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PROVIDENCIA INFECTIONS

The genus Providencia includes urease-producing GRAM-NEGATIVE bacilli that are

responsible for a wide range of human infections. Although most Providencia infections involve
the urinary tract, they are also associated with gastroenteritis and bacteremia. Providencia
infections are uncommon and are usually nosocomial. They represent an emerging problem
because of the increasing prevalence of antibiotic resistance secondary to extended-spectrum beta-
lactamase (ESBL). The 5 species currently in the genus Providencia, in descending order of
prevalence, include Providencia stuartii, Providencia rettgeri, Providencia alcalifaciens,
Providencia rustigianii, and P heimbachae. 3

Pathophysiology

Providencia species are found in multiple animal reservoirs, including flies, birds, cats, dogs,
cattle, sheep, guinea pigs, and penguins, and are resident oral flora in reptiles such as pythons,
vipers, and boas. Providencia species are also found commonly in soil, water, and sewage.
Providencia species have been isolated from urine (most common), stool, and blood, as well as
from sputum, skin, and wound cultures. P stuartii septicemia is primarily of urinary origin. One
case study has described P stuartii as the etiology of infective endocarditis. [6] Another case report
found P rettgeri to be a cause of ocular infections, including keratitis, conjunctivitis, and
endophthalmitis.

P stuartii is frequently isolated in patients with indwelling urinary catheters and is known to
persist in the urinary tract after bladder access is attained. In one study, the mean duration of
bacterial colonization was 6.4 months. [8] The persistence of bacteria in the urinary tract is thought
to be due to an adhesin, mannose-resistant/Klebsiella -like (MR/K) hemagglutinin, which allows
bacteria to adhere to urinary catheters (mediated by 3 fimbriae). [8, 9] In a 1994 study by Rahav et al,
persistence patterns in males and females were found to differ, with P stuartii showing more
persistence in females. Reasons theorized include different receptor characteristics in male and
female urinary tracts and a bacterial predilection for Foley catheters over condom catheters, which
are used more commonly in males. [8]

ESBL-positive P stuartii is an increasing problem in hospitalized patients. In one study, 52% of

223 P stuartii isolates were found to be positive for ESBL in a hospital population that included
ICU, medical, and surgical wards over a 4-year span. [10]

P alcalifaciens, P rettgeri, and P stuartii have been implicated in gastroenteritis. In one study, P
rettgeri and P stuartii were found to be highly invasive using in vivo testing with Caco-2, a human
colon carcinoma cell line. However, a common virulence plasmid was not identified in
Providencia species. [11, 12] Providencia species, most commonly P agalactiae, have been
demonstrated in the stool of symptomatic patients, although testing protocols used to identify
diarrheagenic bacterial pathogens do not generally include Providencia.

P stuartii and, to a lesser extent, P rettgeri are the most common Providencia species that cause
human infection. While uncommon in most clinical settings, these organisms tend to cause cystitis
in patients with bladder catheters and are primarily associated with complicated urinary tract
infections. In a Canadian study in 2001, Providencia species were isolated in 18% of complicated
urinary tract infections. [13] In contrast, Providencia bacteriuria in acute hospital settings is rare
(0.3-1%). [8]
 2

P stuartii is most often found in complicated urinary tract infections in patients with chronic
indwelling urinary catheters or condom catheters. Providencia species are rarely a cause of
uncomplicated urinary tract infections. In a study of patients with urinary catheters living in a
retirement home, P stuartii was the most commonly isolated bacteria, found in 59% of urine
specimens. (The next most common was Escherichia coli, at 32%.) [8]

The mortality rate in patients with Providencia bloodstream infection ranges from 6-33%. The rate
is greater in polymicrobial infection.

Age

Elderly persons are at much greater risk of P stuartii or P rettgeri infection, most likely because
these infections are associated with the use of indwelling urinary catheters, which are more
common used in elderly populations.

P alcalifaciens gastroenteritis has been documented in children and adults. In a 2005 study, a large
outbreak of gastroenteritis was found to be attributable to P alcalifaciens infection. The outbreak
involved students and teachers of two kindergartens and one high school. The prevalence of
infection was higher in children (53% of kindergartners affected vs 36% of adult teachers). [14]
Another study demonstrated that P rettgeri infection is a potential cause of traveler's diarrhea in
adults. [11]