Clinical characteristics and treatment of IMP-type carbapenemase-producing Enterobacteriaceae bacteremia: Case series and literature review.

BACKGROUND: Several carbapenemases have been identified globally in Enterobacteriaceae. In Japan, IMP-type carbapenemase is the most prevalent, although cases of carbapenemase-producing Enterobacteriaceae (CPE) bacteremia are still scarce. The present case series and literature review aimed to elucidate the clinical characteristics and treatment strategies for IMP-type CPE bacteremia. METHODS: Clinical data on pediatric cases of IMP-type CPE bacteremia at the Tokyo Metropolitan Children's Medical Center between 2010 and 2020 were collected, and a review of past studies of IMP-type CPE bacteremia has been provided. RESULTS: Five pediatric episodes of IMP-type CPE bacteremia were identified. Our review of previous literature on IMP-type CPE bacteremia revealed 24 adult patients, but no pediatric patients. All 29 cases had underlying diseases, and 23 (79%) received combination therapy. The median duration of antibiotic therapy was 14 days (interquartile range: 9-14 days). The overall mortality rate was 38% (11/29). The mortality rates associated with monotherapy and combination therapy were 67% (4/6) and 30% (7/23), respectively. CONCLUSIONS: We report the first case series of IMP-type CPE bacteremia in children. Our review of past studies suggests that combination therapy might lead to better survival outcomes in patients with IMP-type CPE bacteremia. Further research is needed to establish an optimal treatment strategy for IMP-type CPE bacteremia.

Hits and misses in treatment of ESCPM gram negative infections.

Treatment of Enterobacter infections is complex and often associated with development of resistance when wrong antibiotics are chosen for treatment despite in vitro susceptibility. This infectious diseases grand round highlights two cases, how antimicrobial and diagnostic stewardship approach could detect and prevent development of such resistance in - vivo.

Factors associated with mortality in Infections caused by Carbapenem-resistant Enterobacteriaceae.

INTRODUCTION: There is little information about weigh of factors possibly associated with mortality, in infections caused by Carbapenem-resistant Enterobacteriaceae (CRE) in Latin America. METHODOLOGY: A case-controls study nested in a historical cohort was performed including all patients with CRE infections diagnosed between June 2013 and December 2018 at Hospital Universitario San Ignacio in Bogotá, Colombia. Univariate and multivariate analysis were performed to compare cases of mortality within the first month after the infection diagnosis with surviving patients. RESULTS: A total of 131 patients were included. The overall 30-day mortality rate was 38.17%. In the multivariate analysis, a direct association was found between mortality and septic shock (OR 26.7 CI6.6-107.3 p < 0.01), post-chemotherapy febrile neutropenia (OR 3.3 CI1.06-10.8 p = 0.04) and Charlson Index ≥ 3 (OR 5.5 CI 1.5-20.06 p < 0.01). An inverse association was found with interventions to control the infectious focus (OR 0.3 CI0.1-0.7 p < 0.01). The MIC of different antibiotics and the use of combined antibiotic therapy (triple therapy vs. double therapy or monotherapy) were not associated with mortality. CONCLUSIONS: In patients with CRE infections, septic shock, a Charlson comorbidity index ≥ 3, and post-chemotherapy febrile neutropenia are independently related to an increase in mortality. The control of the infectious focus is a protective factor. A rapid identification of these patients, and the implementation of measures to control infectious focus and to detect CRE colonization in patients who are going to be taken to myelosuppressive chemotherapy could impact positively the prognosis of these patients.

Hospital Discharge Data Underascertain Enteric Bacterial Infections Among Children.

Many enteric pathogens disproportionately infect children. Hospital discharge data can provide information on severe infections, including cost. However, the diagnosis must be recorded on the discharge record and coded accurately. We estimated the rate of underascertainment in hospital discharge data among children with culture-confirmed Campylobacter, Salmonella, and Escherichia coli O157 infections using linked laboratory and hospital discharge data from an integrated health care organization. We reviewed the International Classification of Diseases, 9th and 10th Revisions, Clinical Modification (ICD-9/10-CM) diagnosis codes on each patient's discharge record. We determined the percentage of patients who had a pathogen-specific diagnosis code (for Campylobacter, Salmonella, or E. coli O157) or nonspecific gastroenteritis code. We included the first admission or positive test and calculated the number of days between specimen submission (outpatient ≤7 days before admission or inpatient) and hospital discharge. Of 65 hospitalized children with culture-confirmed Campylobacter (n = 30), Salmonella (n = 24), or E. coli O157 (n = 11) infections, 55% had that pathogen-specific diagnosis code listed on the discharge record (79% Salmonella, 54% E. coli O157, 37% Campylobacter). The discharge records of the 35 children with a specimen submitted for culture ≥3 days before discharge were 16 times more likely to have a pathogen-specific diagnosis than the records of the 30 children with a specimen submitted <3 days before discharge (83% vs. 23%; odds ratio 15.9, 95% confidence interval: 4.7-53.8). Overall, 34% of records of children with culture-confirmed infection had ≥1 nonspecific gastroenteritis code (Campylobacter 43%, Salmonella 29%, E. coli O157 18%), including 59% of those for children without a pathogen-specific diagnosis (Campylobacter 63%; Salmonella 60%; E. coli O157 40%). This study showed that hospital discharge data under-ascertain enteric illnesses in children even when the infections are culture confirmed, especially for infections that usually have a short length of stay.

Enterobacter endophthalmitis: Clinical settings, susceptibility profile, and management outcomes across two decades.

Purpose: To describe the clinical presentation and management of Enterobacter endophthalmitis and compare with previous in-house published literature. Methods: This was a retrospective interventional comparative case series involving 44 cases with culture proven Enterobacter endophthalmitis from April 2006 to August 2018 who underwent vitrectomy/vitreous biopsy, intravitreal antibiotics with or without additional procedures as appropriate. The current outcomes were compared to the outcomes previously reported a decade back from our center. The mean age at presentation, predisposing factor, number of interventions, interval between inciting event and presentation, type of intravitreal antibiotic used, anatomic, and the functional outcomes were analyzed and compared to the previous series. Results: There were 30 males. Mean age was 22.73 ± 21.35 years (median 14 years). Inciting event was open globe injury in 34 (77.27%) eyes, 4 (9.09%) eyes following cataract surgery, 3 (6.81%) eyes with endogenous endophthalmitis, 2 (4.54%) eyes following keratoplasty, and 1 eye (2.27%) following trabeculectomy. Presenting visual acuity was favorable (≥20/400) in 2 eyes (4.54%), at the final visit it was in 11 eyes (25%). The organisms were most sensitive to ciprofloxacin (95.12%), amikacin (90.47%), and ceftazidime (85.36%). A comparison of the current study with previous in-house study showed that number of eyes with presenting vision ≥20/400 as well as final vision ≥20/400 were comparable. Susceptibility was highest to ciprofloxacin 39 (95.12%) (previous series) and 33 (92%) (current series). Conclusion: Enterobacter organisms show susceptibility to ciprofloxacin, amikacin, and ceftazidime. Susceptibility profile, clinical presentations, and management remain largely similar over many years. Final outcome is unfavorable.

Hafnia alvei pneumonia: a rare cause of infection in the multimorbid or immunocompromised.

Hafnia alvei is a rare, poorly understood commensal bacterium which has, on occasion, been shown to infect humans. We present two cases. The first patient presented with a 1-week history of dyspnoea, pleurisy and a productive cough, and the second with a prodrome of fatigue and night sweats. The former had a history of severe chronic obstructive pulmonary disease and the latter had a history of Crohn's disease. Both patients had underlying comorbidities and immunosuppression, but differed in presentation, radiological findings and recovery. This case series aims to remind readers of the broad differential of pathogens that can lead to disease in the immunocompromised and that one should not dismiss atypical cultured bacteria as commensal too hastily.

Pediatric Febrile Urinary Tract Infection Caused by ESBL Producing Enterobacteriaceae Species.

BACKGROUND: Over the past decade, drug resistance pattern has worsened for many of the uropathogens due to overuse of antibiotics for empiric treatment. The burden of extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae associated urinary tract infections (UTI) has become increasingly more common, limiting treatment options among children presenting with febrile UTI. We investigated the burden and correlates of ESBL producing Enterobacteriaceae associated UTI among children and antibacterial resistance pattern. METHODS: 284 midstream urine specimens were collected using standard aseptic techniques from 284 children who were diagnosed with suspected UTI. Urine culture and bacteria isolation were performed following standard bacteriological techniques. The Kirby-Bauer disk diffusion technique and the double-disc synergy test were used to investigate antibiotic susceptibility and presence of ESBL production. RESULTS: UTI was confirmed using a positive urine culture for a relevant pathogen in 96/284 (33.8%) of the cases. Enterobacteriaceae accounted for 75% (72/96) of etiologies of UTI in children. The most frequent Enterobacteriaceae spp. were E. coli, 44.4% (32/72) and K. pneumonia, 27.8% (20/72). The overall multidrug resistance rate was 86.1% (62/72). ESBL-producers accounted for 41.7% (30/72) of the isolated Enterobacteriaceae. ESBL producing K. pneumonia and E. coli isolates accounted for 70% (14/20) and 37.5% (12/32), respectively. History of UTI in the past 1 year (adjusted odds ratio (AoR) = 0.08, 95%CI (0.01 - 0.57)) and medium family wealth index (AoR = 0.03, 95%CI (0.00 - 0.27)) protected from infection with ESBL-producing Enterobacteriaceae. Conclusion. ESBL production was more common in K. pneumonia and appeared to be a major factor contributing drug resistance UTI in children. The findings call for the need to incorporate ESBL testing in the routine clinical practice. The resistance level to commonly prescribed first-line antibiotics observed within Enterobacteriaceae was alarming calling for strengthened antimicrobial stewardship.

Recurrent urinary tract infections caused by Raoultella planticola after kidney transplant.

Recurrent urinary tract infections are difficult to manage in patients with a history of kidney transplant and may contribute to graft loss. Few cases describe recurrent urinary tract infections due to Raoultella planticola in this population. We describe the management of recurrent urinary tract infections due to R planticola in a kidney transplant recipient and review other case reports of urinary tract infections due to this organism.

Inappropriate empirical antibiotic therapy does not adversely affect the clinical outcomes of patients with acute pyelonephritis caused by extended-spectrum ß-lactamase-producing Enterobacteriales.

Extended-spectrum ß-lactamase-producing Enterobacteriales (ESBL-PE) are often associated with inappropriate empirical therapy (IAT). The aim of this study was to investigate whether IAT of acute pyelonephritis (APN) caused by ESBL-PE is related to adverse outcomes. A retrospective cohort study was performed at a tertiary-care hospital from 2014 through 2016. Patients who had APN caused by ESBL-PE and were definitely treated with appropriate antibiotics for at least 7 days were enrolled. IAT was defined as when inappropriate empirical antibiotics were given 48 h or longer after initial diagnosis of APN. Primary endpoint was treatment failure defined as clinical and/or microbiologic failure. Secondary endpoints were length of hospital stay and recurrence of APN. Propensity score matching was used to adjust heterogeneity of each group. Among 175 eligible cases, 59 patients received IAT and 116 patients received appropriate empirical antimicrobial therapy (AT). Treatment failure was observed in five (8.4%) patients and nine (7.8%) patients in each group, respectively. After matching, the treatment failure rate was similar between both groups (adjusted odd ratio [aOR] 1.05; 95% confidence index [CI] 0.26-4.15). The length of hospital stay (median 11 days in the IAT group versus 11 days in the AT group; P = 0.717) and absence of recurrence within 2 months (90.3% in IAT and 86.7% in AT; P = 0.642) were also similar. IAT did not adversely affect the clinical outcome. In this regard, clinicians should be more cautious about indiscriminate prescription of broad-spectrum antibiotics such as carbapenem empirically for treatment of APN possibly caused by ESBL-PE.

Multicentre randomised controlled trial to investigate usefulness of the rapid diagnostic ßLACTA test performed directly on bacterial cell pellets from respiratory, urinary or blood samples for the early de-escalation of carbapenems in septic intensive care unit patients: the BLUE-CarbA protocol.

INTRODUCTION: The dramatic increase of the incidence of infections caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) has led to an increase of 50% of carbapenem consumption all around Europe in only 5 years. This favours the spread of carbapenem-resistant Gram-negative bacilli (GNB), causing life-threatening infections. In order to limit use of carbapenems for infections actually due to ESBL-PE, health authorities promote the use of rapid diagnostic tests of bacterial resistance. The objective of this work conducted in the intensive care unit (ICU) is to determine whether an early de-escalation of empirical carbapenems guided by the result of the ßLACTA test is not inferior to the reference strategy of de-escalating carbapenems after the antibiogram result has been rendered. METHODS AND ANALYSIS: This multicentre randomised controlled open-label non-inferiority clinical trial will include patients suffering from respiratory and/or urinary and/or bloodstream infections documented with GNB on direct examination and empirically treated with carbapenems. Empirical carbapenems will be adapted before the second dose depending on the results of the ßLACTA test performed directly on the microbiological sample (intervention group) or after 48-72 hours depending on the definite antibiogram (control group). The primary outcome will combine 90-day mortality and percentage of infection recurrence during the ICU stay. The secondary outcomes will include the number of carbapenems defined daily doses and carbapenem-free days after inclusion, the proportion of new infections during ICU stay, new colonisation of patients' digestive tractus with multidrug-resistant GNB, ICU and hospital length of stay and cost-effectiveness ratio. ETHICS AND DISSEMINATION: This protocol has been approved by the ethics committee of Paris-Ile-de-France IV, and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03147807.

A case of Raoultella ornithinolytica urinary tract infection in a pediatric patient.

Raoultella ornithinolytica is a Gram-negative, non-motile, encapsulated, biofilm producing, facultative aerobic bacillus and is found in natural environment. Human infections with R.ornithinolytica is rare in children with only five cases having been reported previously. The present case report describes an urinary tract infection caused by R. ornithinolytica that was identified by MALDI-TOF MS and successfully treated with antibiotic therapy in a 6.5-year-old female child.

Meropenem-vaborbactam: a carbapenem and beta-lactamase inhibitor with activity against carbapenem-resistant Enterobacteriaceae.

Meropenem-vaborbactam is a carbapenem and ß-lactamase inhibitor combination that is newly indicated for the treatment of complicated urinary tract infections (cUTI), including adult pyelonephritis. Vaborbactam was developed due to emergence of carbapenem-resistant strains of Enterobacteriaceae. In a phase I trial, patients that received meropenem-vaborbactam 2-2 g intravenously over 3 h every 8 h, Cmax was 58.2 ± 10.8 µg/mL for meropenem and 59.0 ± 8.4 µg/mL for vaborbactam. AUC0-8 was 186 ± 33.6 µg â€¢ h/mL for meropenem and 204 ± 34.6 µg â€¢ h/mL for vaborbactam. Vss = 16.3 ± 2.6 L for meropenem and 17.6 ± 2.6 L for vaborbactam. Protein binding for vaborbactam averaged 33% in humans. Plasma clearance ranged from 10.42 ± 1.85 to 14.77 ± 2.84 L/h. One phase III trial evaluated efficacy for meropenem-vaborbactam 2-2 g intravenously every 8 h versus piperacillin-tazobactam 4-0.5 g intravenously every 8 h in complicated UTI. It found non-inferiority and statistical superiority for meropenem in overall success at the end of treatment primary end point. In another phase III trial evaluating efficacy in carbapenem-resistant Enterobacteriaceae (CRE) infections, meropenem-vaborbactam 2-2 g intravenously every 8 h was associated with decreased 28-day mortality and increased clinical cure compared with a best available therapy group.

Clinical Outcomes in Patients With Gram-Negative Infections Treated With Optimized Dosing Cefepime Over Various Minimum Inhibitory Concentrations.

BACKGROUND: The Clinical and Laboratory Standards Institute (CLSI) revised cefepime interpretive criteria, introducing the susceptible dose-dependent category for Enterobacteriaceae with a minimum inhibitory concentration (MIC) of 4 to 8 µg/mL in 2014. Limited clinical data support these new categories. This study compares outcomes of patients treated with standard and high-dose cefepime across various MICs. METHODS: We retrospectively reviewed cases of pneumonia or bacteremia caused by gram-negative organisms treated with adequate doses of cefepime for ≥48 hours. Outcomes were compared for MICs of ≤2 (low), 4 (medium), and 8 µg/mL (high). The primary end point was clinical failure, the secondary end point was microbiological failure. RESULTS: Ninety cases met the inclusion criteria: 46, 25, and 19 patients with low, medium, or high MIC, respectively. Multivariate logistic regression revealed that the medium (odds ratio [OR]: 9.13, P < .01) and high (OR: 6.79, P = .01) MIC groups had increased clinical failure. CONCLUSION: Cefepime therapy, even at CLSI-recommended doses, had an increased risk of clinical failure for gram-negative pathogens with MICs of 4 or 8 µg/mL. This finding suggests that higher dosing regimens (2 g every 8 hours or 1 g every 6 hours) may be necessary to treat serious gram-negative infections with elevated MICs.

Prevalencia en España de mecanismos de resistencia a quinolonas en enterobacterias productoras de betalactamasas de clase C adquiridas y/o carbapenemasas / Prevalence of quinolone resistance mechanisms in Enterobacteriaceae producing acquired AmpC Beta-lactamases and/or carbapenemases in Spain

Introducción: En los últimos años se ha observado un incremento de la resistencia a fluoroquinolonas en enterobacterias, estando asociado significativamente a la resistencia a betalactámicos. Nuestro objetivo fue conocer la prevalencia de mecanismos cromosómicos y plasmídicos de resistencia a quinolonas en aislados productores de betalactamasas de claseC adquiridas y/o carbapenemasas. Métodos: Se evaluó la presencia de mecanismos cromosómicos y plasmídicos de resistencia a quinolonas [mutaciones en la región determinante de resistencia a quinolonas de gyrA y parCy genes qnr, aac(6')-Ib-cr y qepA] en 289 aislados de enterobacterias productoras de betalactamasas de claseC adquiridas y/o carbapenemasas recogidos entre febrero y julio de 2009 en 35 hospitales españoles. Resultados: Se detectaron determinantes plasmídicos en 92 aislados (31,8%); en 83 aislados (28,7%) se detectó algún gen qnr, y en 20 (7%), la variante aac(6')-Ib-cr. El gen qnr más prevalente fue qnrB4 (20%), asociado en la mayoría de los casos a DHA-1. El 14,6% de los aislados con una CMI de ciprofloxacino superior a 0,25mg/l no presentaban mutaciones en gyrA ni parC, detectándose en el 90% de los mismos algún determinante plasmídico de resistencia a quinolonas. Conclusión: qnrB4 fue el determinante plasmídico más prevalente, claramente asociado a DHA-1. Los mecanismos plasmídicos en asociación con mecanismos cromosómicos diferentes a las mutaciones en los genes de las topoisomerasas (sobreexpresión de bombas de expulsión, alteración del lipopolisacárido o disminución de porinas) pueden dar lugar a valores de CMI de ciprofloxacino que superan los puntos de corte establecidos por los principales comités internacionales de definición de puntos de corte para interpretación de datos de sensibilidad (AU)

Background: Quinolone resistance in Enterobacteriaceae species has increased over the past few years, and is significantly associated to beta-lactam resistance. The aim of this study was to evaluate the prevalence of chromosomal- and plasmid-mediated quinolone resistance in acquired AmpC Beta-lactamase and/or carbapenemase-producing Enterobacteriaceae isolates. Methods: The presence of chromosomal- and plasmid-mediated quinolone resistance mechanisms [mutations in the quinolone resistance determining region (QRDR) of gyrA and parC and qnr, aac(6')-Ib-cr and qepA genes] was evaluated in 289 isolates of acquired AmpC Beta -lactamase- and/or carbapenemase-producing Enterobacteriaceae collected between February and July 2009 in 35 Spanish hospitals. Results: Plasmid mediated quinolone resistance (PMQR) genes were detected in 92 isolates (31.8%), qnr genes were detected in 83 isolates (28.7%), and the aac(6')-Ib-cr gene was detected in 20 isolates (7%). qnrB4 gene was the most prevalent qnr gene detected (20%), associated, in most cases, with DHA-1. Only 14.6% of isolates showed no mutations in gyrA or parC with a ciprofloxacin MIC of 0.5mg/L or higher, whereas PMQR genes were detected in 90% of such isolates. Conclusion: qnrB4 gene was the most prevalent PMQR gene detected, and was significantly associated with acquired AmpC Beta -lactamase DHA-1. PMQR determinants in association with other chromosomal-mediated quinolone resistance mechanisms, different to mutations in gyrA and parC (increased energy-dependent efflux, altered lipopolysaccharide or porin loss), could lead to ciprofloxacin MIC values that exceed breakpoints established by the main international committees to define clinical antimicrobial susceptibility breakpoints (AU)

A Novel Protocol Obviates Endoscope Sampling for Carbapenem-Resistant Enterobacteriaceae: Experience of a Center with a Prior Outbreak.

BACKGROUND: Numerous published outbreaks, including one from our institution, have described endoscope-associated transmission of multidrug-resistant organisms (MDROs). Individual centers have adopted their own protocols to address this issue, including endoscope culture and sequestration. Endoscope culturing has drawbacks and may allow residual bacteria, including MDROs, to go undetected after high-level disinfection. AIM: To report the outcome of our novel protocol, which does not utilize endoscope culturing, to address our outbreak. METHODS: All patients undergoing procedures with elevator-containing endoscopes were asked to permit performance of a rectal swab. All endoscopes underwent high-level disinfection according to updated manufacturer's guidance. Additionally, ethylene oxide (EtO) sterilization was done in the high-risk settings of (1) positive response to a pre-procedure risk stratification questionnaire, (2) positive or indeterminate CRE polymerase chain reaction (PCR) from rectal swab, (3) refusal to consent for PCR or questionnaire, (4) purulent cholangitis or infected pancreatic fluid collections. Two endoscopes per weekend were sterilized on a rotational basis. RESULTS: From September 1, 2015 to April 30, 2016, 556 endoscopy sessions were performed using elevator-containing endoscopes. Prompted EtO sterilization was done on 46 (8.3%) instances, 3 from positive/indeterminate PCR tests out of 530 samples (0.6%). No CRE transmission was observed during the study period. Damage or altered performance of endoscopes related to EtO was not observed. CONCLUSION: In this pilot study, prompted EtO sterilization in high-risk patients has thus far eliminated endoscope-associated MDRO transmission, although no CRE infections were noted throughout the institution during the study period. Further studies and a larger patient sample will be required to validate these findings.

Successful Treatment of PD Peritonitis Due to Morganella morganii Resistant to Third-Generation Cephalosporins - A Case Report.

Morganella morganii is a rare cause of peritonitis in patients on peritoneal dialysis (PD). Most of the reported cases have resorted to a switch to hemodialysis. We herein report a case of peritonitis due to M. morganii resistant to third-generation cephalosporins, which was treated successfully with intraperitoneal (IP) tobramycin followed by oral ciprofloxacin. Early microbiologic diagnosis is essential in the treatment of peritonitis from rare microorganisms such as Morganella morganii, and appropriate antibiotic therapy is the key to avoiding catheter loss and subsequent switch to hemodialysis.

Nosocomial pneumonia caused by carbapenem-resistant Raoultella planticola: a case report and literature review.

Raoultella planticola is a rare opportunistic pathogen usually invaded immunocompromised patients and sometimes even causes fatal infections. Recently, there is growing concern about the emergence of carbapenem resistance in this species. Here, we describe one case of hospital-acquired pneumonia due to a carbapenem-resistant R. planticola (CRRP) co-producing Klebsiella pneumoniae carbapenemase and extended-spectrum ß-lactamase. A literature review was performed to indicate the microbiological and clinical features of infections caused by CRRP.

Clinical and microbiological features of Providencia bacteremia: experience at a tertiary care hospital

BACKGROUND/AIMS: Providencia species frequently colonize urinary catheters and cause urinary tract infections (UTIs); however, bacteremia is uncommon and not well understood. We investigated the clinical features of Providencia bacteremia and the antibiotic susceptibility of Providencia species. METHODS: We identified cases of Providencia bacteremia from May 2001 to April 2013 at a tertiary care hospital. The medical records of pertinent patients were reviewed. RESULTS: Fourteen cases of Providencia bacteremia occurred; the incidence rate was 0.41 per 10,000 admissions. The median age of the patients was 64.5 years. Eleven cases (78.6%) were nosocomial infections and nine cases (64.3%) were polymicrobial bacteremia. The most common underlying conditions were cerebrovascular/neurologic disease (n = 10) and an indwelling urinary catheter (n = 10, 71.4%). A UTI was the most common source of bacteremia (n = 5, 35.7%). The overall mortality rate was 29% (n = 4); in each case, death occurred within 4 days of the onset of bacteremia. Primary bacteremia was more fatal than other types of bacteremia (mortality rate, 75% [3/4] vs. 10% [1/10], p = 0.041). The underlying disease severity, Acute Physiologic and Chronic Health Evaluation II scores, and Pitt bacteremia scores were significantly higher in nonsurvivors (p = 0.016, p =0.004, and p = 0.002, respectively). Susceptibility to cefepime, imipenem, and piperacillin/tazobactam was noted in 100%, 86%, and 86% of the isolates, respectively. CONCLUSIONS: Providencia bacteremia occurred frequently in elderly patients with cerebrovascular or neurologic disease. Although Providencia bacteremia is uncommon, it can be rapidly fatal and polymicrobial. These characteristics suggest that the selection of appropriate antibiotic therapy could be complicated in Providencia bacteremia.

A novel case of chronic conjunctivitis in a 58-year-old woman caused by Raoultella.

A 58-year-old woman presented to eye emergency with a chronic conjunctivitis which was diagnosed by laboratory microbiological testing to be due to the environmental pathogen Raoultella planticola. The organism was sensitive to Chloramphenicol and the patient made a rapid recovery on these drops. This is the first report of this organism infecting the eye.