The First Known Documented Case of Ewingella Americana Urinary Tract Infection

Abstract

We present a 73-year-old male with a history of end-stage renal disease (ESRD) on dialysis, type 2 diabetes mellitus, coronary artery disease status post stents, prostate carcinoma status post radiation, and prostatectomy, with recurrent bladder neck contracture requiring suprapubic catheter, left urethral stricture with nephrostomy tube placement, penile implant, and recurrent urinary tract infections, who presented to the emergency room complaining of constant bilateral groin pain for one day. Physical exam was significant for suprapubic tenderness and a chronic suprapubic catheter and left-sided nephrostomy tube. An initial examination of the patient's urine revealed turbid, yellow-colored fluid, positive for white blood cells, leukocyte esterase, and bacteria. A urine culture was obtained, which returned positive for E. americana, with >100,000 colony-forming units (CFUs) as well as Enterococcus faecalis (E. faecalis) demonstrating low colony counts. The patient was treated with a seven-day course of meropenem 1 gm twice daily, which improved of his symptoms, and then completed a 10-day course of ertapenem 500 mg daily. The patient received a five-day course of vancomycin 1 gm on dialysis days for additional coverage of E. faecalis, despite low colony counts. This is the first documented case of a urinary tract infection caused by E. americana. The organism is primarily found in immunocompromised individuals, and a debate is still ongoing as to whether it is a true pathogen or exists primarily as an opportunistic infection. We suggest further inquiry and study of this resistant organism are paramount in establishing its role in both immunocompromised as well as immunocompetent individuals. E. americana is a multidrug-resistant organism, which to date has sparse documentation regarding its prevalence and potential for morbidity, especially in compromised individuals. In the era of increasing antibiotic resistance, we suggest that more research is needed to understand the pathogenicity of E. americana.

Ewingella americana Infections in Humans—A Narrative Review

“…The literature search of the PubMed and Scopus databases yielded 72 non-duplicate studies. After screening all the potentially eligible articles and assessing the references of the included articles, only 16 studies met the inclusion criteria and were considered for data extraction [ 7 , 13 , 14 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. These 16 studies provided information on 19 patients.…”

“…The patients with an infection by E. americana had an age range from 0 to 77 years [ 7 , 13 , 14 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. The median was 55 years.…”

“…The median was 55 years. Out of 19 patients, 9 (47.4%) were male [ 7 , 13 , 14 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. Regarding the medical history, 31.6% (6 patients) had surgery in the three months before the diagnosis of infection by E. americana , with 15.8% (3 patients) having had cardiac surgery [ 13 , 14 , 18 ].…”

“…Regarding the medical history, 31.6% (6 patients) had surgery in the three months before the diagnosis of infection by E. americana , with 15.8% (3 patients) having had cardiac surgery [ 13 , 14 , 18 ]. Among all the patients, 26.3% (5 patients) had recent antimicrobial use (within three months before diagnosis of the infection) [ 14 , 18 ], 15.8% (3 patients) had a history of end-stage renal disease (ESRD) and were on peritoneal dialysis [ 19 , 26 , 28 ], 5.3% (1 patient) had ESRD and was on hemodialysis [ 29 ], 15.8% (3 patients) had immunosuppression and, more specifically, 5.3% (1 patient) had an autoimmune syndrome (inflammatory bowel disease) and was on immunosuppression, 10.5% (2 patients) had organ transplantation, with 5.3% (1 patient) having kidney transplantation and 5.3% (1 patient) having allogenous bone marrow transplantation [ 20 , 22 , 23 ]. Additionally, 5.3% (1 patient) was an intravenous drug user [ 24 ].…”

“…E. americana was isolated from the blood in 47.4% (9 patients) [ 13 , 14 , 18 , 20 , 21 , 25 ], the peritoneal fluid in 15.8% (3 patients) [ 19 , 26 , 28 ], the sputum in 10.5% (2 patients), a swab from the conjunctiva in 10.5% (2 patients) [ 7 , 17 ], the synovial fluid in 5.3% (1 patient) [ 24 ], the urine in 5.3% (1 patient) [ 29 ], and the cerebrospinal fluid in 5.3% (1 patient) [ 27 ]. Infection was polymicrobial in 10.5% (2 patients), and the other identified species were Pseudomonas marginata and Enterococcus faecalis [ 13 , 29 ].…”