Medical Care
Antimicrobial Therapy
Medical care of Providencia infection includes initiation of an antimicrobial agent to eradicate infection. Selection of an empirical agent (while awaiting microbiological identification of the organism and susceptibility testing) should be based on known resistance patterns in the patient's locality (eg, community, hospital, long-term care facility). Once the species of the infecting Providencia pathogen has been identified (but before susceptibilities are available), selection of an empiric antimicrobial agent can be based on known patterns of susceptibility across species, as detailed below.
Generally, Providencia species are almost always resistant to tetracyclines, older penicillins, and cephalosporins, with susceptibility to late-generation cephalosporins, aztreonam, imipenem, and meropenem. Providencia species have variable susceptibilities to fluoroquinolones, aminoglycosides, and trimethoprim-sulfamethoxazole (TMP-SMX).
P stuartii is typically the most resistant of all Providencia species. A 2006 Italian study found that ESBL-positive P stuartii made up 10% of all ESBL species and had marked resistance to amoxicillin-clavulanate (81.8%), ampicillin-sulbactam (40.1%), gentamicin (79.5%), and ciprofloxacin (84.1%). In another study, 53% of P stuartii strains isolated were found to produce ESBL. [10]
Carbapenems are the best choice for empirical therapy in life-threatening infections or nosocomial outbreaks suspected to be caused by P stuartii until speciation is confirmed.
Amikacin and beta-lactam/beta-lactamase inhibitors such as piperacillin/tazobactam are good first-line agents in non–life-threatening infections. [15]
P alcalifaciens and P rustigianii tend to be the most susceptible of the Providencia species. Although often resistant to tetracyclines, older penicillins, and cephalosporins, they are usually susceptible to TMP-SMX, fluoroquinolones, aminoglycosides, late-generation cephalosporins, aztreonam, and carbapenems.
P rettgeri tends to fall between the two groups mentioned above with regard to its susceptibility profile.
Once the identity of the pathogen and its susceptibility profile are known, target therapy with the most narrow-spectrum agent to which the organism is susceptible.
Duration of therapy should range from 1-3 weeks, depending on the site of infection (14 d for bacteremia; 14-21 d for complicated or catheter-associated urinary tract infection).
Catheter Removal
If infection is associated with an indwelling device (eg, urinary catheter), remove the catheter. Carefully evaluate the continued need for the catheter. If its use continues to be required, insert a new catheter. If not, discontinue use of the catheter.
Surgical Care
If Providencia infection is associated with an anatomic site amenable to debridement (eg, wound, ulcer) or drainage (eg, abscess), perform these procedures to facilitate bacterial eradication.
Surgical correction of any underlying genitourinary pathology (eg, benign prostatic hyperplasia [BPH], ureteric stricture, nephrolithiasis, tumors) or removal of foreign objects (eg, nephrostomy tubes, ureteral stents) may also help assist with eradication of the infection.
Consultations
Consider consultation with an infectious diseases specialist to help determine the treatment plan.
Consider consultation with a urologist if a suspected structural genitourinary pathology is the underlying etiology of the infection.
Diet
No special diet is required in patients with Providencia infections.
Activity
Activity should not be restricted in patients with Providencia infections.
Prevention
Considering the association of Providencia infections with indwelling devices (eg, urinary catheters, ureteral stent), a careful review of the medical necessity of any such devices is extremely important. The need for such devices should be reviewed periodically, and they should be removed, if possible.
If an indwelling device is required, meticulous care of such devices is important in reducing the likelihood of colonization and infection.
Providencia species are rarely isolated in uncomplicated urinary tract infections. Correction of underlying abnormalities associated with complicated urinary tract infections reduces the risk of Providencia infection. Examples include correction of obstruction (tumors, stones, ureteric strictures) and treatment of functional disorder (neurogenic bladder, vesicoureteral reflux).
Travelers to developing countries should be counseled to avoid raw or undercooked foods and to drink bottled water. Pre-travel referral to a travel medicine specialist may reduce the risk of travel-related illness.
Providencia species are often resistant to multiple antibiotics. Early identification of such infections and prompt institution of infection-control procedures are important for decreasing the likelihood of spread of the organism among patients.
Further Outpatient Care
Monitor the patient for resolution of clinical manifestations and potential toxicities of antibiotics.
Infection may recur, particularly if an indwelling device remains in place. If repeat cultures after treatment continue to demonstrate the organism, clinical evidence of infection should be sought. The urine may continue to be colonized after a course of antibiotic treatment, especially in the presence of an indwelling device (eg, urinary catheter, condom catheter).
Further Inpatient Care
In addition to antimicrobial therapy, inpatient care for Providencia infections may include supportive and general medical care for manifestations that require hospitalization (eg, pneumonia, acute respiratory distress syndrome [ARDS], bloodstream infection, dehydration).
If infection is associated with an indwelling device, such as a urinary catheter, carefully re-evaluate the continued need for this device.
For urinary tract infections, recommend strict measurement of intake and output. Consider bladder scanning in cases of suspected neurogenic bladder.
Transfer
Transfer patients if they develop complications that require therapeutic options that the initial treating facility cannot provide (eg, mechanical ventilation, hemodialysis).
If a patient is being transferred to another medical institution (eg, skilled nursing facility, long-term care facility) following treatment, convey the nature of the infecting organism to the receiving facility. This allows institution of appropriate infection control precautions, if needed.
