Enterobacter Cloacae Device Endocarditis: Case Report, Scoping Study, and Guidelines Review

Abstract

While traditionally an infection of the endocardial surface of heart valves, infective endocarditis (IE), can atypically present as infection of cardiac implantable electronic devices (CIED), including permanent pacemakers (PPM) or automatic implantable cardioverter-defibrillators (AICD). CIED endocarditis, similar to valvular IE, is generally caused by Gram-positive organisms such as Staphylococcus spp., most frequently S. Auerus, but is rarely caused by gram-negative bacteria, both HACEK and non-HACEK species. We present the case of Enterobacter cloacae CIED endocarditis. We also present a scoping study of previous case reports and case series highlighting the risk factors, surgical interventions, and mortality outcomes associated with E. Cloacae endocarditis. We also discuss the current guidelines and recommendations on antibiotic therapies for non-HACEK Gram-negative endocarditis and surgical management of infected CIED extraction and replacement.

Elusive Enterobacter cloacae causing pacemaker endocarditis

“…IE caused by non-HACEK gram-negative bacilli is especially rare, amounting to 1.8 %–3.9 % of IE cases in recent meta-analyses [ 4 , 5 ]. Specifically, E. cloacae endocarditis has seldom been reported, with as few as 14 cases in a recent review, only 2 of which were associated with CIED [ 6 ].…”

“…It is mostly associated with nosocomial bacteremia, urinary tract infections, pneumonia, and rarely endocarditis [ 7 ]. Contrary to the usual association of right-sided endocarditis with gram-negative rods, the Enterobacter species has been most associated with mitral valve infections [ 6 ]. Common predispositions include prior valve disease, prosthetic valves, CIEDs, and prolonged vascular access [ 8 ].…”

“…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 ].…”

“…While involving the cardiothoracic surgery team seems to be universally supported, reports vary regarding outcomes as some cite increased mortality with surgery (44 % with surgery vs. 30 % without surgery) [ 12 ]. Regardless of the multi-disciplinary approach, endocarditis due to non-HACEK gram negative-rods and E. cloacae has seen an elevated mortality rate of around 24 % and 42.9 %, respectively [ 2 , 6 ].…”

Systematic review: Mechanisms used by Klebsiella pneumoniae and Enterobacter spp to acquire their antibiotic multiresistant and what treatment alternatives exist.

“…it was also found that the misuse of antibiotics is the most prevalent mechanism of multidrug resistance (62.5%). 38,39,40 Additionally, Carbapenemases are the second mechanism, but with special attention to blaNDM-1, which represents (18.8%). 41 Finally, there are 16srRNA methylases, MCR gene, and AmpC β-lactamases with (6.3%).…”