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

Serratia marcescens is the primary pathogenic species of Serratia. Rare reports have described disease resulting from infection with Serratia plymuthica,¹ Serratia liquefaciens,² Serratia rubidaea,³ 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.⁴

Since 1906, physicians have used S marcescens as a biological marker for studying the transmission of microorganisms because, until the 1950s, this bacterium was generally considered a harmless saprophyte. Only since the 1960s has S marcescens been recognized as an opportunistic pathogen in humans.⁵

Pathophysiology

In the hospital, Serratia species tend to colonize the respiratory and urinary tracts, rather than the gastrointestinal tract, in adults.

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

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

Cases of Serratia arthritis have been reported in outpatients receiving intra-articular injections.

Frequency

United States

Serratia species are responsible for 1.4% of nosocomial bloodstream infections.

International

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

Mortality/Morbidity

• The crude mortality rate associated with Serratia nosocomial bloodstream infection is 26%.
• Serratia meningitis and Serratia endocarditis carry a high mortality rate.

Age

Outbreaks of Serratia infection occur in neonates and infants. In adults, most Serratia infections 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

• Sepsis: Patients with Serratia sepsis may present with fever, chills, shock, and respiratory distress.
• Urinary tract infection
• • Approximately 30-50% of patients with Serratia urinary tract infections are asymptomatic. Symptoms may include 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 for with Serratia urinary tract infections include diabetes mellitus, urinary tract obstruction, and renal failure.
• Respiratory tract infection
• • Patients with Serratia respiratory tract infection are usually are colonized with Serratia species after instrumentation (eg, ventilation, bronchoscopy), especially those with chronic obstructive pulmonary disease.
  • Serratia pneumonia may develop, but this is rare. Patients with pneumonia may have fever, chills, productive cough (sometimes with pseudohemoptysis⁶), hypotension, dyspnea, and/or chest pain.
• Meningitis or cerebral abscess
• • Serratia meningitis or cerebral abscesses 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).
• Intra-abdominal infections: Patients with Serratia intra-abdominal infections may present with biliary drainage, hepatic abscess, pancreatic abscess, and peritoneal exudate. Serratia peritonitis can complicate peritoneal dialysis.⁷
• Osteomyelitis and arthritis: Serratia osteomyelitis and arthritis may develop following hematogenous spread in persons who are addicted to intravenous drugs or may be caused exogenously by surgery, open trauma, or intra-articular injection.
• Endocarditis: Patients with Serratia endocarditis may present with fever, petechiae, and, occasionally, embolic complications (eg, stroke, arterial emboli).
• Ocular infections: Patients with Serratia ocular infections present with keratitis or endophthalmitis.
• Soft-tissue infections: Patients with Serratia soft-tissue infections may have surgical scars, cellulitis, phlebitis, or skin infections.
• Otitis media: Patients with Serratia otitis media present with earaches, hearing loss, and ear discharge.
• Parotitis: Serratia parotitis is rare.

Physical

• Pink hypopyon in the absence of hyphema may suggest S marcescens endophthalmitis.⁸

Causes

• Sepsis or bacteremia
• • The main risk factor for Serratia sepsis/bacteremia is hospitalization. Placement of intravenous, intraperitoneal, or urinary catheters and prior instrumentation of the respiratory tract have been identified as risk factors among 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.⁹ A multistate outbreak of S marcescens bloodstream infection was linked to contaminated intravenous magnesium sulfate distributed in the United States by a compounding pharmacy.¹⁰
  • Contamination of a faucet resulted in 2 cases of bacteremia during an outbreak of 10 S marcescens infections in an intensive care unit.¹¹
• Urinary tract infection
• • Ninety percent of patients with Serratia urinary tract infection 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: Serratia respiratory tract infection may develop 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 infection (8 developed septic bronchitis; 1 developed empyema), while another 9 patients developed only S marcescens colonization of the respiratory tract.¹¹
• Meningitis and cerebral abscess: Serratia meningitis or cerebral abscess may develop in premature children and neonates with prior sepsis. Serratia meningitis may also develop in adults who have experienced head trauma or have undergone neurosurgery, epidural injection, or lumbar puncture.
• Osteomyelitis and arthritis: 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 wearing soft and rigid contact lenses.
  • Serratia endophthalmitis usually occurs after eye surgery.
• Parotitis: Bacterial parotitis may develop in individuals with prior sialectasia.
• Cutaneous infections: Dermal abscesses and skin ulcers in the legs have appeared after a toe-web infection.¹²

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
  • Intravenous fluids suspected of being contaminated
• Cerebrospinal fluid
• • Polynuclear pleocytosis
  • High protein level
  • Low glucose level

Imaging Studies

• Perform chest radiography in patients with suspected pneumonia or with respiratory distress.
• Abdominal ultrasonography or CT scanning is used to rule out obstructive hydronephrosis or intra-abdominal abscesses (eg, hepatic, pancreatic).
• Transthoracic or transesophageal echocardiography may reveal valvular vegetations and valvular or paravalvular regurgitation.
• Perform spinal CT scanning or MRI if spondylitis is suspected.

Procedures

• Lumbar puncture should be performed in all patients with suspected meningitis. Signs of increased intracranial pressure (focal neurologic abnormalities, seizure, altered mental status) should prompt evaluation with CT scanning prior to 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 in most patients with Serratia infection. Home therapy is an option in 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 of Serratia infection, 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. Extended spectrum beta-lactamases are produced by most S marcescens strains.¹³

Serratia infections should be treated with an aminoglycoside plus an antipseudomonal beta-lactam, as the single use of a beta-lactam can select for resistant strains. 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 with Serratia bacteria.

Deterrence/Prevention

• Avoid reusing single-use vials, and reject possibly contaminated intravenous fluids.
• Avoid using soaps or disinfectants that may be contaminated.
• Avoid using tap water for administration of medication orally or via a nasogastric tube in critically ill patients.¹¹
• Use disposable ECG leads.
• Emphasize standard precautions. Hospital employees should wash their hands before and after contact with patients. The most common mechanism of Serratia transmission in nosocomial outbreaks is through soiled hands. Long-term carriage of an epidemic strain of S marcescens on the hands of a health care worker has been described.¹⁴
• Intravenous lines should be removed as soon as possible.

Prognosis

• Severe Serratia infection (bacteremia) carries a mortality rate of 26%. Among survivors, the prognosis for complete recovery is good.
• S marcescens endophthalmitis carries a poor prognosis in terms of 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 Serratia infections 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

1. Carrero P, Garrote JA, Pacheco S, et al. Report of six cases of human infection by Serratia plymuthica. J Clin Microbiol. Feb 1995;33(2):275-6. [Medline].
2. Grohskopf LA, Roth VR, Feikin DR, et al. Serratia liquefaciens bloodstream infections from contamination of epoetin alfa at a hemodialysis center. N Engl J Med. May 17 2001;344(20):1491-7. [Medline].
3. Ursua PR, Unzaga MJ, Melero P, et al. Serratia rubidaea as an invasive pathogen. J Clin Microbiol. Jan 1996;34(1):216-7. [Medline].
4. Anonymous. The miracle microbe: Serratia marcescens. [Full Text].
5. Yu VL. Serratia marcescens: historical perspective and clinical review. N Engl J Med. Apr 19 1979;300(16):887-93. [Medline].
6. Rastogi V, Purohit P, Peters BP, et al. Pulmonary infection with serratia marcescens. Indian J Med Microbiol. Jul-Sep 2002;20(3):167-8. [Medline].
7. Hiremath S, Biyani M. Technique survival with Serratia peritonitis. Adv Perit Dial. 2006;22:73-6. [Medline].
8. al Hazzaa SA, Tabbara KF, Gammon JA. Pink hypopyon: a sign of Serratia marcescens endophthalmitis. Br J Ophthalmol. Dec 1992;76(12):764-5. [Medline].
9. Ostrowsky BE, Whitener C, Bredenberg HK, et al. Serratia marcescens bacteremia traced to an infused narcotic. N Engl J Med. May 16 2002;346(20):1529-37. [Medline].
10. Sunenshine RH, Tan ET, Terashita DM, et al. A multistate outbreak of Serratia marcescens bloodstream infection associated with contaminated intravenous magnesium sulfate from a compounding pharmacy. Clin Infect Dis. Sep 1 2007;45(5):527-33. [Medline].
11. Horcajada JP, Martinez JA, Alcon A, et al. Acquisition of multidrug-resistant Serratia marcescens by critically ill patients who consumed tap water during receipt of oral medication. Infect Control Hosp Epidemiol. Jul 2006;27(7):774-7. [Medline].
12. Friedman ND, Peterson NB, Sumner WT, et al. Spontaneous dermal abscesses and ulcers as a result of Serratia marcescens. J Am Acad Dermatol. Aug 2003;49(2 Suppl Case Reports):S193-4. [Medline].
13. Mlynarczyk A, Mlynarczyk G, Pupek J, et al. Serratia marcescens isolated in 2005 from clinical specimens from patients with diminished immunity. Transplant Proc. Nov 2007;39(9):2879-82. [Medline].
14. de Vries JJ, Baas WH, van der Ploeg K, et al. Outbreak of Serratia marcescens colonization and infection traced to a healthcare worker with long-term carriage on the hands. Infect Control Hosp Epidemiol. Nov 2006;27(11):1153-8. [Medline].
15. Alonso Fernandez R, Baquero Mochales F. [The genus Serratia: its biology, clinical effects and epidemiology]. Rev Clin Esp. Apr 1994;194(4):294-9. [Medline].
16. Aron M, Goel R, Gupta NP, et al. Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomy for branched renal calculi. J Endourol. Mar 2005;19(2):136-9. [Medline].
17. Bosi C, Davin-Regli A, Charrel R, et al. Serratia marcescens nosocomial outbreak due to contamination of hexetidine solution. J Hosp Infect. Jul 1996;33(3):217-24. [Medline].
18. Bruckner DA, Colonna P, Bearson BL. Nomenclature for aerobic and facultative bacteria. Clin Infect Dis. Oct 1999;29(4):713-23. [Medline].
19. Capitano B, Nicolau DP, Potoski BA, et al. Meropenem administered as a prolonged infusion to treat serious gram-negative central nervous system infections. Pharmacotherapy. Jun 2004;24(6):803-7. [Medline].
20. Civen R, Vugia DJ, Alexander R, et al. Outbreak of Serratia marcescens infections following injection of betamethasone compounded at a community pharmacy. Clin Infect Dis. Oct 1 2006;43(7):831-7. [Medline].
21. Cohen SM, Flynn HW Jr, Miller D. Endophthalmitis caused by Serratia marcescens. Ophthalmic Surg Lasers. Mar 1997;28(3):195-200. [Medline].
22. Demetriou CA, Cunha BA. Serratia marcescens bacteremia after carotid endarterectomy and coronary artery bypass grafting. Heart Lung. Jul-Aug 1999;28(4):293-4. [Medline].
23. Dominguez Herrera JM, Jimenez Mejias ME, et al. [Acute bacterial parotitis caused by Serratia marcescens]. Rev Clin Esp. Apr 1996;196(4):271-2. [Medline].
24. Edmond MB, Wallace SE, McClish DK, et al. Nosocomial bloodstream infections in United States hospitals: a three-year analysis. Clin Infect Dis. Aug 1999;29(2):239-44. [Medline].
25. Edson RS, Terrell CL. The aminoglycosides. Mayo Clin Proc. May 1999;74(5):519-28. [Medline].
26. Eisenstein BI, Zaleznik DF. Enterobacteriaceae. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. Vol 2. Philadelphia, Pa: Churchill Livingstone; 2000:2294-2310.
27. Gurevich I, Tafuro PA, Cunha BA. Serratia peritonitis in hemodialysis patients. Clinical Microbiology Newsletter. 1987;9:55-56.
28. Haddy RI, Mann BL, Nadkarni DD, et al. Nosocomial infection in the community hospital: severe infection due to Serratia species. J Fam Pract. Mar 1996;42(3):273-7. [Medline].
29. Hejazi A, Falkiner FR. Serratia marcescens. J Med Microbiol. Nov 1997;46(11):903-12. [Medline].
30. Hellinger WC, Brewer NS. Carbapenems and monobactams: imipenem, meropenem, and aztreonam. Mayo Clin Proc. Apr 1999;74(4):420-34. [Medline].
31. Heltberg O, Skov F, Gerner-Smidt P, et al. Nosocomial epidemic of Serratia marcescens septicemia ascribed to contaminated blood transfusion bags. Transfusion. Mar 1993;33(3):221-7. [Medline].
32. Hertle R, Schwarz H. Serratia marcescens internalization and replication in human bladder epithelial cells. BMC Infect Dis. Jun 9 2004;4:16. [Medline].
33. Hsieh S, Babl FE. Serratia marcescens cellulitis following an iguana bite. Clin Infect Dis. May 1999;28(5):1181-2. [Medline].
34. Johnson DH, Cunha BA, Klein NC. Serratia. Infect Dis Pract. 1993;17:6-8.
35. Johnson JS, Croall J, Power JS, et al. Fatal Serratia marcescens meningitis and myocarditis in a patient with an indwelling urinary catheter. J Clin Pathol. Oct 1998;51(10):789-90. [Medline].
36. Kirschke DL, Jones TF, Craig AS, et al. Pseudomonas aeruginosa and Serratia marcescens contamination associated with a manufacturing defect in bronchoscopes. N Engl J Med. Jan 16 2003;348(3):214-20. [Medline].
37. Manfredi R, Nanetti A, Ferri M, et al. Clinical and microbiological survey of Serratia marcescens infection during HIV disease. Eur J Clin Microbiol Infect Dis. Apr 2000;19(4):248-53. [Medline].
38. McLeod SD, Goei SL, Taglia DP, et al. Nonulcerating bacterial keratitis associated with soft and rigid contact lens wear. Ophthalmology. Mar 1998;105(3):517-21. [Medline].
39. Munoz G, Alio JL, Perez-Santonja JJ, et al. Ulcerative keratitis caused by Serratia marcescens after laser in situ keratomileusis. J Cataract Refract Surg. Feb 2004;30(2):507-12. [Medline].
40. Pai HH, Chen WC, Peng CF. Cockroaches as potential vectors of nosocomial infections. Infect Control Hosp Epidemiol. Nov 2004;25(11):979-84. [Medline].
41. Royo P, del Valle O, Boquete T. [Epidemiology of Serratia marcescens between 1987 and 1995 at Vall d'Hebron Hospital]. Enferm Infecc Microbiol Clin. Dec 1997;15(10):519-27. [Medline].
42. Sehdev PS, Donnenberg MS. Arcanum: The 19th-century Italian pharmacist pictured here was the first to characterize what are now known to be bacteria of the genus Serratia. Clin Infect Dis. Oct 1999;29(4):770, 925. [Medline].
43. Shih HI, Lee HC, Lee NY, et al. Serratia marcescens bacteremia at a medical center in southern Taiwan: high prevalence of cefotaxime resistance. J Microbiol Immunol Infect. Oct 2005;38(5):350-7. [Medline].
44. Sickbert-Bennett EE, Weber DJ, Gergen-Teague MF, et al. Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses. Am J Infect Control. Mar 2005;33(2):67-77. [Medline].
45. Sokalski SJ, Jewell MA, Asmus-Shillington AC, et al. An outbreak of Serratia marcescens in 14 adult cardiac surgical patients associated with 12-lead electrocardiogram bulbs. Arch Intern Med. Apr 1992;152(4):841-4. [Medline].
46. Tanaka T, Takahashi H, Kobayashi JM, et al. A nosocomial outbreak of febrile bloodstream infection caused by heparinized-saline contaminated with Serratia marcescens, Tokyo, 2002. Jpn J Infect Dis. Oct 2004;57(5):189-92. [Medline].
47. van der Vorm ER, Woldring-Zwaan C. Source, carriers, and management of a Serratia marcescens outbreak on a pulmonary unit. J Hosp Infect. Dec 2002;52(4):263-7. [Medline].
48. Weinstein RA. Lessons from an epidemic, again. N Engl J Med. May 17 2001;344(20):1544-5. [Medline].
49. Yannelli B, Schoch PA, Cunha BA. Serratia infections in the hospital. Clinical Microbiology Newsletter. 1987;9:157-160.

Article Last Updated: Oct 1, 2008