First Case of Infective Endocarditis Due to NDM-Type Carbapenemase-Producing Serratia marcescens in a Preterm Infant: A Case Report
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Serratia marcescens (S. marcescens) is a Gram-negative rod-shaped bacterium belonging to the Enterobacteriaceae family, commonly found in various environments. This opportunistic pathogen can cause urinary tract infections, respiratory infections, and septicemia, but endocarditis is particularly rare and concerning due to its rapid and devastating progression. We report the second case in the world of infective endocarditis (IE) caused by S. marcescens in a preterm infant born at 34 weeks of gestation. The patient was a preterm male infant born at 34 weeks of gestation, from a triplet pregnancy, admitted to the neonatal intensive care unit on day 2 of life for respiratory distress. The mother, aged 39, had undiagnosed gestational diabetes. Premature rupture of membranes had occurred 10 days before delivery, necessitating prophylactic treatment with amoxicillin. On day 4 of life, the newborn developed a fever with elevated CRP levels and leukocytosis, leading to antibiotic therapy with colistin, imipenem, and amikacin. Blood cultures revealed the presence of carbapenemase-producing S. marcescens sensitive to fluoroquinolones. A cardiac ultrasound showed a vegetation on the mitral valve, confirming the diagnosis of IE. Despite intensive treatment, the newborn died on day 16 of life due to septic shock. This rare case of endocarditis caused by S. marcescens highlights the severity of this infection in preterm infants. Treatment relies on appropriate antibiotic therapy. Prevention requires strict hygiene measures. Further research is needed to establish optimal therapeutic recommendations.
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The reviewers have highlighted minor concerns with the work presented. Please ensure that you address their comments. In addition, please be sure to make sure the conclusion section of the manuscript contains some kind of lesson learned or insight for treatment or diagnosis of similar future cases. Would you advise doing anything differently?
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The reviewers have highlighted minor concerns with the work presented. Please ensure that you address their comments. In addition, please be sure to make sure the conclusion section of the manuscript contains some kind of lesson learned or insight for treatment or diagnosis of similar future cases. Would you advise doing anything differently?
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Comments to Author
Thank you for your very interesting article with a brief and effective summary about first Moroccan case of IE due to NDM-type carbapenemase-producing Serratia marcescens in a preterm infant. I have three minor comments only: 1. Discussion: Authors did not mention the fact S. marcescens can occur not only in a region of mitral valve but also the tricuspid one. Thus, I strongly recommend to mention them and add suitable references to the article, i.e.: https://pubmed.ncbi.nlm.nih.gov/37256420/ 2. Authors mention also references published more than 20 years ago. I would recommend to use max 10 years old cases, if possible. 3. I would add at least 1-2 more echo images.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are …
Comments to Author
Thank you for your very interesting article with a brief and effective summary about first Moroccan case of IE due to NDM-type carbapenemase-producing Serratia marcescens in a preterm infant. I have three minor comments only: 1. Discussion: Authors did not mention the fact S. marcescens can occur not only in a region of mitral valve but also the tricuspid one. Thus, I strongly recommend to mention them and add suitable references to the article, i.e.: https://pubmed.ncbi.nlm.nih.gov/37256420/ 2. Authors mention also references published more than 20 years ago. I would recommend to use max 10 years old cases, if possible. 3. I would add at least 1-2 more echo images.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
This is a case report describing a presentation of IE in a preterm infant caused by Serratia marcescens, which was found to be resistant to carbapenems mediated by an NDM carbapenemase. This case is novel in that prior to this report, there previously had not been any documented cases of Serratia marcescens leading to IE with this type of resistance pattern. Overall, the paper is well written, thoughtful, and with increasing rates of bacterial resistance throughout the world, provides a meaningful contribution to the academic corpus of literature regarding antimicrobial resistance patterns. I have no major points for suggested changes, but do have some minor points for consideration: 1. Line 7. Appears to be a minor typo, but I suspect "children" needs to be capitalized. 2. Line 16 - 17. I would …
Comments to Author
This is a case report describing a presentation of IE in a preterm infant caused by Serratia marcescens, which was found to be resistant to carbapenems mediated by an NDM carbapenemase. This case is novel in that prior to this report, there previously had not been any documented cases of Serratia marcescens leading to IE with this type of resistance pattern. Overall, the paper is well written, thoughtful, and with increasing rates of bacterial resistance throughout the world, provides a meaningful contribution to the academic corpus of literature regarding antimicrobial resistance patterns. I have no major points for suggested changes, but do have some minor points for consideration: 1. Line 7. Appears to be a minor typo, but I suspect "children" needs to be capitalized. 2. Line 16 - 17. I would clarify what exactly is unique about the case, in terms of novelty, and remain consistent. The title reports that this is the "first Moroccan Case" but here, the case is framed as "the second case in the world". Both are true, but I recommend specifying exactly what is unique and staying consistent throughout the text. Is the case novel because it's the first case of IE due to Serratia marcescens in a pre - term infant? Or because it's the first case of IE due to Serratia marcescens in a pre - term infant with an NDM carbapenamase? It's a matter of semantics, but will help readers appreciate the importance of your case submission. 3. Line 36 - 39. I would provide a statistic explaining how rare IE due to Serratia marcescens is - there are quite a few case reports from my review - but it would add more to novelty of this case if you could quantitatively describe how rare this process occurs in adults, let alone children. I also would add citation to the last sentence of this paragraph - I would argue that biofilm formation of Serratia is not common knowledge for most readers. Here is a possible reference: "Shanks R. M. Q., Stella N. A., Kalivoda E. J. et al., A Serratia marcescens OxyR homolog mediates surface attachment and biofilm formation, Journal of Bacteriology. (2007) 189, no. 20, 7262-7272, https://doi.org/10.1128/jb.00859-07, 2-s2.0-35048885742." 4. Line 64 and 90 - can you specify exactly how many blood bottles were positive? Was it 3 total pediatric vials? Or 3 sets? Aerobic or anaerobic? This related to the point 6 below. It appears that there was 1 positive vial on admission, and 1 vial on day 5 and 6? 5. Line 94. Could you provide more detail regarding the echocardiogram findings. How many vegetations were identified? How big were the vegetations? The text in the body of the paper suggests more then one vegetation, but the image only shows one vegetation. 6. Line 95. The 2011 modified Duke Criteria are referenced, but there were recent updates in 2023 with the Duke - ISCVID criteria (https://pubmed.ncbi.nlm.nih.gov/37138445/). Is there any reason not to use these updates, and does the case meet criteria based on these updated guidelines? By my review, there are 1 major criteria (Echo with vegetation), and 2 minor (fever + micro evidence falling short of major criterion), unless Serratia has been isolated in 3 or more separate blood culture sets. Please correct me if I am misunderstanding the text in your paper, but does this case technically meet criteria for definitive IE (either by the 2011 modified Dukes Criteria or 2023 update)? The criteria for possible IE are still met, and the wording in this paragraph would need to be revised. 7. Line 127 - 128: Same comment per above. Is there a reason not use the 2023 Duke-ISCVD updates? 8. Line 137-138: Are these the only two possible hypotheses for imipenem resistance? Carbapenem resistance can be mediated by more than a carbapenamase or upregulation of a beta-lactamase. Could an efflux pump or porin mutation leading to carbapenem resistance also been a possibility as well? 9. Line 143: I agree there is no consensus with the treatment of IE caused by Serratia marcescens. But there are guidelines regarding treatment of MBL carbapenamases, including combination therapy with ceftazidime avibactam + aztreonam or cefidericol. There are observational studies suggesting efficacy, and this regimen has been included in the expert opinion for the 2022 IDSA Guidelines for treatment of ESBL-E and CRE (doi: 10.1093/cid/ciac268), question 5). Are these not options in treatment, or could be possible options? Admittedly, the data in the pediatric population is limited, which is why this case report is important, but consider including in your discussion. 10. Line 151-152: The topic of infection control is a new topic introduced in the conclusion - I did not see any data regarding infection control measures or approaches within the body of the case report. Any references regarding the effectiveness of preventing specifically Serratia via strict hygiene measures? Is this well established? Are you referring to hand washing, contact precautions? I would provide a bit of discussion in the paper regarding infection control, if this is position is so definitively stated in the conclusion.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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