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

Serratia are opportunistic gram-negative bacteria classified in the tribe Klebsielleae and the large family Enterobacteriaceae.

Serratia marcescens is the only pathogenic species of Serratia, except for rare reports of disease resulting from infection with Serratia plymuthica, Serratia liquefaciens, Serratia rubidaea, and Serratia odorifera.

Some strains of S marcescens are capable of producing a pigment called prodigiosin, which ranges in color from dark red to pale pink, depending on the age of the colonies. S marcescens has a predilection for growth on starchy foodstuffs, where the pigmented colonies are easily mistaken for drops of blood.

In 1819, Bartolomeo Bizio, a pharmacist from Padua, Italy, discovered and named S marcescens when he identified the bacterium as the cause of a miraculous bloody discoloration in a cornmeal mush called polenta. Bizio named Serratia in honor of an Italian physicist named Serrati, who invented the steamboat, and Bizio chose marcescens from the Latin word for decaying because the bloody pigment was found to deteriorate quickly.

Since 1906, physicians have used S marcescens as a biological marker for studying the transmission of microorganisms, because until the 1950s, this bacterium generally was considered a harmless saprophyte. Only since the 1960s has S marcescens been recognized as an opportunistic human pathogen.

Pathophysiology

In the hospital, Serratia tends to colonize the respiratory and urinary tracts of adults, rather than the gastrointestinal tract.

Serratia causes about 2% of nosocomial infections of the bloodstream, lower respiratory tract, urinary tract, surgical wounds, and skin and soft tissues of adult patients. Outbreaks of S marcescens meningitis, wound infections, and arthritis have occurred in pediatric wards.

Serratia has caused endocarditis and osteomyelitis in people addicted to heroin.

Cases of arthritis resulting from Serratia infection are reported in outpatients who have received intraarticular injections.

Frequency

United States

Serratia species cause 1.4% of nosocomial bloodstream infections.

International

The prevalence of Serratia in nosocomial infections is diminishing, but these bacteria still are able to cause hospital outbreaks, especially in intensive care units.

Mortality/Morbidity

• Crude mortality for nosocomial bloodstream infection with Serratia is 26%.
• Mortality is high in patients with meningitis and endocarditis caused by Serratia infection.

Age

Outbreaks occur in neonates and infants. In adults, most cases are isolated, but occasional nosocomial outbreaks occur.

CLINICAL

Section 3 of 10  

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

History

• Patients with Serratia sepsis may present with fever, chills, shock, and respiratory distress.
• Urinary tract infection
• • Approximately 30-50% of patients are asymptomatic. When symptoms are present, patients may have fever, frequent urination, dysuria, pyuria, or pain upon urination.
  • In 90% of cases, patients have a history of recent surgery or instrumentation of the urinary tract.
  • Important risk factors include diabetes mellitus, urinary tract obstruction, and renal failure.
• Respiratory tract infection
• • These patients usually are colonized with Serratia after instrumentation (eg, ventilation, bronchoscopy), especially those patients with chronic obstructive pulmonary disease.
  • Patients may have pneumonia, but this development is rare. If pneumonia develops, patients may have fever, chills, productive cough (sometimes with pseudohemoptysis), hypotension, dyspnea, or chest pain.
• Meningitis or cerebral abscess
• • Meningitis or cerebral abscesses resulting from Serratia infection may develop in premature children and neonates with prior sepsis. Patients who have experienced head trauma or have undergone neurosurgery, lumbar puncture, or even epidural injections are at risk of developing meningitis or cerebral abscess.
  • The symptoms are those of gram-negative meningitis (eg, headache, fever, vomiting, stupor, coma).
• Patients with intraabdominal infections resulting from Serratia infection may present with biliary drainage, hepatic abscess, pancreatic abscess, and peritoneal exudate.
• Patients with Serratia infection may have osteomyelitis or arthritis, which can be hematogenous in people addicted to intravenous drugs or may be caused exogenously by surgery, open trauma, or intraarticular injection.
• Patients with endocarditis resulting from Serratia infection may present with fever, petechiae, and, occasionally, embolic complications (eg, stroke, arterial emboli).
• Patients with Serratia-related ocular infections will have keratitis or endophthalmitis.
• Patients with soft tissue infections resulting from Serratia may have surgical scars, cellulitis, phlebitis, or skin infections.
• Patients with Serratia-related otitis media have earaches, hearing loss, and ear discharge.
• Bacterial parotitis associated with Serratia infection is rare.

Physical

• Pink hypopyon in the absence of hyphema may suggest S marcescens endophthalmitis.

Causes

• Sepsis or bacteremia
• • The main risk factor is hospitalization. Placement of intravenous, intraperitoneal, or urinary catheters and prior instrumentation of the respiratory tract have been identified as risk factors for inpatients.
  • Other risk factors include cardiac valve replacement, transfusions, and the use of contaminated intravenous infusions. An outbreak of bacteremia was caused by pooling the residual contents of preservative-free epoetin vials for later use. Another outbreak was traced to tampering with an infused narcotic by a hospital employee. In addition, 2 cases of bacteremia during an outbreak of S marcescens infections were traced to contamination of a faucet in an intensive care unit.
• Urinary tract infection
• • In 90% of cases, patients have a history of recent surgery or instrumentation of the urinary tract.
  • Important risk factors are diabetes mellitus, urinary tract obstruction, and renal failure.
• Respiratory tract colonization appears after instrumentation (eg, ventilation, bronchoscopy), especially in patients with chronic obstructive pulmonary disease. During an outbreak of S marcescens infections traced to a contaminated faucet (including consumption of tap water from the faucet) in an intensive care unit, 9 patients developed respiratory tract colonization: septic bronchitis in 8 and empyema in 1.
• Meningitis or cerebral abscess may result from Serratia infection in premature children and neonates with prior sepsis. Meningitis can also develop in adults who have experienced head trauma or have undergone neurosurgery, epidural injection, or lumbar puncture.
• Osteomyelitis or arthritis can be hematogenous in people addicted to intravenous drugs or can be caused exogenously by surgery, open trauma, or intraarticular injection.
• Ocular infections
• • Serratia infection frequently causes nonulcerating bacterial keratitis, which is associated with soft and rigid contact lens wear.
  • Endophthalmitis usually occurs after eye surgery.
• Bacterial parotitis can appear in individuals with prior sialectasia.
• Dermal abscesses and skin ulcers in the legs have appeared after a toe-web infection.

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

• CBC count with differential
• • Leukocytosis with neutrophilia
  • Leukopenia (rare)
  • Presence of more than 10% immature neutrophils (ie, bands)
  • Possible anemia
• Serum biochemistry for glucose, urea, and creatinine
• Bacterial cultures and antibiograms
• • Blood
  • Urine
  • Samples of abscesses or effusions
  • Catheters suspected of being contaminated
  • Liquid soaps or disinfectants suspected of being contaminated
  • IV fluids suspected of being contaminated
• Cerebrospinal fluid
• • Polynuclear pleocytosis
  • High protein level
  • Low glucose level

Imaging Studies

• Perform chest radiography if pneumonia is suspected or in the presence of respiratory distress.
• Abdominal ultrasonography or computed tomography (CT) scans will rule out obstructive hydronephrosis or intraabdominal abscesses (eg, hepatic, pancreatic, other).
• Transthoracic or transesophageal echocardiography may reveal valvular vegetations and valvular or paravalvular regurgitation.
• Perform a spinal CT scan or MRI if spondylitis is suspected.

Procedures

• Lumbar puncture should be performed in all patients with suspected meningitis. If signs of increased intracranial pressure are present (focal neurologic abnormalities, seizure, or altered mental status), obtain a head CT scan prior to the puncture to exclude cerebral abscess or mass lesion.

TREATMENT

Section 6 of 10  

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

Medical Care

Antibiotic therapy is the primary treatment for most patients. Home therapy is an option for patients who are clinically stable.

Surgical Care

Purulent collections (abscesses) may require drainage.

Consultations

• Consult a cardiac surgeon if considering valve replacement in patients with infective endocarditis.
• In a possible nosocomial outbreak, strain typing may assist the epidemiologic investigation.

MEDICATION

Section 7 of 10  

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

S marcescens is naturally resistant to ampicillin, macrolides, and first-generation cephalosporins. In Taiwan, 92% of the strains are resistant to cefotaxime, but 99% are still susceptible to ceftazidime. Therapy for Serratia infections should include an aminoglycoside in addition to an antipseudomonal beta-lactam, as the single use of a beta-lactam can select for resistant mutants. Most strains are susceptible to amikacin, but reports indicate increasing resistance to gentamicin and tobramycin. Quinolones also are highly active against most strains. Definitive therapy should be based on the results of susceptibility testing because multiresistant strains are common.

Drug Category: Antibiotics

Empiric antimicrobial therapy should cover all likely pathogens in the context of the clinical setting.

FOLLOW-UP

Section 8 of 10  

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

Further Inpatient Care

• Remove or change catheters suspected of being contaminated.

Deterrence/Prevention

• Avoid reusing single-use vials, and reject possibly contaminated IV fluids.
• Avoid using soaps or disinfectants that may be contaminated.
• Use disposable ECG leads.
• Emphasize standard precautions. Hospital employees should wash their hands before and after contact with patients. The most frequent mechanism of transmission in nosocomial outbreaks is through soiled hands.
• IV lines should be removed as soon as possible.

Prognosis

• The mortality rate for severe infection (bacteremia) is 26%. For those who survive, the prognosis for complete recovery is good.
• Patients with S marcescens endophthalmitis have a poor prognosis for maintaining vision.

MISCELLANEOUS

Section 9 of 10  

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

Special Concerns

• If bacterial disease is suspected in a patient who is severely immunocompromised and infected with HIV, consider the diagnosis of Serratia infection.
• Risk factors for severe infections with Serratia include old age, previous antibiotic treatment, and chronic or debilitating diseases.

REFERENCES

Section 10 of 10

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

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Article Last Updated: Jan 29, 2007