Inpatient & Outpatient Medications

Enterobacter infections that are improving may warrant switch from an intravenous regimen to an oral medication such as a quinolone or TMP-SMZ in accordance with sensitivity testing, when feasible. Ciprofloxacin (500-750 mg PO q12h if renal function is normal) is an acceptable alternative in patients who are able to tolerate oral medication as long as they are not coadministered products that contain divalent cations (calcium or dairy products, iron, magnesium, zinc). There are no specific guidelines for the treatment of endocarditis caused by enteric gram-negative bacilli. The AHA recommends involvement of an infectious diseases specialist, cardiothoracic surgeon, as well as consideration for combination antibiotic therapy ideally using antibiotics from two different classes.

Some patients with Enterobacter infections may require longer therapy with intravenous antibiotics. In those who meet criteria for home antibiotic therapy, the selected intravenous medication should not usually require more than 3-times-daily infusion. Ertapenem and tigecycline may be considered for such patients in conjunction with antimicrobial susceptibility testing results, infectious disease specialists and home infusion therapy experts. Close monitoring while on antibiotics and after stopping antibiotics is essential.

Deterrence/Prevention

When hospital (ICU) outbreaks of Enterobacter infections occur, isolation and barrier protection should be implemented. Isolation precautions should also be implemented when a multidrug-resistant organism is isolated.

Hand washing or use of alcohol or other disinfecting hand gels by health care workers between contacts with patients prevents transmission of these and other nosocomial bacteria. This is particularly true in ICUs.

Prior antibiotic administration is a major factor for colonization and secondary infections with these multiple-antibiotic–resistant organisms. Clinicians are advised to avoid unnecessary administration of antimicrobial agents or to avoid unnecessary prolonged administration. For surgical prophylaxis, administration of antibiotics for longer than 24 hours is rarely justifiable.

Education programs for physicians and hospital personnel regarding risk reduction for transmission of Enterobacter species and other nosocomial pathogens should be implemented in every hospital. This is usually the responsibility of the Infection Prevention and Control team.

Comprehensive guidelines regarding isolation for and prevention of nosocomial infections and management of infections by multidrug-resistant organisms (eg, ESBL-producing Enterobacter species) in health care settings are available at the Centers for Disease Control Web site (Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007; Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006).

The Centers for Disease Control and Prevention (CDC) has expanded its guidelines for preventing the spread of carbapenem-resistant Enterobacteriaceae (CRE). Noting that most cases of CRE found in the United States have been isolated from patients who received overnight treatment in medical facilities outside the country, the new recommendations are as follows^{[71, 72]}:

When a CRE is found in a patient who within the previous 6 months had stayed overnight in a non-US health-care facility, the isolate should undergo confirmatory susceptibility testing and the carbapenem resistance mechanism should be determined
Rectal screening cultures should be ordered for any patient admitted to a health-care facility in the United States after being hospitalized within the previous 6 months in another country; such patients should be placed on contact precautions until the results of the screenings are available.

Prognosis

See Mortality/Morbidity.

Questions

Davin-Regli A, Lavigne JP, Pagès JM. Enterobacter spp.: Update on Taxonomy, Clinical Aspects, and Emerging Antimicrobial Resistance. Clin Microbiol Rev. 2019 Sep 18. 32 (4):[QxMD MEDLINE Link].
Santajit S, Indrawattana N. Mechanisms of Antimicrobial Resistance in ESKAPE Pathogens. Biomed Res Int. 2016. 2016:2475067. [QxMD MEDLINE Link]. [Full Text].
Rice LB. Federal funding for the study of antimicrobial resistance in nosocomial pathogens: no ESKAPE. J Infect Dis. 2008 Apr 15. 197 (8):1079-81. [QxMD MEDLINE Link].
Davin-Regli A, Pagès JM. Enterobacter aerogenes and Enterobacter cloacae; versatile bacterial pathogens confronting antibiotic treatment. Front Microbiol. 2015. 6:392. [QxMD MEDLINE Link].
Mezzatesta ML, Gona F, Stefani S. Enterobacter cloacae complex: clinical impact and emerging antibiotic resistance. Future Microbiol. 2012 Jul. 7 (7):887-902. [QxMD MEDLINE Link].
Tindall BJ, Sutton G, Garrity GM. Enterobacter aerogenes Hormaeche and Edwards 1960 (Approved Lists 1980) and Klebsiella mobilis Bascomb et al. 1971 (Approved Lists 1980) share the same nomenclatural type (ATCC 13048) on the Approved Lists and are homotypic synonyms, with consequences for the name Klebsiella mobilis Bascomb et al. 1971 (Approved Lists 1980). Int J Syst Evol Microbiol. 2017 Feb. 67 (2):502-504. [QxMD MEDLINE Link].
Lockhart SR, Abramson MA, Beekmann SE, et al. Antimicrobial resistance among Gram-negative bacilli causing infections in intensive care unit patients in the United States between 1993 and 2004. J Clin Microbiol. 2007 Oct. 45(10):3352-9. [QxMD MEDLINE Link].
Hidron AI, Edwards JR, Patel J, Horan TC, Sievert DM, Pollock DA. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control Hosp Epidemiol. 2008 Nov. 29(11):996-1011. [QxMD MEDLINE Link].
National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) report, data summary from October 1986-April 1997, issued May 1997. A report from the NNIS System. Am J Infect Control. 1997 Dec. 25(6):477-87. [QxMD MEDLINE Link].
National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) System report, data summary from January 1990-May 1999, issued June 1999. Am J Infect Control. 1999 Dec. 27(6):520-32. [QxMD MEDLINE Link].
National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004 Dec. 32(8):470-85. [QxMD MEDLINE Link].
National Nosocomial Infections Surveillance System. Intensive Care Antimicrobial Resistance Epidemiology (ICARE) Surveillance Report, data summary from January 1996 through December 1997: A report from the National Nosocomial Infections Surveillance (NNIS) System. Am J Infect Control. 1999 Jun. 27(3):279-84. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention (CDC). Vital signs: carbapenem-resistant Enterobacteriaceae. MMWR Morb Mortal Wkly Rep. 2013 Mar 8. 62 (9):165-70. [QxMD MEDLINE Link].
Rossi F, Baquero F, Hsueh PR, et al. In vitro susceptibilities of aerobic and facultatively anaerobic Gram-negative bacilli isolated from patients with intra-abdominal infections worldwide: 2004 results from SMART (Study for Monitoring Antimicrobial Resistance Trends). J Antimicrob Chemother. 2006 Jul. 58(1):205-10. [QxMD MEDLINE Link].
Chow JW, Satishchandran V, Snyder TA, et al. In vitro susceptibilities of aerobic and facultative gram-negative bacilli isolated from patients with intra-abdominal infections worldwide: the 2002 Study for Monitoring Antimicrobial Resistance Trends (SMART). Surg Infect (Larchmt). 2005 Winter. 6(4):439-48. [QxMD MEDLINE Link].
Deal EN, Micek ST, Ritchie DJ, et al. Predictors of in-hospital mortality for bloodstream infections caused by Enterobacter species or Citrobacter freundii. Pharmacotherapy. 2007 Feb. 27(2):191-9. [QxMD MEDLINE Link].
Ye Y, Li JB, Ye DQ, et al. Enterobacter bacteremia: Clinical features, risk factors for multiresistance and mortality in a Chinese University Hospital. Infection. 2006 Oct. 34(5):252-7. [QxMD MEDLINE Link].
Gallagher PG, Ball WS. Cerebral infarctions due to CNS infection with Enterobacter sakazakii. Pediatr Radiol. 1991. 21(2):135-6. [QxMD MEDLINE Link].
Drudy D, Mullane NR, Quinn T, et al. Enterobacter sakazakii: an emerging pathogen in powdered infant formula. Clin Infect Dis. 2006 Apr 1. 42(7):996-1002. [QxMD MEDLINE Link].
Yan QQ, Condell O, Power K, Butler F, Tall BD, Fanning S. Cronobacter species (formerly known as Enterobacter sakazakii) in powdered infant formula: a review of our current understanding of the biology of this bacterium. J Appl Microbiol. 2012 Mar 16. [QxMD MEDLINE Link].
Iversen C, Lehner A, Mullane N, Marugg J, Fanning S, Stephan R, et al. Identification of "Cronobacter" spp. (Enterobacter sakazakii). J Clin Microbiol. 2007 Nov. 45(11):3814-6. [QxMD MEDLINE Link].
Palmer DL, Kuritsky JN, Lapham SC, et al. Enterobacter mediastinitis following cardiac surgery. Infect Control. 1985 Mar. 6(3):115-9. [QxMD MEDLINE Link].
Tunkel AR, Fisch MJ, Schlein A, et al. Enterobacter endocarditis. Scand J Infect Dis. 1992. 24(2):233-40. [QxMD MEDLINE Link].
Wengrofsky P, Soleiman A, Benyaminov F, Oleszak F, Salciccioli L, McFarlane SI. Enterobacter Cloacae Device Endocarditis: Case Report, Scoping Study, and Guidelines Review. Cardiol Vasc Res (Wilmington). 2019. 3 (3):10. [QxMD MEDLINE Link]. [Full Text].
Francis MJ, Chin J, Lomiguen CM, Glaser A. Cotton fever resulting in Enterobacter asburiae endocarditis. IDCases. 2020. 19:e00688. [QxMD MEDLINE Link]. [Full Text].
Durand ML, Calderwood SB, Weber DJ, et al. Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med. 1993 Jan 7. 328(1):21-8. [QxMD MEDLINE Link].
Pathengay A, Trehan HS, Mathai A, et al. Enterobacter endophthalmitis: clinicomicrobiologic profile and outcomes. Retina. 2012 Mar. 32(3):558-62. [QxMD MEDLINE Link].
Bouige A, Fourcade C, Bicart-See A, Félicé MP, Gautie L, Krin G, et al. Characteristics of Enterobacter cloacae prosthetic joint infections. Med Mal Infect. 2019 Oct. 49 (7):511-518. [QxMD MEDLINE Link]. [Full Text].
Singhal N, Kumar M, Kanaujia PK, Virdi JS. MALDI-TOF mass spectrometry: an emerging technology for microbial identification and diagnosis. Front Microbiol. 2015. 6:791. [QxMD MEDLINE Link]. [Full Text].
De Florio L, Riva E, Giona A, Dedej E, Fogolari M, Cella E, et al. MALDI-TOF MS Identification and Clustering Applied to Enterobacter Species in Nosocomial Setting. Front Microbiol. 2018. 9:1885. [QxMD MEDLINE Link]. [Full Text].
Maki DG, Weise CE, Sarafin HW. A semiquantitative culture method for identifying intravenous-catheter-related infection. N Engl J Med. 1977 Jun 9. 296(23):1305-9. [QxMD MEDLINE Link].
Paterson DL. Resistance in gram-negative bacteria: enterobacteriaceae. Am J Med. 2006 Jun. 119(6 Suppl 1):S20-8; discussion S62-70. [QxMD MEDLINE Link].
Ritchie DJ, Alexander BT, Finnegan PM. New antimicrobial agents for use in the intensive care unit. Infect Dis Clin North Am. 2009 Sep. 23(3):665-81. [QxMD MEDLINE Link].
Petty LA, Henig O, Patel TS, Pogue JM, Kaye KS. Overview of meropenem-vaborbactam and newer antimicrobial agents for the treatment of carbapenem-resistant Enterobacteriaceae. Infect Drug Resist. 2018. 11:1461-1472. [QxMD MEDLINE Link]. [Full Text].
Tamma PD, Aitken SL, Bonomo RA, Mathers AJ, van Duin D, Clancy CJ. Infectious Diseases Society of America Guidance on the Treatment of Extended-Spectrum β-lactamase Producing Enterobacterales (ESBL-E), Carbapenem-Resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with Difficult-to-Treat Resistance (DTR-P. aeruginosa). Clin Infect Dis. 2021 Apr 8. 72 (7):1109-1116. [QxMD MEDLINE Link].
Wu JY, Srinivas P, Pogue JM. Cefiderocol: A Novel Agent for the Management of Multidrug-Resistant Gram-Negative Organisms. Infect Dis Ther. 2020 Mar. 9 (1):17-40. [QxMD MEDLINE Link]. [Full Text].
Mulani MS, Kamble EE, Kumkar SN, Tawre MS, Pardesi KR. Emerging Strategies to Combat ESKAPE Pathogens in the Era of Antimicrobial Resistance: A Review. Front Microbiol. 2019. 10:539. [QxMD MEDLINE Link]. [Full Text].
Jacoby GA. AmpC beta-lactamases. Clin Microbiol Rev. 2009 Jan. 22(1):161-82, Table of Contents. [QxMD MEDLINE Link]. [Full Text].
Sharara SL, Amoah J, Pana ZD, Simner PJ, Cosgrove SE, Tamma PD. Is Piperacillin-Tazobactam Effective for the Treatment of Pyelonephritis Caused by Extended-Spectrum β-Lactamase-Producing Organisms?. Clin Infect Dis. 2020 Nov 5. 71 (8):e331-e337. [QxMD MEDLINE Link]. [Full Text].
Sader HS, Castanheira M, Shortridge D, Mendes RE, Flamm RK. Antimicrobial Activity of Ceftazidime-Avibactam Tested against Multidrug-Resistant Enterobacteriaceae and Pseudomonas aeruginosa Isolates from U.S. Medical Centers, 2013 to 2016. Antimicrob Agents Chemother. 2017 Nov. 61 (11):[QxMD MEDLINE Link].
Stone GG, Newell P, Gasink LB, Broadhurst H, Wardman A, Yates K, et al. Clinical activity of ceftazidime/avibactam against MDR Enterobacteriaceae and Pseudomonas aeruginosa: pooled data from the ceftazidime/avibactam Phase III clinical trial programme. J Antimicrob Chemother. 2018 Sep 1. 73 (9):2519-2523. [QxMD MEDLINE Link].
Robin F, Auzou M, Bonnet R, Lebreuilly R, Isnard C, Cattoir V, et al. In Vitro Activity of Ceftolozane-Tazobactam against Enterobacter cloacae Complex Clinical Isolates with Different β-Lactam Resistance Phenotypes. Antimicrob Agents Chemother. 2018 Sep. 62 (9):[QxMD MEDLINE Link].
Heller I, Grif K, Orth D. Emergence of VIM-1-carbapenemase-producing Enterobacter cloacae in Tyrol, Austria. J Med Microbiol. 2012 Apr. 61:567-71. [QxMD MEDLINE Link].
Deshpande P, Rodrigues C, Shetty A, Kapadia F, Hedge A, Soman R. New Delhi Metallo-beta lactamase (NDM-1) in Enterobacteriaceae: treatment options with carbapenems compromised. J Assoc Physicians India. 2010 Mar. 58:147-9. [QxMD MEDLINE Link].
Lowman W, Sriruttan C, Nana T, et al. NDM-1 has arrived: first report of a carbapenem resistance mechanism in South Africa. S Afr Med J. 2011 Nov 25. 101(12):873-5. [QxMD MEDLINE Link].
Bush K, Jacoby GA, Medeiros AA. A functional classification scheme for beta-lactamases and its correlation with molecular structure. Antimicrob Agents Chemother. 1995 Jun. 39(6):1211-33. [QxMD MEDLINE Link].
A new Phenotypic Test for the Detection of Carbapenemases - The Modified Carbapenem Inactivation Method (mCIM). CLSI AST News Update. Available at https://clsi.org/media/1802/ast_newsletter_final_2017.pdf. June 2017; Accessed: June 7, 2019.
Grant J, Afra K. Point-counterpoint: the MERINO trial and what it should imply for future treatment of ESBL bacteria. Official Journal of the Association of Medical Microbiology and Infectious Disease Canada. 2019. 4:125-130. [Full Text].
Loutit JS, et al. Meropenem-Vaborbactam (MV) Compared With Piperacillin-Tazobactam (PT) in the Treatment of Adults With Complicated Urinary Tract Infections (cUTI), Including Acute Pyelonephritis (AP) in a Phase 3 Randomized, Double-Blind, Double-Dummy Trial (TANGO 1). Open Forum Infectious Diseases. 2016. Vol 3. No. suppl_1:. Presented at the Infectious Diseases Society of America IDWeek. San Diego, CA. October 4-8, 2017. [Full Text].
Woodford N, Dallow JW, Hill RL, et al. Ertapenem resistance among Klebsiella and Enterobacter submitted in the UK to a reference laboratory. Int J Antimicrob Agents. 2007 Apr. 29(4):456-9. [QxMD MEDLINE Link].
Souli M, Kontopidou FV, Papadomichelakis E, et al. Clinical experience of serious infections caused by Enterobacteriaceae producing VIM-1 metallo-beta-lactamase in a Greek University Hospital. Clin Infect Dis. 2008 Mar 15. 46(6):847-54. [QxMD MEDLINE Link].
Pintado V, San Miguel LG, Grill F, et al. Intravenous colistin sulphomethate sodium for therapy of infections due to multidrug-resistant gram-negative bacteria. J Infect. 2008 Mar. 56(3):185-90. [QxMD MEDLINE Link].
Gupta S, Govil D, Kakar PN, Prakash O, Arora D, Das S. Colistin and polymyxin B: A re-emergence. Indian J Crit Care Med. 2009 Apr-Jun. 13(2):49-53. [QxMD MEDLINE Link]. [Full Text].
Lo-Ten-Foe JR, de Smet AM, Diederen BM, et al. Comparative evaluation of the VITEK 2, disk diffusion, etest, broth microdilution, and agar dilution susceptibility testing methods for colistin in clinical isolates, including heteroresistant Enterobacter cloacae and Acinetobacter baumannii strains. Antimicrob Agents Chemother. 2007 Oct. 51(10):3726-30. [QxMD MEDLINE Link].
Gales AC, Jones RN, Sader HS. Global assessment of the antimicrobial activity of polymyxin B against 54 731 clinical isolates of Gram-negative bacilli: report from the SENTRY antimicrobial surveillance programme (2001-2004). Clin Microbiol Infect. 2006 Apr. 12(4):315-21. [QxMD MEDLINE Link].
Walkty A, DeCorby M, Nichol K, Karlowsky JA, Hoban DJ, Zhanel GG. In vitro activity of colistin (polymyxin E) against 3,480 isolates of gram-negative bacilli obtained from patients in Canadian hospitals in the CANWARD study, 2007-2008. Antimicrob Agents Chemother. 2009 Nov. 53(11):4924-6. [QxMD MEDLINE Link]. [Full Text].
Zhang R, Cai JC, Zhou HW, Nasu M, Chen GX. Genotypic characterization and in vitro activities of tigecycline and polymyxin B for members of the Enterobacteriaceae with decreased susceptibility to carbapenems. J Med Microbiol. 2011 Dec. 60:1813-9. [QxMD MEDLINE Link].
Ratnam I, Franklin C, Spelman DW. In vitro activities of 'new' and 'conventional' antibiotics against multi-drug resistant Gram negative bacteria from patients in the intensive care unit. Pathology. 2007 Dec. 39(6):586-8. [QxMD MEDLINE Link].
Reinert RR, Low DE, Rossi F, et al. Antimicrobial susceptibility among organisms from the Asia/Pacific Rim, Europe and Latin and North America collected as part of TEST and the in vitro activity of tigecycline. J Antimicrob Chemother. 2007 Nov. 60(5):1018-29. [QxMD MEDLINE Link].
Halstead DC, Abid J, Dowzicky MJ. Antimicrobial susceptibility among Acinetobacter calcoaceticus-baumannii complex and Enterobacteriaceae collected as part of the Tigecycline Evaluation and Surveillance Trial. J Infect. 2007 Jul. 55(1):49-57. [QxMD MEDLINE Link].
DiPersio JR, Dowzicky MJ. Regional variations in multidrug resistance among Enterobacteriaceae in the USA and comparative activity of tigecycline, a new glycylcycline antimicrobial. Int J Antimicrob Agents. 2007 May. 29(5):518-27. [QxMD MEDLINE Link].
Abdallah M, Olafisoye O, Cortes C, Urban C, Landman D, Quale J. Activity of eravacycline against Enterobacteriaceae and Acinetobacter baumannii, including multidrug-resistant isolates, from New York City. Antimicrob Agents Chemother. 2015 Mar. 59 (3):1802-5. [QxMD MEDLINE Link]. [Full Text].
Livermore DM, Mushtaq S, Warner M, Woodford N. In Vitro Activity of Eravacycline against Carbapenem-Resistant Enterobacteriaceae and Acinetobacter baumannii. Antimicrob Agents Chemother. 2016 Jun. 60 (6):3840-4. [QxMD MEDLINE Link]. [Full Text].
Giacobbe DR, Ciacco E, Girmenia C, Pea F, Rossolini GM, Sotgiu G, et al. Evaluating Cefiderocol in the Treatment of Multidrug-Resistant Gram-Negative Bacilli: A Review of the Emerging Data. Infect Drug Resist. 2020. 13:4697-4711. [QxMD MEDLINE Link]. [Full Text].
Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O'Grady NP, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2009 Jul 1. 49 (1):1-45. [QxMD MEDLINE Link]. [Full Text].
Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015 Oct 13. 132 (15):1435-86. [QxMD MEDLINE Link]. [Full Text].
Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013 Jan. 56 (1):e1-e25. [QxMD MEDLINE Link]. [Full Text].
Hawser SP, Bouchillon SK, Hoban DJ, Badal RE. In vitro susceptibilities of aerobic and facultative anaerobic Gram-negative bacilli from patients with intra-abdominal infections worldwide from 2005-2007: results from the SMART study. Int J Antimicrob Agents. 2009 Dec. 34(6):585-8. [QxMD MEDLINE Link].
Bassetti M, Righi E, Fasce R, et al. Efficacy of ertapenem in the treatment of early ventilator-associated pneumonia caused by extended-spectrum beta-lactamase-producing organisms in an intensive care unit. J Antimicrob Chemother. 2007 Aug. 60(2):433-5. [QxMD MEDLINE Link].
Yang FC, Yan JJ, Hung KH, Wu JJ. Characterization of ertapenem-resistant Enterobacter cloacae in a Taiwanese university hospital. J Clin Microbiol. 2012 Feb. 50(2):223-6. [QxMD MEDLINE Link]. [Full Text].
Fox S. Carbapenem-Resistant Enterobacteriaceae: New Precautions. Medscape Medical News. Feb 19 2013. [Full Text].
Centers for Disease Control and Prevention. New Carbapenem-Resistant Enterobacteriaceae Warrant Additional Action by Healthcare Providers. CDC. Feb 14 2013. [Full Text].
Abbott SL, Janda JM. Enterobacter cancerogenus ("Enterobacter taylorae") infections associated with severe trauma or crush injuries. Am J Clin Pathol. 1997 Mar. 107(3):359-61. [QxMD MEDLINE Link].
Alhambra A, Cuadros JA, Cacho J, et al. In vitro susceptibility of recent antibiotic-resistant urinary pathogens to ertapenem and 12 other antibiotics. J Antimicrob Chemother. 2004 Jun. 53(6):1090-4. [QxMD MEDLINE Link].
Caplan ES, Hoyt NJ. Identification and treatment of infections in multiply traumatized patients. Am J Med. 1985 Jul 15. 79(1A):68-76. [QxMD MEDLINE Link].
Clark NM, Patterson J, Lynch JP 3rd. Antimicrobial resistance among gram-negative organisms in the intensive care unit. Curr Opin Crit Care. 2003 Oct. 9(5):413-23. [QxMD MEDLINE Link].
Cosgrove SE, Kaye KS, Eliopoulous GM, et al. Health and economic outcomes of the emergence of third-generation cephalosporin resistance in Enterobacter species. Arch Intern Med. 2002 Jan 28. 162(2):185-90. [QxMD MEDLINE Link].
Cunha BA. Antibiotic Essentials. 9th ed. Sudbury, MA: Jones & Bartlett; 2010.
Cunha BA. Enterobacter: Colonization & infection. Infect Dis Pract. 1999. 23:41-3.
Cunha BA. Once-daily tigecycline therapy of multidrug-resistant and non-multidrug-resistant gram-negative bacteremias. J Chemother. 2007 Apr. 19(2):232-3. [QxMD MEDLINE Link].
Cunha BA. Pharmacokinetic considerations regarding tigecycline for multidrug-resistant (MDR) Klebsiella pneumoniae or MDR Acinetobacter baumannii urosepsis. J Clin Microbiol. 2009 May. 47(5):1613. [QxMD MEDLINE Link]. [Full Text].
Cunha BA, McDermott B, Nausheen S. Single daily high-dose tigecycline therapy of a multidrug-resistant (MDR) Klebsiella pneumoniae and Enterobacter aerogenes nosocomial urinary tract infection. J Chemother. 2007 Dec. 19(6):753-4. [QxMD MEDLINE Link].
Cunha BA, Theodoris AC, Yannelli B. Enterobacter cloacae graft infection/bacteremia in a hemodialysis patient. Am J Infect Control. 2000 Apr. 28(2):181-3. [QxMD MEDLINE Link].
De Champs C, Sirot D, Chanal C, et al. A 1998 survey of extended-spectrum beta-lactamases in Enterobacteriaceae in France. The French Study Group. Antimicrob Agents Chemother. 2000 Nov. 44(11):3177-9. [QxMD MEDLINE Link].
Donati L, Scamazzo F, Gervasoni M, et al. Infection and antibiotic therapy in 4000 burned patients treated in Milan, Italy, between 1976 and 1988. Burns. 1993 Aug. 19(4):345-8. [QxMD MEDLINE Link].
Foster DR, Rhoney DH. Enterobacter meningitis: organism susceptibilities, antimicrobial therapy and related outcomes. Surg Neurol. 2005 Jun. 63(6):533-7; discussion 537. [QxMD MEDLINE Link].
Fritsche TR, Stilwell MG, Jones RN. Antimicrobial activity of doripenem (S-4661): a global surveillance report (2003). Clin Microbiol Infect. 2005 Dec. 11(12):974-84. [QxMD MEDLINE Link].
Fritsche TR, Strabala PA, Sader HS, et al. Activity of tigecycline tested against a global collection of Enterobacteriaceae, including tetracycline-resistant isolates. Diagn Microbiol Infect Dis. 2005 Jul. 52(3):209-13. [QxMD MEDLINE Link].
Gallagher PG. Enterobacter bacteremia in pediatric patients. Rev Infect Dis. 1990 Sep-Oct. 12(5):808-12. [QxMD MEDLINE Link].
Hanna H, Afif C, Alakech B, Boktour M, et al. Central venous catheter-related bacteremia due to gram-negative bacilli: significance of catheter removal in preventing relapse. Infect Control Hosp Epidemiol. 2004 Aug. 25(8):646-9. [QxMD MEDLINE Link].
Hoffmann H, Sturenburg E, Heesemann J, et al. Prevalence of extended-spectrum beta-lactamases in isolates of the Enterobacter cloacae complex from German hospitals. Clin Microbiol Infect. 2006 Apr. 12(4):322-30. [QxMD MEDLINE Link].
Jiang X, Ni Y, Jiang Y, et al. Outbreak of infection caused by Enterobacter cloacae producing the novel VEB-3 beta-lactamase in China. J Clin Microbiol. 2005 Feb. 43(2):826-31. [QxMD MEDLINE Link].
Kang CI, Kim SH, Park WB, et al. Bloodstream infections caused by Enterobacter species: predictors of 30-day mortality rate and impact of broad-spectrum cephalosporin resistance on outcome. Clin Infect Dis. 2004 Sep 15. 39(6):812-8. [QxMD MEDLINE Link].
Kaye KS, Cosgrove S, Harris A, et al. Risk factors for emergence of resistance to broad-spectrum cephalosporins among Enterobacter spp. Antimicrob Agents Chemother. 2001 Sep. 45(9):2628-30. [QxMD MEDLINE Link].
Larson EL, Cimiotti JP, Haas J, et al. Gram-negative bacilli associated with catheter-associated and non-catheter-associated bloodstream infections and hand carriage by healthcare workers in neonatal intensive care units. Pediatr Crit Care Med. 2005 Jul. 6(4):457-61. [QxMD MEDLINE Link].
Leverstein-van Hall MA, Blok HE, et al. Extensive hospital-wide spread of a multidrug-resistant enterobacter cloacae clone, with late detection due to a variable antibiogram and frequent patient transfer. J Clin Microbiol. 2006 Feb. 44(2):518-24. [QxMD MEDLINE Link].
Liu CP, Wang NY, Lee CM, et al. Nosocomial and community-acquired Enterobacter cloacae bloodstream infection: risk factors for and prevalence of SHV-12 in multiresistant isolates in a medical centre. J Hosp Infect. 2004 Sep. 58(1):63-77. [QxMD MEDLINE Link].
Livermore DM. beta-Lactamases in laboratory and clinical resistance. Clin Microbiol Rev. 1995 Oct. 8(4):557-84. [QxMD MEDLINE Link].
Livermore DM, Oakton KJ, Carter MW, et al. Activity of ertapenem (MK-0826) versus Enterobacteriaceae with potent beta-lactamases. Antimicrob Agents Chemother. 2001 Oct. 45(10):2831-7. [QxMD MEDLINE Link].
Luzzaro F, Docquier JD, Colinon C, et al. Emergence in Klebsiella pneumoniae and Enterobacter cloacae clinical isolates of the VIM-4 metallo-beta-lactamase encoded by a conjugative plasmid. Antimicrob Agents Chemother. 2004 Feb. 48(2):648-50. [QxMD MEDLINE Link].
Markowitz SM, Smith SM, Williams DS. Retrospective analysis of plasmid patterns in a study of burn unit outbreaks of infection due to Enterobacter cloacae. J Infect Dis. 1983 Jul. 148(1):18-23. [QxMD MEDLINE Link].
Mushtaq S, Ge Y, Livermore DM. Comparative activities of doripenem versus isolates, mutants, and transconjugants of Enterobacteriaceae and Acinetobacter spp. with characterized beta-lactamases. Antimicrob Agents Chemother. 2004 Apr. 48(4):1313-9. [QxMD MEDLINE Link].
Paterson DL, Rossi F, Baquero F, et al. In vitro susceptibilities of aerobic and facultative Gram-negative bacilli isolated from patients with intra-abdominal infections worldwide: the 2003 Study for Monitoring Antimicrobial Resistance Trends (SMART). J Antimicrob Chemother. 2005 Jun. 55(6):965-73. [QxMD MEDLINE Link].
Pitout JD, Nordmann P, Laupland KB, et al. Emergence of Enterobacteriaceae producing extended-spectrum beta-lactamases (ESBLs) in the community. J Antimicrob Chemother. 2005 Jul. 56(1):52-9. [QxMD MEDLINE Link].
Pitout JD, Thomson KS, Hanson ND, et al. Plasmid-mediated resistance to expanded-spectrum cephalosporins among Enterobacter aerogenes strains. Antimicrob Agents Chemother. 1998 Mar. 42(3):596-600. [QxMD MEDLINE Link].
Ristuccia PA, Cunha BA. Enterobacter. Infect Control. 1985 Mar. 6(3):124-8. [QxMD MEDLINE Link].
Rupp ME, Fey PD. Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae: considerations for diagnosis, prevention and drug treatment. Drugs. 2003. 63(4):353-65. [QxMD MEDLINE Link].
Sader HS, Jones RN, Dowzicky MJ, et al. Antimicrobial activity of tigecycline tested against nosocomial bacterial pathogens from patients hospitalized in the intensive care unit. Diagn Microbiol Infect Dis. 2005 Jul. 52(3):203-8. [QxMD MEDLINE Link].
Sader HS, Jones RN, Stilwell MG, et al. Tigecycline activity tested against 26,474 bloodstream infection isolates: a collection from 6 continents. Diagn Microbiol Infect Dis. 2005 Jul. 52(3):181-6. [QxMD MEDLINE Link].
Sanders CC, Sanders WE Jr. beta-Lactam resistance in gram-negative bacteria: global trends and clinical impact. Clin Infect Dis. 1992 Nov. 15(5):824-39. [QxMD MEDLINE Link].
Sanders WE Jr, Sanders CC. Enterobacter spp.: pathogens poised to flourish at the turn of the century. Clin Microbiol Rev. 1997 Apr. 10(2):220-41. [QxMD MEDLINE Link].
Siegel JD, Rhinehart E, Jackson M, Chiarello L and the HICPAC. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare SEttings 2007. Centers for Disease Contol. Available at http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf. Accessed: 1 April 12008.
Siegel JD, Rhinehart E, Jackson M, Chiarello L, HICPAC. Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006. Centers for Disease Control. Available at http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf. Accessed: accessed 1 April 2008.
Tresoldi AT, Padoveze MC, Trabasso P, et al. Enterobacter cloacae sepsis outbreak in a newborn unit caused by contaminated total parenteral nutrition solution. Am J Infect Control. 2000 Jun. 28(3):258-61. [QxMD MEDLINE Link].
v Dijk Y, Bik EM, Hochstenbach-Vernooij S, v d Vlist GJ, Savelkoul PH, Kaan JA, et al. Management of an outbreak of Enterobacter cloacae in a neonatal unit using simple preventive measures. J Hosp Infect. 2002 May. 51(1):21-6. [QxMD MEDLINE Link].
Watson JT, Jones RC, Siston AM, et al. Outbreak of catheter-associated Klebsiella oxytoca and Enterobacter cloacae bloodstream infections in an oncology chemotherapy center. Arch Intern Med. 2005 Dec 12-26. 165(22):2639-43. [QxMD MEDLINE Link].
Wendt C, Lin D, von Baum H. Risk factors for colonization with third-generation cephalosporin-resistant enterobacteriaceae. Infection. 2005 Oct. 33(5-6):327-32. [QxMD MEDLINE Link].
Wisplinghoff H, Bischoff T, Tallent SM, et al. Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis. 2004 Aug 1. 39(3):309-17. [QxMD MEDLINE Link].
Lazarovitch T, Amity K, Coyle JR, Ackerman B, Tal-Jasper R, Ofer-Friedman H, et al. The Complex Epidemiology of Carbapenem-Resistant Enterobacter Infections: A Multicenter Descriptive Analysis. Infect Control Hosp Epidemiol. 2015 Sep 24. 1-9. [QxMD MEDLINE Link].

Media Gallery

Radiograph of an open right tibial fracture in a 21-year-old male marine who was wounded when an improvised explosive device detonated while he was on patrol in Iraq.

of 1

Author

Susan L Fraser, MD Infectious Diseases Physician, Providence St Peter Hospital; Associate Professor of Medicine, University of Washington School of Medicine; Infectious Diseases Staff, VA Puget Sound

Susan L Fraser, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, HIV Medicine Association, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA is a member of the following medical societies: Charleston County Medical Association, Infectious Diseases Society of America, South Carolina Infectious Diseases Society

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Christian P Sinave, MD Associate Professor, Department of Medical Microbiology and Infectious Diseases, University of Sherbrooke Faculty of Medicine, Canada

Christian P Sinave, MD is a member of the following medical societies: American Society for Microbiology, Association of Medical Microbiology and Infectious Disease Canada

Disclosure: Nothing to disclose.

Maria D Mileno, MD Associate Professor of Medicine, Division of Infectious Diseases, The Warren Alpert Medical School of Brown University

Maria D Mileno, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International Society of Travel Medicine, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Acknowledgements

Michael Arnett, MD Resident Physician, Department of Medicine, Tripler Army Medical Center

Disclosure: Nothing to disclose.