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Enterobacter Spp.: Pathogens Poised to Flourish at the Turn of the Century

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Enterobacter Spp.: Pathogens Poised to Flourish at the Turn of the Century CLINICAL MICROBIOLOGY REVIEWS, Apr. 1997, p. 220–241 Vol. 10, No. 2 0893-8512/97/$04.0010 Copyright q 1997, American Society for Microbiology Enterobacter spp.: Pathogens Poised To Flourish at the Turn of the Century W. EUGENE SANDERS, JR., AND CHRISTINE C. SANDERS* Department of Medical Microbiology and Immunology, Creighton University School of Medicine, Omaha, Nebraska 68178 INTRODUCTION .......................................................................................................................................................220 MICROBIOLOGY ......................................................................................................................................................221 The Organism..........................................................................................................................................................221 General Epidemiology ............................................................................................................................................221 Pathogenesis ............................................................................................................................................................222 ANTIMICROBIAL SUSCEPTIBILITY....................................................................................................................223 RESISTANCE..............................................................................................................................................................224 Prevalence ................................................................................................................................................................224 Factors Associated with Resistance......................................................................................................................224 Mechanisms of Resistance.....................................................................................................................................224 Emergence of Resistance During Therapy ..........................................................................................................225 CLINICAL MANIFESTATIONS ..............................................................................................................................225 Bacteremia ...............................................................................................................................................................225 Demographics......................................................................................................................................................225 Signs, symptoms, and laboratory findings ......................................................................................................226 Portals of entry ...................................................................................................................................................227 Risk factors for development of bacteremia ...................................................................................................227 Determinants of the outcome of bacteremia...................................................................................................228 Comparisons with bacteremias due to other enteric bacilli .........................................................................229 Lower Respiratory Tract Infections .....................................................................................................................230 Infections of Skin and Soft Tissues......................................................................................................................232 Institutionally acquired infections of surgical wounds and burns ..............................................................232 Soft tissue infections in healthy individuals ...................................................................................................232 Endocarditis.............................................................................................................................................................233 Intra-abdominal Infections....................................................................................................................................233 Urinary Tract Infections........................................................................................................................................233 Central Nervous System Infections ......................................................................................................................233 Ophthalmic Infections............................................................................................................................................234 Septic Arthritis and Osteomyelitis .......................................................................................................................235 Cotton Fever ............................................................................................................................................................235 Mimicry of Syndromes Commonly Attributed to Other Organisms ...............................................................235 PERSPECTIVE ON THE FUTURE.........................................................................................................................235 ACKNOWLEDGMENTS ...........................................................................................................................................236 REFERENCES ............................................................................................................................................................236 INTRODUCTION more easily treatable infectious agents, such as group A strep- tococci or Staphylococcus aureus. Other recent developments Enterobacter spp. have been recognized as increasingly im- include recognition of relatively high rates of coinfection with portant pathogens in recent years. Most of these organisms are other pathogens, predominance in liver and lung transplant innately resistant to older antimicrobial agents and have the infections, etiologic role in cotton fever, and increasing inci- ability to rapidly develop resistance to newer agents. They have dence in a variety of clinical syndromes. increased in incidence as causes of nosocomial infections in Because of dramatic changes and expansion of the knowl- general, while multiply resistant strains have emerged in areas edge of Enterobacter spp., we initiated a review of the recent of high cephalosporin use within the hospital. More recently, it literature. The following databases were searched for the pe- appears that Enterobacter spp., including multiply resistant riod 1990 to 1995: Medline, Excerpta Medica, Biosis, and Zen- strains, have spilled over into the community, occasionally in- eca internal database. Approximately 1,300 citations were fecting otherwise well individuals. These organisms have been identified. Abstracts and summaries were obtained for each implicated in an increasing number of clinical syndromes, oc- whenever possible. From this compilation, complete publica- casionally mimicking those traditionally associated with other, tions were selected for review on the basis of their relative contribution of new knowledge to the field or ability to provide * Corresponding author. Mailing address: Department of Medical access to the voluminous older literature. Herein, we have Microbiology and Immunology, Creighton University School of Med- preferentially cited these publications. In addition, we have icine, 2500 California Plaza, Omaha, NE 68178. Phone: (402) 280- selectively cited older publications that provided necessary 1881. Fax: (402) 280-1225. background to document recent trends, represented major 220 VOL. 10, 1997 ENTEROBACTER SPP. 221 TABLE 1. Differentiation between species of Enterobacter most 43, 77, 80, 91, 125, 126, 137, 140, 167, 204, 208, 229, 237, 238). commonly recovered from clinical materiala Due to the metabolic diversity within certain species, biotyping Reaction of: has been a useful approach for strain identification in certain settings (125, 126). However, biotyping may not distinguish Test E. E. E. E. true strain differences in some instances (18, 80, 91, 137, 167, aerogenes cloacae sakazakii agglomerans 237). The antimicrobial susceptibility pattern is generally un- Lysine decarboxylase 122 2 reliable for strain differentiation (18, 80, 91, 167). Different Arginine dihydrolase 211 2 patterns can arise from the same strain before and after mu- Ornithine decarboxylase 111 2 tation of chromosomal genes affecting the expression of b-lac- Growth in KCN 111Variable tamase (see below). Conversely, similar antimicrobial suscep- 112 Fermentation of D-sorbitol Variable tibility patterns can be seen among strains shown to be distinct a Data from references 58 to 60 and 136. by a variety of other methods. Typing by bacteriocin or bacte- riophage pattern or serotyping based upon O or H antigens has also been developed (43, 77, 126, 137, 144, 238). However, all original contributions, or complemented the presentation of of these approaches require the use of highly specific reagents recent material. We review microbiology, epidemiology, anti- that may not be available outside a limited number of refer- microbial susceptibility and resistance, clinical manifestations, ence laboratories. Furthermore, the susceptibility to bacterio- and outcomes of therapy, and we conclude
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