Catheter-associated Hafnia alvei-induced Urosepsis

Hafnia alvei, belonging to the Enterobacteriaceae family, is a gram-negative, facultative anaerobe. The organism predominantly colonizes the gastrointestinal tract and, less often, the tissues, urine, and catheters. A 75-year-old male presented with a dry cough, fatigue, decreased appetite, intermittent disorientation, and difficulty ambulating. He had a history of self-catheterization due to urinary retention. He was scheduled to undergo transcatheter aortic valve replacement for enterococcal endocarditis. Physical examination was not significant for any changes. Urine analysis revealed positive leukocyte esterase, the presence of red and white blood cells, urine bacteria, and hyaline casts. The patient was started on empiric intravenous ceftriaxone. Urine culture grew Hafnia alvei and he was switched over to cefepime due to greater susceptibility. On day four, he started deteriorating clinically and was treated with four pressors but remained hypotensive and eventually became anuric. The patient developed septic shock with multiple organ dysfunction syndromes. Despite all measures, his clinical condition failed to improve, and he was continued with comfort measures only. The literature on Hafnia alvei-induced urosepsis is poor and fragmentary. Our patient showed resistance to most beta-lactam antibiotics, including cefuroxime, ceftriaxone, and ceftazidime, along with intermediate susceptibility to piperacillin/tazobactam and was managed with intravenous cefepime based on the sensitivity report. Inducible Bush group 1 beta-lactamase produced by Hafnia alvei is postulated to be responsible for antibiotic resistance. Physicians should remain vigilant of Hafnia alvei-induced urosepsis in patients with long-term catheterization initiating appropriate treatment.