Professional Documents
Culture Documents
Enterobacter Cloacae
Enterobacter Cloacae
Epidemiology
Frequency
United States
National surveillance programs continually demonstrate that Enterobacter species
remain a significant source of morbidity and mortality in hospitalized patients.
In the Surveillance and Control of Pathogens of Epidemiological Importance [SCOPE]
project, 24,179 nosocomial bloodstream infections from 1995-2002 were
analyzed. Enterobacter species were the second-most-common gram-negative
organism behind Pseudomonas aeruginosa; however, both bacteria were reported to
each represent 4.7% of bloodstream infections in ICU settings. Enterobacterspecies
represent 3.1% of bloodstream infections in non-ICU wards. Of nearly 75,000 gramnegative organisms collected from ICU patients in the United States between 1993 and
2004, Enterobacter species comprised 13.5% of the isolates. Multidrug resistance
increased over time, especially in infections caused by E cloacae.[3]
The National Healthcare Safety Network (NHSN) reported on healthcare-associated
infections (HAI) between 2006 and 2007. They found Enterobacter species to be the
eighth most common cause of HAI (5% of all infections) and the fourth most common
gram-negative cause of HAIs.[4]
Previous reports from the National Nosocomial Infections Surveillance System (NNIS)
demonstrated that Enterobacter species caused 11.2% of pneumonia cases in all types
of ICUs, ranking third after Staphylococcus aureus (18.1%) and P aeruginosa (17%).
The corresponding rates among patients in pediatric ICUs were 9.8% for pneumonia,
6.8% for bloodstream infections, and 9.5% for UTIs. [5, 6, 7]
Enterobacter species were also among the most frequent pathogens involved in
surgical-site infections, as reported in the NNIS report from October 1986 to April 1997.
Enterobacter species can cause disease in virtually any body compartment. They
are responsible for frequent and severe nosocomial infections that require prolonged
hospitalization, multiple and varied imaging studies and laboratory tests, various
surgical and nonsurgical procedures, and powerful and expensive antimicrobial
agents. Most importantly, Enterobacter infections that do not directly causing death
cause considerable suffering in many patients, most of whom are already afflicted with
chronic diseases.
In patients with Enterobacter bacteremia, the most important factor in
determining the risk of mortality is the severity of the underlying disease. Higher 30day mortality rates were noted in patients presenting with septic shock and increasing
Acute Physiology and Chronic Health Evaluation II scores. Other factors implicated,
independently or by association, in the outcome of Enterobacter bacteremia include
thrombocytopenia, hemorrhage, a concurrent pulmonary focus of infection, renal
insufficiency, admission in an ICU, prolonged hospitalization, prior surgery,
intravascular and/or urinary catheters, immunosuppressive therapy, neutropenia,
antibiotic resistance, and inappropriate antimicrobial therapy.
Crude mortality rates associated with Enterobacter infections range from 1587%, but most reported rates range from 20-46%. Attributable mortality rates are
reported to range from 6-40%.
o
E cloacae infection is associated with the highest mortality rate of
allEnterobacter infections.
o
Apprehension
High fever or hypothermia
Tachycardia
Hypoxemia
Tachypnea
Cyanosis
Patients with pulmonary consolidation may present with crackling sounds, dullness to
percussion, tubular breath sounds, and egophony. Pleural effusion may manifest as
dullness to percussion and decreased breath sounds.
See Clinical Presentation for more detail.
Diagnosis
Laboratory studies
Studies for the evaluation of Enterobacter infections include the following:
Electrolyte evaluation
Fluid analysis, such as cells and differential, proteins, glucose, and, in some
cases, pH, lactate dehydrogenase, and amylase; required for pleural, articular,
pericardial, peritoneal, and cerebrospinal fluids
Urine analysis: Always indicated for urinary tract infections (UTIs)
Factors in the microbiologic diagnosis and assessment of Enterobacter infection include
the following:
The most important test to document Enterobacter infections is culture; when the
patient presents with signs of systemic inflammation (eg, fever, tachycardia,
tachypnea) with or without shock (eg, hypotension, decreased urinary output), blood
cultures are mandatory
Direct Gram staining of the specimen is also useful, because it allows rapid
diagnosis of an infection caused by gram-negative bacilli and helps in the selection of
antibiotics with known activity against most of these bacteria
In the laboratory, growth of Enterobacter isolates is expected to be detectable in
24 hours or less; Enterobacter species grow rapidly on selective (ie, MacConkey) and
nonselective (ie, sheep blood) agars
Imaging studies
Studies used in the investigation and management of Enterobacter infections include
the following:
ManaGEMENT
E cloacae, E aerogenes, and most otherEnterobacter species are resistant to the
narrow-spectrum penicillins that traditionally have good activity against other
Enterobacteriaceae such as E coli (eg, ampicillin, amoxicillin) and to firstgeneration and second-generation cephalosporins (eg, cefazolin, cefuroxime).
They also are usually resistant to cephamycins such as cefoxitin. Initial
resistance to third-generation cephalosporins (eg, ceftriaxone, cefotaxime,
ceftazidime) and extended-spectrum penicillins (eg, ticarcillin, azlocillin,
piperacillin) varies but can develop during treatment. The activity of the fourthgeneration cephalosporins (eg, cefepime) is fair, and the activity of the
carbapenems (eg, imipenem, meropenem, ertapenem, doripenem) is excellent.
However, resistance has been reported, even to these agents
Surgical care is indicated as for other sources of infection: drainage or debridement of
abscesses, infected collections, or osteomyelitic foci.