This document discusses two cases of successful treatment for septicemia caused by Elizabethkingia meningoseptica in immunocompromised adults. The bacteria, known for its resistance to many antibiotics, was effectively treated with a combination of rifampicin, trimethoprim/sulfamethoxazole, and levofloxacin, while highlighting the importance of identifying the source of infection, often found in water systems. Enhanced microbiological surveillance and timely identification are essential for improving treatment outcomes in such cases.

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2. a pol l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 1 5 e1 1 8
Available online at www.sciencedirect.com
Case Report
Successful treatment of two cases of Elizabethkingia
meningoseptica septicemia and a review of the
literature
Ujjwayini Ray a,*, Soma Dutta b, Chandrashish Chakravarty c,
Indrajit Kumar Tiwari c
a Consultant Microbiologist, Apollo Gleneagles Hospitals, 58, Canal Circular Road, Kolkata 54, West Bengal, India
b Registrar Microbiology, Apollo Gleneagles Hospitals, 58, Canal Circular Road, Kolkata 54, West Bengal, India
c Consultant Critical Care Medicine, Apollo Gleneagles Hospitals, 58, Canal Circular Road, Kolkata 54, West Bengal,
India
a r t i c l e i n f o
Article history:
Received 12 February 2014
Accepted 7 May 2014
Available online 2 June 2014
Keywords:
Elizabethkingia meningoseptica
Septicemia
Adults
Immunocompromised
a b s t r a c t
Elizabethkingia meningoseptica is emerging as a cause of hospital acquired infection partic-ularly
in immunocompromised adults. The treatment of this bacterium is difficult since it
is intrinsically resistant to a number of antibiotics. Here we report two cases of septicemia
in patients who were critically ill and were successfully treated with appropriate antibi-otics.
Cotrimoxazole, quinolones, and rifampicin seem to be drugs effective against E.
meningoseptica. Antibiotic susceptibility results are ineffective in guiding treatment. The
bacterium particularly colonizes water pipelines and tap faucets and occurrence of infec-tion
by this bacterium should direct attention towards eradicating the source of this
bacterium.
Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
An aging population, the AIDS epidemic, the growth of
chemotherapeutic options for cancer treatment, a growing
transplant population and high end critical care medicine
with multiple interventions has resulted in a large population
of immunocompromised patients. In immunocompromised
patients, micro organisms with low pathogenic potential that
is usually efficiently controlled by the immune system can
suddenly cause life-threatening diseases that may be difficult
to treat with currently available anti-infectives. Elizabethkingia
meningoseptica is one such bacteria which is emerging as an
important cause of serious opportunistic infection in immu-nocompromised
hosts.1,2 E. meningoseptica has undergone
several taxonomic changes and was previously known as
Flavobacterium meningosepticum and Chryseobacterium meningo-septicum
and finally it was named after bacteriologist Elizabeth
O. King who first isolated the bacteria.3 E. meningoseptica is a
non-motile, non-fermenting, oxidase positive, aerobic bacilli.
We here report two cases of serious infection by E. meningo-septica
which were successfully treated.
* Corresponding author. Tel.: þ91 9830639480 (mobile).
E-mail address: dr_uray@rediffmail.com (U. Ray).
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
http://dx.doi.org/10.1016/j.apme.2014.05.012
0976-0016/Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

3. 116 a p o l l o me d i c i n e 1 1 ( 2 0 1 4 ) 1 1 5 e1 1 8
2. Case report
2.1. Case 1
An 18-year-old female patient suffering from refractory
Hodgkin's lymphoma (STAGE IV B) underwent autologous
bone marrow transplant (BMT). She was put on immunosup-pressive
therapy with tacrolimus and mycophenolate mofetil
to prevent graft rejection. She engrafted successfully initially
with neutrophil on day 9th followed by platelets on day 12th
post transplant. On day 10th post transplant she became
septic and was managed with broad spectrum antibiotics
meropenem and teicoplanin after sending samples for cul-ture.
Both the aerobic blood culture and urine culture samples
showed growth of gram negative bacilli. The isolates were
oxidase positive, non-motile and non-fermenter. Further
identification and sensitivity was done in VITEK 2C (Bio-merieux)
automated system. The isolates were identified as E.
meningoseptica .The isolates were sensitive only to levofloxacin
[Minimum Inhibitory Concentration (MIC) 2 mg/ml] when
tested in VITEK using AST N090 cards and were resistant to all
other commonly used antibiotics. E. meningoseptica was also
isolated from the throat swab of this patient during routine
pre-transplant surveillance. In view of the above findings
levofloxacin was added. Subsequently blood culture became
sterile. On day 15th post transplant the patient developed
severe respiratory distress and had to be intubated and
ventilated to support her respiratory functions. A broncho-alveolar
lavage was performed at that time. BAL fluid culture
also showed heavy growth of E. meningoseptica. But she
continued to have repeated episodes of respiratory distress
and her condition deteriorated and was shifted to the ICU
(Intensive Care Unit). Levofloxacin was discontinued and
vancomycin, trimethoprim/sulphamethoxazole and rifam-picin
(drugs which are effective against E. meningoseptica ac-cording
to various literature.) were started on day 22 post
transplant. Urine culture still showed growth of E. meningo-septica
and Chest X ray had persistent infiltrates. Vancomycin
was added on day 30th post transplant since it is reported to
have therapeutic effect on E. meningoseptica .After about a
week of above therapy the patient started improving and
thereafter E. meningoseptica was not isolated from any of the
clinical samples. Rifampicin and trimethoprim/sulphame-thoxazole
was continued for 10 more days and thereafter
rifampicin was stopped and trimethoprim/sulphamethox-azole
was continued for one month. Vancomycin was
administered for a week. Her condition improved gradually
and she was extubated on Day 37 post transplant and
remained well with minimum oxygen requirement.
2.2. Case 2
A 25-year-old patient following caesarean section two days
back was admitted to the hospital with abdominal pain and
distention. The CAT scan of abdomen revealed severe acute
pancreatitis (Balthazer E, CTSI 4/10) along with blood clots in
pelvis with pleural and peritoneal effusion. At the time of
admission she had features of disseminated intra vascular
coagulation (DIC) for which she was treated with fresh frozen
plasma. She underwent surgical intervention for removal of
pelvic blood clots and adhesionolysis. But despite her
pancreatitis and coagulation parameters improving, her con-dition
worsened and she developed fever and respiratory
distress and was put on mechanical ventilation on day 10th of
hospitalization. She started having spikes of high tempera-ture.
Suspecting sepsis with multidrug resistant bacteria she
was empirically treated with polymyxin B, teicoplanin and
caspofungin. Her chest X-ray showed presence of bilateral
infiltrates. Blood and Endotracheal (E.T) secretion sent for
culture showed growth of E. meningoseptica. The isolate was
moderately sensitive to levofloxacin (MIC 4 mg/ml) and resis-tant
to other antibiotics such as quinolones, beta lactams,
aminoglycosides, trimethoprim/sulphamethoxazole, doxycy-cline.
Following the isolation of E. meningoseptica the poly-myxin
B was substituted with rifampicin and trimethoprim/
sulphamethoxazole. A repeat blood culture sent three days
later again showed growth of E. meningoseptica. Gradually the
patient started improving and she was extubated four days
after starting E. meningoseptica specific antibiotics. The rifam-picin
was continued for two weeks and trimethoprim/sul-phamethoxazole
was continued for a total of three weeks.
Repeat blood and urine cultures after 14 days were sterile and
the patient was discharged in a haemodynamically stable
condition.
3. Discussion
E. meningoseptica used to be implicated as a cause of infection
in neonates. The literature is replete with cases of E. menin-goseptica
primarily in pediatric patients with neonates in
particular.3 E. meningoseptica is a well known cause of neonatal
meningitis particularly in premature infants and often occurs
as outbreaks with a very high mortality rate.4 But recent
literature search has shown that E. meningoseptica is emerging
as a cause of infection in hospitalized adults as well. In adults
E. meningoseptica has been mainly responsible for blood stream
and respiratory infection unlike pediatric patients where
meningitis is the most common presentation.2 In adults E.
meningoseptica is increasingly being reported as a cause of
nosocomial infection in immunocompromised hosts. Respi-ratory
infection in adults is mostly associated with mechani-cal
ventilation.5
In both the above mentioned cases the patients were
immunocompromised e one being a BMT recipient heavily on
immunosuppressant therapy and the other was a patient with
multiorgan involvement in the form of pancreatitis, acute
respiratory distress syndrome, and DIC with multiple blood
transfusions.
Respiratory route seems to be the portal of entry of the
bacteria .Both our patients had severe chest infection and E.
meningoseptica was isolated from BAL (Broncho Alveolar
Lavage) and E.T secretion in significant numbers.
In the first case E. meningoseptica was isolated from the
throat swab sample during routine surveillance days before
infection by E. meningoseptica was detected. E. meningoseptica
was also isolated from the tap water of Bone Marrow Trans-plant
unit where the first case initially was admitted.

4. a pol l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 1 5 e1 1 8 117
It is well documented that contaminated respiratory
equipment has been the source of infection in ventilated pa-tients.
6 This may be true for this bacterium as well.
Environmental studies have shown that E. meningoseptica
can survive in chlorinated water supplies, often colonize sink
basins and taps and thus becomes a potential reservoir for
infection in the hospital environment and can infect patients
via contaminated medical devices.7 A recent study by Balm
et al has shown that 44% of taps in the critical care units are
colonized with E. meningoseptica.8
Treatment with E. meningoseptica infection is difficult and
challenging as this organism is inherently resistant to many
antimicrobial agents such as beta lactams including carba-penems
and aztreonam (due to production of beta lactamases
and metallobetalactamases), polymyxins, aminoglycosides,
and chloramphenicol that are the mainstay of treatment for
gram negative sepsis. They are often susceptible to agents
generally used to treat gram positive bacterial infections such
as rifampicin, clindamycin, cotrimoxazole, quinolones and
vancomycin.9 However use of Rifampicin alone in countries
like India where tuberculosis is endemic is not advocated.
The difficulty in treating this infection is compounded by
the fact that MIC breakpoints have not being established for
this bacterium by Clinical and Laboratory Standards Institu-te(
CLSI). Moreover results of susceptibility testing vary when
different methods are used thus adding to the difficulty of
selecting the appropriate antibiotic. Disc diffusion method is
unreliable .The use of inactive drugs may be the cause of poor
outcome in many patients.9
Hsu et al have studied 118 patients with bacteremia and
have concluded that institution of effective antibiotic therapy
after the availability of culture results is an independent
predictor of mortality. They have also shown that E. menin-goseptica
septicemia patients treated with carbapenems have
higher mortality than when they are treated with other anti-biotics
such as fluoroquinolones.10
The SENTRY antimicrobial surveillance programme which
was initiated in 1997 to monitor antimicrobial resistance for
both community acquired and nosocomial infection has
revealed Chryseobacterium strains exhibit resistance to ami-noglycosides,
tetracyclines, chloramphenicol, erythromycin,
clindamycin and teicoplanin.11The same study has shown
that fluoroquinolones have favorable susceptibility pattern
against E. meningoseptica with levofloxacin being slightly more
effective than ciprofloxacin and that the susceptibility to
doxycycline and trimethoprim/sulphamethoxazole appears
variable. Rifampicin and vancomycin in combination has
been used successfully in meningitis cases. But recently in-vestigators
have questioned the usefulness of vancomycin
since in vitro susceptibility data points towards a high MIC of
vancomycin against E. meningoseptica.12,13
In the first case the patient was initially treated with lev-ofloxacin
and subsequently with rifampicin and trimetho-primesulphamethoxazole
and the organism was successfully
eradicated from blood, urine and respiratory samples. In the
second case the cure was affected with rifampicin and tri-methoprimesulphamethoxazole.
Both the patients were
successfully treated with the proper antibiotics after the cor-rect
identification was made. Thus timely identification of E.
meningoseptica is very crucial since appropriate antibiotic
therapy is vital for eradicating infection. All oxidase positive
organism resistant to Polymyxin group (Poly B & Poly E) of
antibiotics should be further characterized. Reporting of all
non-fermenter oxidase positive organisms as Pseudomonas
sp may result in inappropriate antibiotic therapy resulting in
poor outcome. E. meningoseptica septicemia can be life
threatening if not detected and treated with appropriate an-tibiotics.
A study by Lin et al from Taiwan has shown high
mortality of patients with nosocomial bloodstream infection
due to E. meningoseptica. They have further shown that shock
and use of inappropriate antibiotics in these patients are
significantly associated with mortality.14
Isolation of E. meningoseptica should necessitate enhanced
environmental surveillance since E. meningoseptica has the
potential to cause outbreaks and any incriminating source
should be dealt appropriately. In our case flushing of pipelines
and changing of tap faucets resulted in eradication of organ-ism
from the water source and no new infection with E.
meningoseptica was reported.
In conclusions it can be said that E. meningoseptica is an
emerging bacteria causing infection in critically ill adult pa-tients.
The use of Polymyxin group of drugs that are the main
stay of treatment for carbapenem resistant bacteria may have
resulted in the emergence of these intrinsic polymyxin resis-tant
bacteria. Contaminated equipments and water is the
possible source of infection. Infection with E. meningoseptica
necessitates enhanced microbiological surveillance particu-larly
of the water and hand washing sinks so as to be able to
identify the source of the bacteria. Identification of this bac-terium
is difficult and may be wrongly reported as Pseudo-monas
sp. A high index of suspicion should be present in order
to be able to identify this bacterium. Antibiotic therapy is
challenging as E. meningoseptica is intrinsically resistant to
many of the high end antibiotics used in critical care units
particularly Polymyxin group of drugs to which this is intrin-sically
resistant. The currently used CLSI guideline for anti-biotic
susceptibility testing is not helpful for guiding antibiotic
therapy against this organism. Rifampicin, trimetho-primesulphamethoxazole
and levofloxacin alone or in com-bination
seem to be effective against E. meningoseptica.
However the use of Rifampicin alone for the treatment of E.
meningoseptica is to be discouraged. Timely identification and
appropriate therapy is crucial in eradicating this bacterium
and there by improving patients' outcome.
Conflicts of interest
All authors have none to declare.
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