysis also revealed P. micra (formerly Peptostreptococcus micros). This anaerobic coccus is part of the normal human oral and gastrointestinal flora, primarily causing infections in the oral cavity [15Murdoch DA. Gram-positive anaerobic cocci. Clin Microbiol Rev 1998; 11(1): 81-120.
[PMID: 9457430]
]. It has been speculated that the microbe is part of the vaginal flora and that it could play a role in obstetric infections paralleling its role in the development of periodontitis [15Murdoch DA. Gram-positive anaerobic cocci. Clin Microbiol Rev 1998; 11(1): 81-120.
[PMID: 9457430]
]. Our finding supports this hypothesis.

Furthermore, the species G. asaccharolytica was identified by the analysis. To our knowledge this species has been described only once before by Ulger-Toprak et al. [6Ulger-Toprak N, Summanen PH, Liu C, Rowlinson MC, Finegold SM. Gemella asaccharolytica sp. nov., isolated from human clinical specimens. Int J Syst Evol Microbiol 2010; 60(Pt 5): 1023-6.
[http://dx.doi.org/10.1099/ijs.0.001966-0] [PMID: 19666813]
] in three patients with an arm wound, an infection following a cut finger and from a labial abscess, respectively.

Finally, we identified S. moniliformis from the amniotic fluid by molecular analysis. This bacterium is naturally occurring in the nasopharynx of wild and laboratory rats and is acquired through the bite or scratch of a rodent or by ingestion of contaminated water or food. It is the etiologic agent of rat-bite fever or in the absence of a rat, Haverhill fever. The disease is characterized by irregular fever with flu-like symptoms and a rash [16Pins MR, Holden JM, Yang JM, Madoff S, Ferraro MJ. Isolation of presumptive Streptobacillus moniliformis from abscesses associated with the female genital tract. Clin Infect Dis 1996; 22(3): 471-6.
[http://dx.doi.org/10.1093/clinids/22.3.471] [PMID: 8852965]
]. Amnionitis and abscesses associated with the female genital tract have been described [16Pins MR, Holden JM, Yang JM, Madoff S, Ferraro MJ. Isolation of presumptive Streptobacillus moniliformis from abscesses associated with the female genital tract. Clin Infect Dis 1996; 22(3): 471-6.
[http://dx.doi.org/10.1093/clinids/22.3.471] [PMID: 8852965]
, 17Faro S, Walker C, Pierson RL. Amnionitis with intact amniotic membranes involving Streptobacillus moniliformis. Obstet Gynecol 1980; 55(3)(Suppl.): 9S-11.
[http://dx.doi.org/10.1097/00006250-198003001-00003] [PMID: 7360458]
]. In contrast to the patient described by Faro et al., our patient had high fever and was unwell. There was no known history of a rat bite.

In our case, it was only possible to do susceptibility testing on the A. christensenii strain as the other present species were identified by non-culture methodology. However, the published literature supports a relevant antibiotic coverage by the antibiotics given to our case consistent with the quick recovery of mother and child [5De Martino SJ, Mahoudeau I, Brettes JP, Piemont Y, Monteil H, Jaulhac B. Peripartum bacteremias due to Leptotrichia amnionii and Sneathia sanguinegens, rare causes of fever during and after delivery. J Clin Microbiol 2004; 42(12): 5940-3.
[http://dx.doi.org/10.1128/JCM.42.12.5940-5943.2004] [PMID: 15583348]
, 18Christensen JJ, Korner B, Casals JB, Pringler N. Aerococcus-like organisms: use of antibiograms for diagnostic and taxonomic purposes. J Antimicrob Chemother 1996; 38(2): 253-8.
[http://dx.doi.org/10.1093/jac/38.2.253] [PMID: 8877539]
-20Uemura H, Hayakawa K, Shimada K, et al. Parvimonas micra as a causative organism of spondylodiscitis: a report of two cases and a literature review. Int J Infect Dis IJID Off Publ Int Soc Infect Dis 2014; 23: pp. 53-5.].

In conclusion, we present a case of chorioamnionitis consisting of five different microorganisms, where only A. christensenii could be identified by culture. Because of molecular diagnostic approaches, the polymicrobial nature of this infection was revealed. Albeit rare to very rare, all the bacteria identified have earlier been associated with infection or habitation in the female genital tract and this case underlines and stresses the possible role of these pathogens in female genital tract infections.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflicts of interest.

ACKNOWLEDGEMENTS

None declared.

REFERENCES

[1] Hastings-Tolsma M, Bernard R, Brody MG, Hensley J, Koschoreck K, Patterson E. Chorioamnionitis: prevention and management. MCN Am J Matern Child Nurs 2013; 38(4): 206-12.
[http://dx.doi.org/10.1097/NMC.0b013e3182836bb7] [PMID: 23579417]
[2] Riggs JW, Blanco JD. Pathophysiology, diagnosis, and management of intraamniotic infection. Semin Perinatol 1998; 22(4): 251-9.
[http://dx.doi.org/10.1016/S0146-0005(98)80013-X] [PMID: 9738989]
[3] Lamont RF, Sobel JD, Akins RA, et al. The vaginal microbiome: new information about genital tract flora using molecular based techniques. BJOG 2011; 118(5): 533-49.
[http://dx.doi.org/10.1111/j.1471-0528.2010.02840.x] [PMID: 21251190]
[4] Collins MD, Jovita MR, Hutson RA, Ohlén M, Falsen E. Aerococcus christensenii sp. nov., from the human vagina. Int J Syst Bacteriol 1999; 49(Pt 3): 1125-8.
[http://dx.doi.org/10.1099/00207713-49-3-1125] [PMID: 10425770]
[5] De Martino SJ, Mahoudeau I, Brettes JP, Piemont Y, Monteil H, Jaulhac B. Peripartum bacteremias due to Leptotrichia amnionii and Sneathia sanguinegens, rare causes of fever during and after delivery. J Clin Microbiol 2004; 42(12): 5940-3.
[http://dx.doi.org/10.1128/JCM.42.12.5940-5943.2004] [PMID: 15583348]
[6] Ulger-Toprak N, Summanen PH, Liu C, Rowlinson MC, Finegold SM. Gemella asaccharolytica sp. nov., isolated from human clinical specimens. Int J Syst Evol Microbiol 2010; 60(Pt 5): 1023-6.
[http://dx.doi.org/10.1099/ijs.0.001966-0] [PMID: 19666813]
[7] Jensen KH, Dargis R, Christensen JJ, Kemp M. Ribosomal PCR and DNA sequencing for detection and identification of bacteria: experience from 6 years of routine analyses of patient samples. APMIS 2014; 122(3): 248-55.
[http://dx.doi.org/10.1111/apm.12139] [PMID: 23879657]
[8] Morita M, Wang HL. Association between oral malodor and adult periodontitis: a review. J Clin Periodontol 2001; 28(9): 813-9.
[http://dx.doi.org/10.1034/j.1600-051x.2001.028009813.x] [PMID: 11493349]
[9] Cabrera IB, Quinones JN, Durie DE, et al. Intracervical balloon placement and the risk of chorioamnionitis in term rupture of membranes. Obstet Gynecol 2014; 123(Suppl. 1): 43S.
[http://dx.doi.org/10.1097/01.AOG.0000447324.05518.6e]
[10] Cahill AG, Duffy CR, Odibo AO, Roehl KA, Zhao Q, Macones GA. Number of cervical examinations and risk of intrapartum maternal fever. Obstet Gynecol 2012; 119(6): 1096-101.
[http://dx.doi.org/10.1097/AOG.0b013e318256ce3f] [PMID: 22617572]
[11] DiGiulio DB. Diversity of microbes in amniotic fluid. Semin Fetal Neonatal Med 2012; 17(1): 2-11.
[http://dx.doi.org/10.1016/j.siny.2011.10.001] [PMID: 22137615]
[12] Wang X, Buhimschi CS, Temoin S, Bhandari V, Han YW, Buhimschi IA. Comparative microbial analysis of paired amniotic fluid and cord blood from pregnancies complicated by preterm birth and early-onset neonatal sepsis. PLoS One 2013; 8(2): e56131.
[http://dx.doi.org/10.1371/journal.pone.0056131] [PMID: 23437088]
[13] Jose A, Cunha BA, Klein NC, Schoch PE. Aerococcus christensenii native aortic valve subacute bacterial endocarditis (SBE) presenting as culture negative endocarditis (CNE) mimicking marantic endocarditis. Heart Lung 2014; 43(2): 161-3.
[http://dx.doi.org/10.1016/j.hrtlng.2013.11.005] [PMID: 24341951]
[14] Boennelycke M, Christensen JJ, Arpi M, Krause S. Leptotrichia amnionii found in septic abortion in Denmark. Scand J Infect Dis 2007; 39(4): 382-3.
[http://dx.doi.org/10.1080/00365540601053022] [PMID: 17454911]
[15] Murdoch DA. Gram-positive anaerobic cocci. Clin Microbiol Rev 1998; 11(1): 81-120.
[PMID: 9457430]
[16] Pins MR, Holden JM, Yang JM, Madoff S, Ferraro MJ. Isolation of presumptive Streptobacillus moniliformis from abscesses associated with the female genital tract. Clin Infect Dis 1996; 22(3): 471-6.
[http://dx.doi.org/10.1093/clinids/22.3.471] [PMID: 8852965]
[17] Faro S, Walker C, Pierson RL. Amnionitis with intact amniotic membranes involving Streptobacillus moniliformis. Obstet Gynecol 1980; 55(3)(Suppl.): 9S-11.
[http://dx.doi.org/10.1097/00006250-198003001-00003] [PMID: 7360458]
[18] Christensen JJ, Korner B, Casals JB, Pringler N. Aerococcus-like organisms: use of antibiograms for diagnostic and taxonomic purposes. J Antimicrob Chemother 1996; 38(2): 253-8.
[http://dx.doi.org/10.1093/jac/38.2.253] [PMID: 8877539]
[19] Rasmussen M. Aerococci and aerococcal infections. J Infect 2013; 66(6): 467-74.
[http://dx.doi.org/10.1016/j.jinf.2012.12.006] [PMID: 23277106]
[20] Uemura H, Hayakawa K, Shimada K, et al. Parvimonas micra as a causative organism of spondylodiscitis: a report of two cases and a literature review. Int J Infect Dis IJID Off Publ Int Soc Infect Dis 2014; 23: pp. 53-5.

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"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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