The clinical challenge of Elizabethkingia infections: multidrug resistance, epidemiology, and management strategies.

Elizabethkingia species, particularly E. anophelis, have emerged as formidable opportunistic pathogens causing severe infections such as meningitis, bacteremia, and pneumonia, with mortality rates ranging from 24% to 60%. This narrative review provides a comprehensive overview of the complex resistance mechanisms of these bacteria, drawing on in vitro studies, genomic analyses, and observational clinical data. Where available, we indicate the level of supporting evidence, and highlight mechanisms supported by gene knockout experiments, single-strain proteomic analyses, or retrospective case series. We further examine the selective pressure exerted by environmental metal ions on resistance evolution, synthesize clinical epidemiology (including sources, transmission, and risk factors) largely derived from outbreak investigations and case series, and discuss antimicrobial therapy and susceptibility testing approaches based predominantly on in vitro data and clinical observations. We propose a conceptual framework that links environmental heavy-metal co-selection, biofilm-mediated persistence, and imipenem-induced outer membrane vesicle (iOMV)-mediated stress adaptation into an ecological-clinical continuum, offering a roadmap for integrated infection control. Finally, we outline future directions for infection control, such as novel drug target screening and strategies to mitigate environmental selection pressures, aiming to inform clinicians and public health efforts against this serious threat.