AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Providencia species may cause infection at various sites. In recent years, the incidence of infection has increased, especially in certain patient groups. One species of the organisms now known as members of the genus Providencia was first recognized by Rettger in 1904. He isolated the organism from chickens during an epidemic of fowl cholera. This isolate was not characterized further until 1918, when it was named Bacterium rettgeri.

Organisms belonging to the genus Providencia have undergone many taxonomic changes since their first description, with frequent confusion and overlap between organisms of the closely related genera of Providencia, Proteus, and Morganella. Kauffman first proposed the genus name Providencia in 1951, referring to a group of organisms studied by Stuart and colleagues at Brown University in Providence, Rhode Island.

Today, 5 Providencia species are recognized: Providencia stuartii, Providencia rettgeri, Providencia alcalifaciens, Providencia rustigianii, and Providencia heimbachae.

Microbial Ecology and Pathophysiology: In humans, Providencia species have been isolated from urine, stool, and blood, as well as from the throat, perineum, axilla, and wounds. P stuartii and P rettgeri have also been found in various water sources.

P rettgeri has been isolated from a number of animals, including poultry and reptiles. This species probably is pathogenic in animals and has been reported to cause meningitis in crocodiles. Finally, P rustigianii and P heimbachae have been isolated from penguins.

P stuartii is the most common species causing human infection. This organism is extremely common in patients with long-term indwelling urinary catheters. Its ability to persist in catheterized urine is likely due to an adhesin, mannose-resistant/klebsiellalike (MR/K) hemagglutinin, which allows it to adhere to the urinary catheter.

P alcalifaciens, P rettgeri, and P stuartii may cause invasive diarrhea.

Frequency

United States

P stuartii and, to a lesser extent, P rettgeri are the most commonly found of the Providencia species. While uncommon in most clinical settings, these organisms have a predilection for catheterized urine.

P stuartii comprises up to 61% of all bacterial pathogens isolated from the urine of patients with long-term indwelling urinary catheters.

When a P stuartii infection invades the bloodstream, it is almost always of urinary origin. In one study, Providencia species accounted for 3% of all gram-negative bloodstream infections. A case of endocarditis due to P stuartii has been reported.

Mortality/Morbidity

Mortality in patients with bloodstream infection ranges from 6-33%. Mortality is greater in polymicrobial infection.

Race

All races appear to be equally susceptible.

Sex

Males and females appear to be equally susceptible. Persistence of P stuartii in catheterized urine, however, appears to be greater in females than in males.

Age

• Elderly persons are at much greater risk of infection due to P stuartii or P rettgeri. This is likely due to the fact that these infections are associated with the use of indwelling urinary catheters, and the use of such devices is much more common in the elderly population.
• Most studies of P alcalifaciens–associated diarrhea have been conducted in children. A recent study demonstrated that Providencia species are important causes of traveler's diarrhea in adults, as well. Whether the risk of such infection is greater at younger ages is unclear.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• P stuartii and P rettgeri
• • P rettgeri may be isolated less commonly because it is more frequently susceptible to aminoglycosides, and these agents are frequently used empirically in the hospitalized population.
  • In urinary tract infections, patients often have long-standing dependence on an indwelling urinary catheter.
  • Both species have recently been implicated as causes of traveler's diarrhea.
  • Patients who have recently undergone a urinary tract procedure with instrumentation are also at greater risk of infection.
  • Patients with respiratory tract infection are more likely to have been intubated or to have had intratracheal suctioning. These conditions promote airway colonization.
  • Patients with burns are at higher risk of wound infection with Providencia species.
• P alcalifaciens, P rustigianii, and P heimbachae
• • These Providencia species are most likely to elicit GI symptoms.
  • P alcalifaciens is associated with overseas travel.

Physical

• P stuartii and P rettgeri
• • Urinary tract infection is associated with typical features, including dysuria, frequency, hematuria, cloudy urine, suprapubic tenderness, and fever, but, often, few localizing signs.
  • Bloodstream infection is associated with fever, tachycardia, hypotension, chills, nausea, vomiting, and lethargy. Vascular collapse is uncommon.
  • Respiratory tract: Cough is most common. Often, patients have very few signs and symptoms. Isolation of organism from sputum frequently represents colonization rather than true infection.
  • Gastroenteritis is most commonly associated with diarrhea, but abdominal pain, vomiting, and fever can also be present. Vomiting may be common with P rettgeri infection.
• P alcalifaciens, P rustigianii, and P heimbachae
• • While P alcalifaciens has been demonstrated in the stool of symptomatic patients, the clinical significance of isolating P rustigianii and P heimbachae is less certain.
  • Signs and symptoms of GI tract infection include abdominal pain, vomiting, dehydration, and bloody stool. Fever is uncommon.

Causes

• Urinary tract infection with P stuartii or, less commonly, P rettgeri is associated with long-term indwelling urinary devices and complicated cystitis.
• • Many patients developing such infections are residents of long-term care facilities.
  • When bloodstream infection occurs with one of these organisms, it is most commonly from a urinary tract origin.
  • Finally, some evidence suggests that patients with underlying comorbidities may be at greater risk of acquiring such infections.
• Gastroenteritis due to P alcalifaciens, P rettgeri, and P stuartii may be seen after travel to developing countries.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Obtain bacterial Gram stain and culture from the suspected site of infection. In a patient requiring hospitalization for suspected infection or in whom a bloodstream infection is suspected, obtain 2 sets of blood cultures.
• Obtain urinalysis in patients with suspected urinary tract infection. The presence of white cells or leukocyte esterase may help to distinguish urinary tract colonization from infection.
• Routine laboratory testing is not helpful except to assist in excluding other diseases from the differential diagnosis.
• Once an organism has been identified, susceptibility testing is extremely important because many Providencia species may be resistant to multiple antibiotics. The problem of multidrug resistance among Providencia species may be increasing. General characterizations can be made.
• • P stuartii tends to be the least susceptible of all Providencia species. It is almost always resistant to tetracyclines, older penicillins and cephalosporins, and trimethoprim-sulfamethoxazole (TMP-SMX). It usually is resistant to fluoroquinolones and aminoglycosides. It is more often susceptible to late-generation cephalosporins, aztreonam, and carbapenems.
  • 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 usually are susceptible to TMP-SMX, fluoroquinolones, aminoglycosides, late-generation cephalosporins, aztreonam, and carbapenems.
  • P rettgeri tends to fall between the 2 groups mentioned above with regard to its susceptibility profile.

Imaging Studies

• Obtain a chest radiograph to exclude pneumonia in suggestive cases.

Other Tests

• In persons returning from overseas travel with diarrheal symptoms of unclear etiology, stool may be cultured for Providencia species.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Medical care is directed primarily at 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 (see Lab Studies).
  • Once the identity of the pathogen and its susceptibility profile are known, selection of directed therapy should focus on treatment with the narrowest-spectrum agent to which the organism is susceptible.
  • Duration of therapy should range from 7-14 days, depending on the site of infection (14 d for bloodstream infection).
  • Selection of an oral agent (if available) is preferred to avoid complication associated with intravenous catheters.
• If infection is associated with an indwelling device (eg, urinary catheter), remove the catheter. Carefully evaluate the continued requirement of the catheter. If its use continues to be required, insert a new catheter. If not, discontinue use of the catheter.

Surgical Care

• If infection is associated with an anatomic site amenable to debridement (eg, wound, ulcer) or drainage (eg, abscess), perform these procedures to facilitate bacterial eradication.

Consultations

• Consider consultation with an infectious diseases specialist to help determine the treatment plan.

Diet

• No special diet is required.

Activity

• Activity should not be restricted.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical therapy is directed at eradication of the infecting Providencia organism through the use of an antimicrobial agent to which the organism is susceptible.

Drug Category: Antibiotics

Selection of empiric antimicrobial therapy must take into account the likely pathogens given the clinical setting. Selection of final antimicrobial therapy, once the identity of the infecting organism is known, should favor the safest and most cost-effective agent with the narrowest spectrum of activity to which the infecting pathogen is susceptible.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• In addition to antimicrobial therapy, inpatient care 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 reevaluate the continued need for this device.

Further Outpatient Care

• Follow 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).

In/Out Patient Meds

• Administration of antibiotics, based on susceptibility testing, should be continued for 7-14 days.

Transfer

• Transfer patients if they develop complications requiring 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.

Deterrence/Prevention

• Because many Providencia infections are associated with indwelling devices (eg, urinary catheters), careful review of the medical necessity of any such devices is extremely important. The need for such device 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 helping to reduce the likelihood of colonization and infection.
• Travelers to developing countries should be counseled to avoid raw or undercooked foods and to drink bottled water.
• Providencia species often may be resistant to multiple antibiotics. Early identification of such infections and prompt institution of infection control procedures are important in decreasing the likelihood of spread of the organism among patients.

Complications

• Infection with P stuartii and P rettgeri, particularly if bloodstream involvement exists, has been associated with a number of complications.
• • Sepsis/vascular collapse
  • Renal failure
  • Pneumonia
  • ARDS
• GI tract infection may be associated with bloody diarrhea and dehydration.

Prognosis

• Mortality in patients with bloodstream involvement of infection ranges from 6-33%.
• Patients with polymicrobial bacteremia have increased mortality.
• Evidence that early appropriate antimicrobial therapy is associated with decreased mortality is inconclusive.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to consider Providencia in a differential diagnosis may result in selection of inappropriate empiric antimicrobial therapy and, possibly, increased morbidity and mortality.

Special Concerns

• Residents of long-term care facilities, particularly those with chronic indwelling urinary devices, are at particularly high risk of Providencia urinary tract infection.
• Travelers returning from overseas may be at higher risk of diarrhea due to P alcalifaciens.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Albert MJ, Faruque AS, Mahalanabis D. Association of Providencia alcalifaciens with diarrhea in children. J Clin Microbiol. May 1998;36(5):1433-5. [Medline].
• Hawkey PM. Providencia stuartii: a review of a multiply antibiotic-resistant bacterium. J Antimicrob Chemother. Mar 1984;13(3):209-26. [Medline].
• Haynes J, Hawkey PM. Providencia alcalifaciens and travelers'' diarrhea. BMJ. Jul 8 1989;299(6691):94-5. [Medline].
• Hickman-Brenner FW, Farmer JJ, Steigerwalt AG, Brenner DJ. Providencia rustigianii: a new species in the family Enterobacteriaceae formerly known as Providencia alcalifaciens biogroup 3. J Clin Microbiol. Jun 1983;17(6):1057-60. [Medline].
• Kaslow RA, Lindsey JO, Bisno AL, Price A. Nosocomial infection with highly resistant, Proteus rettgeri. Report of an epidemic. Am J Epidemiol. Sep 1976;104(3):278-86. [Medline].
• Krake PR, Tandon N. Infective endocarditis due to Providenca stuartii. South Med J. Oct 2004;97(10):1022-3. [Medline].
• Matsuda T, Beppu T, Hirota M, et al. [A long-term surviving case of multiple metastatic liver tumors from rectal cancer treated with microwave coagulation therapy (MCT)]. Gan To Kagaku Ryoho. Oct 1999;26(12):1921-4. [Medline].
• Muder RR, Brennen C, Wagener MM, Goetz AM. Bacteremia in a long-term-care facility: a five-year prospective study of 163 consecutive episodes. Clin Infect Dis. Mar 1992;14(3):647-54. [Medline].
• O''Hara CM, Brenner FW, Miller JM. Classification, identification, and clinical significance of Proteus, Providencia, and Morganella. Clin Microbiol Rev. Oct 2000;13(4):534-46. [Medline].
• Stock I, Wiedemann B. Natural antibiotic susceptibility of Providencia stuartii, P. rettgeri, P. alcalifaciens and P. rustigianii strains. J Med Microbiol. Jul 1998;47(7):629-42. [Medline].
• Tumbarello M, Citton R, Spanu T, et al. ESBL-producing multidrug-resistant Providencia stuartii infections in a university hospital. J Antimicrob Chemother. Feb 2004;53(2):277-82. [Medline].
• Warren JW. Providencia stuartii: a common cause of antibiotic-resistant bacteriuria in patients with long-term indwelling catheters. Rev Infect Dis. Jan-Feb 1986;8(1):61-7. [Medline].
• Wenzel RP, Hunting KJ, Osterman CA, Sande MA. Providencia stuartii, a hospital pathogen: potential factors for its emergence and transmission. Am J Epidemiol. Aug 1976;104(2):170-80. [Medline].
• Woods TD, Watanakunakorn C. Bacteremia due to Providencia stuartii: review of 49 episodes. South Med J. Feb 1996;89(2):221-4. [Medline].
• Yoh M, Matsuyama J, Ohnishi M, et al. Importance of Providencia species as a major cause of travellers' diarrhoea. J Med Microbiol. Nov 2005;54(Pt 11):1077-82. [Medline].

Article Last Updated: Apr 19, 2006