Case Presentation: An 80-year-old female with a history of hypoxic encephalopathy, chronic respiratory failure on mechanical ventilation through tracheostomy, End stage renal disease on hemodialysis through right arm arterio-venous fistula who presented immediately after dialysis session with hypotension, tachycardia and hypoglycemia from nursing home. Physical exam was remarkable for a temperature of 100.5 F, blood pressure of 85/37 mm of Hg, heart rate of 93 beats per minute with diffuse abdominal tenderness. Her chest xray showed left lower lobe infiltrate and computed tomography(CT) of abdomen showed thickening of the left side of the colon. Her labs were significant for a White blood count of 14.5 k/mmcu(ref range: 4-11 k/mmcu), and a lactate of 5.1 mmol/lt(ref range 0.7-2.0 mmol/lt). The blood cultures were sent and she was started on empirical antibiotics with vancomycin and piperacillin/tazobactam for septic shock. She was also supported hemodynamically with norepinephrine at the rate of 20 mics/min. Her Cultures grew Elizabethkingia meningosepticawhich was resistant to all antibiotcs except for trimethoprim-sulfamethoxazole. She also developed diarrhea and was diagnosed with Clostridium difficle infection. She was continued on vancomycin, piperacillin/tazobactam and was started on trimethoprim-sulfamethoxazole, rifampin, amikacin and colisitin. She was also started on oral vancomycin and fidaxomicin for C. difficle colitis. Eventually she started to respond in terms of decreasing white blood count, negative blood cultures and was off the pressors after 11 days of treatment and was sent back to nursing home to continue treatment for a total of 21 days.

Discussion: E. meningoseptica has been documented as a pathogen among immunocompetent neonates, but adult patients on mechanical ventilation and bedside hemodialysis may be more prone to this infection. E. meningoseptica often colonizes sink basins and taps and has become a potential reservoir for infections in the hospital environment. These infections associated with a poor outcome, with a cumulative mortality of 33% among postneonates. They are resistant to many antimicrobial classes commonly used to treat infections caused by gram-negative bacteria (aminoglycosides, chloramphenicol) but are often susceptible to agents generally used to treat infections caused by gram-positive bacteria (rifampicin, quinolones, vancomycin, trimethoprim-sulfamethoxazole). Recognition of this organism should immediately initiate antibiotic changes as per the sensitivity patterns. Active infection control measures like regularly inspecting the hospital water tanks, water surveillance, and hyperchlorinating the water might be required for controlling infection with this bacterium.

Conclusions: Elizabethkingia meningoseptica is a gram-negative bacillus which has been associated with various nosocomial infections. This multidrug resistant organism which initially was associated with neonatal infections have recently been identified as source of infection in immunocompromised hosts especially in hemodialysis patients. Its resistance to conventional empirical antimicrobials for gram negative bacteria have resulted in unfavorable outcomes among the patients. This calls for need to be familiar with this organism, active infection control measures and changing antibiotics as per sensitivity pattern.