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Ventilator-associated pneumonia due to carbapenem-resistant Providencia

rettgeri

Article  in  BMJ Case Reports · July 2021

DOI: 10.1136/bcr-2021-243908

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Department of Anesthesia and
Critical Care, AIIMS Rishikesh,
Rishikesh, India
Correspondence to
Dr Nupur B Patel;
​nupurbpatel@​yahoo.​co.​in
Accepted 10 June 2021
© BMJ Publishing Group
Limited 2021. No commercial
re-­use. See rights and
permissions. Published by BMJ.
To cite: Patel NB, Jain G,
Chandrakar S, et al. BMJ
Case Rep 2021;14:e243908.
doi:10.1136/bcr-2021-
243908
Ventilator-­associated pneumonia due to carbapenem-­
resistant Providencia rettgeri
Nupur B Patel  ‍ ‍, Gaurav Jain, Saurabh Chandrakar  ‍ ‍, Beeraling Ningappa Walikar
SUMMARY
Ventilator-­associated pneumonia (VAP) is one of the
leading cause of mortality and morbidity in critically ill
patients on mechanical ventilation. We report a case of
VAP caused by Providencia rettgeri in a postoperative
58-­year-­old man with prepyloric perforation. The
patient’s ICU stay was complicated by VAP. As the
organism was carbapenem resistant, high-­dose extended
infusion of meropenem along with cefepime was started.
Early identification and treatment helped in successful
weaning of the patient from the ventilator. Providencia
is an emerging nosocomial pathogen with an increase
in resistance pattern. This case highlights the rarity and
importance of Providencia as a cause of VAP.
BACKGROUND
Ventilator-­associated pneumonia (VAP) is defined
as pneumonia that occurs 48 hours or more after
endotracheal intubation. The incidence of VAP
is 9%–27% with a mortality rate of 9%–13%.1
Common pathogens known to cause VAP are Pseu-
domonas (24.4%), Staphylococcus aureus (20.4%),
Enterobacteriaceae (14.1% includes Klebsiella spp,
Escherichia coli, Proteus spp, Enterobacter spp,
Serratia spp and Citrobacter spp), Streptococcus sp
(12.1%), Haemophilus sp (9.8%), Acinetobacter
sp (7.9%), Neisseria sp (2.6%), Stenotrophomonas
maltophilia (1.7%), coagulase-­ negative Staphy-
lococcus (1.4%), others (4.7% includes Coryne-
bacterium, Moraxella, Enterococcus and fungi).1
Providencia rettgeri, a gram negative bacillus, is a
rare cause of VAP. To the best of our knowledge,
this is the first reported case of VAP in India due to
carbapenem-­resistant P. rettgeri.
CASE PRESENTATION
A 58-­ year-­
old man presented to the emergency
department with abdominal pain and vomiting
for 3 days. The pain was sudden in onset, initially
localised to the umbilicus and then spread to the
entire abdomen. He had received analgesic (tablet
paracetamol) and antiemetic (tablet ondansetron)
from a primary care physician. But his symptoms
were not relieved and for the past 24 hours, he had
severe abdominal distension with non-­passage of
stool or flatus for which he came to the hospital.
He did not have any previous surgical history or
any comorbidities. On examination, he was dehy-
drated, tachycardic (122 breaths/min) and tachy-
pnoeic (34 breaths/min). Abdomen was distended
with generalised and rebound tenderness. Guarding
and rigidity were present and bowel sounds were
diminished.
Patel NB, et al. BMJ Case Rep 2021;14:e243908. doi:10.1136/bcr-2021-243908
Case report
BMJ Case Rep: first published as 10.1136/bcr-2021-243908 on 5 July 2021. Downloaded from http://casereports.bmj.com/ on July 6, 2021 at AIIMS Rishikesh. Protected by copyright.
An abdominal X-­ray was done, which showed air
under the diaphragm with dilated bowels. A diag-
nosis of hollow viscous perforation was made and he
was immediately taken for emergency laparotomy.
He was intubated using rapid sequence induction
with continuous cricoid pressure to prevent aspi-
ration. He had prepyloric perforation, which was
repaired by an omental patch. During the surgery,
patient developed hypotension for which fluid
boluses were given and low-­dose norepinephrine
was started. Arterial blood gas (ABG) was suggestive
of metabolic acidosis. Postoperatively, he was trans-
ferred to the intensive care unit (ICU) in view of
septic shock. On arrival to the ICU, he had a heart
rate of 112 beats/min, blood pressure of 132/76 mm
Hg with norepinephrine 20 μg/min and saturation
of 98% with endotracheal tube in situ. He was put
on invasive mechanical ventilator synchronised
intermittent mandatory ventilation mode with tidal
volume of 400 mL, pressure support (PS) of 12 cm
H2O, PEEP (Positive end expiratory pressure) of
6 cm H2O, respiratory rate of 18 breaths/min and
fractional inspired oxygen (FiO2) of 40%.
INVESTIGATIONS
In the ICU baseline ABG, chest X-­ray and routine
blood investigations were done (table 1). ABG
showed metabolic acidosis with a pH of 7.21,
partial pressure of oxygen of 112 mmHg, partial
pressure of carbon dioxide of 30 mmHg, bicar-
bonate of 15 mEq and base deficit of −12 mEq.
Initial chest X-­
ray (figure 1A) was normal. He
was empirically started on injection (intravenous)
ceftriaxone 1 g two times per day and metronida-
zole 500 mg three times per day after taking blood
cultures. Fluid boluses were administered as he
was fluid responsive. Gradually, he was tapered off
the vasopressors on postoperative day 2 and was
planned for weaning. The next day, he developed
fever (101 F), tachypnoea (28 breaths/min) and
tachycardia (132 breaths/min) with an increase in
ventilatory requirements (FiO2: 60%, PS: 15 cm
Figure 1  Chest X-­ray on intensive care unit admission
(A) and on postoperative day 3 (1B).
1
 Case report

BMJ Case Rep: first published as 10.1136/bcr-2021-243908 on 5 July 2021. Downloaded from http://casereports.bmj.com/ on July 6, 2021 at AIIMS Rishikesh. Protected by copyright.
Table 1  Laboratory data at admission and during hospitalisation
Postoperative day 3
Variable ICU admission (VAP onset) Day 5 Day 7 Day 10 Day 12
Haemoglobin (g/dL) 10.6 8.7 9 10.8 899 10.1
White cell count (×109/L) 7000 16 600 17 200 9080 8520 6400
Platelets (/μL) 250 000 170 000 267 900 396 000 288 000 286 000
Neutrophils (%) 74 88 84 72 68 71
Creatinine (mg/dL) 1.2 1.4 1.42 0.88 1.1 0.92
Procalcitonin (mg/L) 2 15 3
ICU, intensive care unit; VAP, ventilator-­associated pneumonia.

H2O and PEEP: 10 cm H2O). He had purulent endotracheal
secretions. Repeat chest X-­ray was done on postoperative day 3,
which showed right lower zone consolidation (figure 1B). Blood
investigations showed an increase in white blood cell count with
elevated procalcitonin (table 1). A diagnosis of VAP was made.
Blood, urine and tracheal cultures were taken. Antibiotic was
broadened to intravenous meropenem 1 g three times per day.
Tracheal culture revealed 1 000 000 CFU/mL non-­haemolytic
gram-­negative bacilli. The organism was a non-­lactose fermenter,
positive for mannitol, citrate, urease, rhamnose and inositol, and

Figure 2  Antibiogram of endotracheal secretion.

2 Patel NB, et al. BMJ Case Rep 2021;14:e243908. doi:10.1136/bcr-2021-243908

negative for sucrose. It was identified as P. rettgeri by VITEK 2
automated system.
TREATMENT
As the organism was carbapenem resistant (figure 2), high-­dose
extended infusion of meropenem (2 g) over 3 hours three times
per day was given along with high-­dose intravenous cefepime
2 g three times per day. Urine and blood cultures did not reveal
any bacterial growth. Gradually, the patient was weaned off the
ventilator on postoperative day 10. He was shifted to the surgery
ward on postoperative day 12.
OUTCOME AND FOLLOW-UP
Antibiotics were continued for a total duration of 14 days.
He was discharged on postoperative day 16 and was asked to
follow-­up in surgery outpatient clinics after 1 month.
DISCUSSION
Providencia is a urease producing gram-­negative bacillus ubiq-
uitously found in the environment. Providencia can naturally
be found in the gastrointestinal tract. It belongs to the family
Morganellaceae consisting of five common species, that is,
Providencia alcalifaciens, Providencia rustigianii, P. rettgeri,
Providencia stuartii and Providencia heimbachae.2 It seldom
causes human infection. P. stuartii and P. rettgeri are reported
as pathogens in some immunocompromised patients. P. stuartii
can cause complicated urinary tract infections in patients with
long standing urinary catheters.3 P. alcalifaciens and P. rettgeri
are associated with gastroenteritis and Traveler’s diarrhoea.4
There are reports of community-­acquired pneumonia, menin-
gitis, surgical site infection, ocular infection, meningitis, intra-­
abdominal infection and septicaemia caused by Providencia.5
Learning points
►► Ventilator-­associated pneumonia (VAP) is associated with an
increase in morbidity and mortality.
►► Providencia is an emerging nosocomial pathogen with an
increase in resistance pattern.
►► This case highlights the rarity and importance of Providencia
as a cause of VAP.
►► However, more information is required to clarify the
pathogenicity.
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Patel NB, et al. BMJ Case Rep 2021;14:e243908. doi:10.1136/bcr-2021-243908
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Case report
BMJ Case Rep: first published as 10.1136/bcr-2021-243908 on 5 July 2021. Downloaded from http://casereports.bmj.com/ on July 6, 2021 at AIIMS Rishikesh. Protected by copyright.
Providencia is not commonly found in tracheal aspirates but,
when it is, it is usually deemed to be colonisation (ie, not a
source of infection). But in our patient, the colony-­forming unit
count and sensitivity pattern were in favour of its pathogenicity.
Also, there was clinical and radiological improvement after anti-
biotics were broadened and the patient was gradually weaned
off the ventilator.
Providencia sp are generally resistant to polymyxin, tetra-
cyclines, older generation cephalosporins and ampicillin but
susceptible to newer cephalosporins, imipenem, meropenem
and aztreonam. They have variable susceptibilities to aminogly-
cosides, trimethoprim–sulfamethoxazole and fluoroquinolones.6
In our case, the organism was carbapenem resistant, so we had
limited antibiotic options. High-­dose extended meropenem infu-
sion was proven effective against some enterobacteria.7 Hence,
we decided to start high-­dose extended meropenem infusion
along with high-­dose cefepime for our patient.
Acknowledgements  Dr Biswajeet (Department of Microbiology, All India Institute
of Medical Sciences, Rishikesh, India).
Contributors  NBP: writing the report. GJ: helped in writing and drafting. SC:
helped in writing and drafting. BNW: helped in writing and drafting.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Next of kin consent obtained.
Provenance and peer review  Not commissioned; externally peer reviewed.
ORCID iDs
Nupur B Patel http://​orcid.​org/​0000-​0001-​9929-​0391
Saurabh Chandrakar http://​orcid.​org/​0000-​0003-​2449-​2153
REFERENCES
1 Kalanuria AA, Ziai W, Zai W, Mirski M, et al. Ventilator-­Associated pneumonia in the
ICU. Crit Care 2014;18:208.
2 Wie S-­H. Clinical significance of Providencia bacteremia or bacteriuria. Korean J Intern
Med 2015;30:167–9.
3 Sagar S, Narasimhaswamy N, D’Souza J. Providencia rettgeri: an emerging nosocomial
Uropathogen in an indwelling urinary Catheterised patient. JCDR.
4 Yoh M, Matsuyama J, Ohnishi M, et al. Importance of Providencia species as a major
cause of travellers’ diarrhoea. J Med Microbiol 2005;54:1077–82.
5 Sharma D, Sharma P, Soni P. First case report of Providencia rettgeri neonatal sepsis.
BMC Res Notes 2017;10:536.
6 Shin S, Jeong SH, Lee H, et al. Emergence of multidrug-­resistant Providencia rettgeri
isolates co-­producing NDM-1 carbapenemase and PER-1 extended-­spectrum
β-lactamase causing a first outbreak in Korea. Ann Clin Microbiol Antimicrob
2018;17:20.
7 Levy Hara G, Gould I, Endimiani A, et al. Detection, treatment, and prevention of
carbapenemase-­producing Enterobacteriaceae: recommendations from an international
Working group. J Chemother 2013;25:129–40.
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