A 72-year-old man with a history of severe COPD presented to the ER with 2 weeks of shortness of breath and productive cough. He denied sick contacts, hospitalizations, antibiotic use, or travel. On exam, patient was in mild respiratory distress with tachypnea, tachycardia and fever. He had decreased breath sounds bilaterally with diffuse expiratory wheezing. Lab was significant for a leukocytosis of 21,000. ABG, procalcitonin and chest X-ray were unremarkable. Patient was admitted to the hospital and treated for acute exacerbation of COPD with levofloxacin and prednisone. On hospital day 2, the blood culture returned with Elizabethkingia meningoseptica with multidrug resistance to all except ciprofloxacin. Since the patient showed significant clinical improvement and surveillance blood culture was negative to date, he was discharged home with levofloxacin for 14 days. The sputum culture though ordered at admission was not collected until the day of discharge. Five days later, the sputum culture returned with Elizabethkingia meningoseptica with intermediate levofloxacin susceptibility and surveillance blood culture remained negative. The patient was contacted at home and reported continued improvement so per discussion with Infectious Disease, he was continued on levofloxacin with resolution of symptoms at clinic follow-up.
Discussion: Elizabethkingia meningoseptica is a non-fermenting, Gram-negative bacillus which can be found in plants, soil, and fresh and salt water. It has been isolated from hospital water supplies, saline solutions used for antibiotic preparation and medical devices. In the last decade, it has been an emerging pathogen in hospitalized patients and has been implicated as a cause of nosocomial pneumonias, sepsis, abdominal infections, endocarditis, cellulitis, and meningitis. Risk factors include neonates, the immuncompromised, prolonged hospital stays, indwelling central venous catheters and prior antibiotic use. 14-day mortality ranges from 23% to 52% owing to its unique susceptibility pattern. Unlike other Gram-negative bacillus, E. meningoseptica is resistant to many antibiotics usually effective against Gram-negative bacteria such as beta-lactams, aminoglycosides, aztreonam and carbapenems and oddly susceptible to antibiotics used to treat Gram-positive infections.
Nosocomial infections caused by Elizabethkingia meningoseptica are increasing in incidence. This is a case of E. meningosepticabacteremia in an immunocompetent patient presenting from the community. This Gram-negative infection is challenging to treat due to its unique multidrug resistance to antibiotics usually effective against Gram-negative organisms and its unusual susceptibility to agents reserved for Gram-positive organisms. Hospitalists should be aware of this emerging pathogen in the hospital setting and as in this case, from the community, and its unique susceptibility pattern to avoid inappropriate empiric antibiotic choice and treatment failure. Current literature, although limited, suggests empiric treatment with vancomycin, rifampin, fluoroquinolones, piperacillin-tazobactam, minocycline, trimethoprim-sulfamethoxazole or possibly tigecycline until susceptibility patterns are obtained.