Infective endocarditis due to Enterobacter cloacae resistant to third- and fourth-generation cephalosporins

Abstract

We report the case of using a long-term combination of meropenem and amikacin to treat infective endocarditis caused by Enterobacter cloacae resistant to third- and fourth-generation cephalosporins. Multi-drug resistant Gram-negative bacilli, such as the E. cloacae in our study, may become possible pathogens of infective endocarditis. Our experience with this case indicates that long-term use of a combination of β-lactam and aminoglycosides might represent a suitable management option for future infective endocarditis cases due to non-Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella spp. (HACEK group) Gram-negative bacilli such as ours.

Device-associated aortic valve endocarditis due to a complicated Enterobacter cloacae urinary tract infection

“…E. Cloacae is a biofilm forming organism which results in the secretion of extracellular polymeric substances that support the colonization of bacterial organisms. Moreover, E. Cloacae contains a chromosome-encoded AmpC β-lactam genes which permit these organisms to intrinsically produce AmpC β-lactamase conferring resistance to most antibiotics including penicillins and cephalosporins [3] .…”

Elusive Enterobacter cloacae causing pacemaker endocarditis

“…Due to the highly uncommon incidence of endocarditis with E. cloacae , or the non-HACEK gram-negative bacilli in general, its management has continued to pose a conundrum. Current guidelines endorsed by the Infectious Diseases Society of America and the American Heart Association recommend dual antibiotic therapy and early cardiothoracic surgical consultation in non-HACEK endocarditis cases [ 8 , 9 ]. The suggested therapy is a fourth-generation cephalosporin or carbapenem, along with an aminoglycoside or quinolone for a total of 6 weeks [ 6 , 8 , 9 ].…”

“…Current guidelines endorsed by the Infectious Diseases Society of America and the American Heart Association recommend dual antibiotic therapy and early cardiothoracic surgical consultation in non-HACEK endocarditis cases [ 8 , 9 ]. The suggested therapy is a fourth-generation cephalosporin or carbapenem, along with an aminoglycoside or quinolone for a total of 6 weeks [ 6 , 8 , 9 ]. Due to the Amp C inducible beta-lactamases expression associated with non-HACEK gram-negative rods that provide resistance to multiple beta-lactam antibiotics, consultation with an Infectious Disease specialist is merited as additional laboratory screening and in-vitro testing would be required [ 2 , 10 ].…”

Challenges of managing <em>Enterobacter</em> endocarditis; a review of two cases

“…Combination therapy with a beta lactam (penicillins, cephalosporins or carbapenems) and an aminoglycoside is effective for non-HACEK group endocarditis (2). Despite the in-vitro sensitivity to cefotaxime or ceftriaxone, some bacteria such as Enterobacter species can develop rd inducible resistance to 3 generation cephalosporins due to their inherent AmpC beta-lactam gene resulting in therapeutic failures (2,3).…”