Polysialic acid (PSA) is a unique polysaccharide that plays critical roles in many bioprocesses, which makes it useful in a wide range of biomedical applications. The increased demand for PSA has led to considerable efforts to improve its production using bacteria, such as Escherichia coli. Bioprocess optimization and metabolic engineering have allowed the efficient production of PSA. This review aims to summarize the metabolism of PSA with an emphasis on the importance of the key pathway components. In addition, this review provides an update on state of the art PSA production using E. coli with a special emphasis on strategies of strain engineering and process development for the enhanced production of PSA.