The patient is a 60 something female with a history of a ureteral stone, left ureteral stent, kidney stones, HTN, CHF, obesity, pyelonephritis, and type 2 diabetes. The stent and stone was supposed to be removed a few weeks after the initial visit and scope. However, one thing leads to another as it often does, and you don't keep your date with the urologist (I get that, seems it could be kinda weird) and get sepsis. Happens to everyone. So in to the hospital it is with a fever of 105F, 30 breaths per minute, and tachy to 120. The ED and ICU do their magic and then the stone and stent are removed, the patient is still alive, and the world seems calm for a minute.
Then the cultures come back from urine, E. coli, K. oxytoca, & E. faecalis; and blood, Bacteroides fragilis and more K. oxytoca. The PCR shows CTX-M gene and the susceptibility results show resistance to ampicillin/sulbactam, cefazolin, cefepime, ceftazidime, ceftriaxone, gentamycin, tobramycin, and TMP/SMX; intermediate resistance to ciprofloxacin. The patient was then started on ertapenem and here we be.
Klebsiella oxytoca is a gram-negative rod and gets its name from the the Greek words for sour (oxus) and producing (tokos) and is inherently resistant to a lot of cillins (pen, amp, amox, ox, carb, ticar). While for some K. oxytoca the beta-lactamase inhibitors can be effective, others have gained mutations to counter the counters and make them ineffective. When this and other 'kelbbies' have active extended spectrum beta-lactamase (ESBL) guns, they will often have resistance to aminoglycosides. That being said, like our patient above, carbapenems are often the first choice.
Weird, ESBL Klebsiella infections are usually nosocomial. The pt had been out of the hospital for weeks. Lo, here lies the answer: discharged with PO levofloxacin. Maybe enough to keep the beasts at bay for a while? Maybe the intermediate resistance to ciprofloxacin stopped the course short of eradication? Or a combo hit of diabetes and obesity led to a dug in infection and a sub-par dose of the antibiotic? I'm would wager the stone that was left in had something to do with it also, but I'm just the nurse. Either way, the rock is out, and the IV ertapenem is flowing. At least flowing every 24 hours. So, yeah.
Klebbie meningitis sounds pretty terrible, as I move through my reading on whatever the hell this post is about. From a case report in 1991, a patient with "Klebsiella pneumoniae producing a CAZ-5 extended-spectrum beta-lactamase and an Enterobacter aerogenes producing a derepressed cephalosporinase" a cure was only achieved after 8 grams of imipenem a day. Geez that's a lot of antibiotics. Imagine the diarrhea...... From the reading I am finding, intraventricular agents are often used in combination with IV agents as well.
OK so I don't know what happened to the patient, such is my life, but still it is interesting to me. The increasing rates of antibiotic resistance are quite scary. It may not be another COVID that causes us to all suit up for every patient, but untreatable bacteria and fungi. Think of the limited number of agents we have to some of these bugs. It is very conceivable and likely that there has been (I just didn't find it in my reading) a totally drug resistant klebbie out there. MDR A. baumannii for example has an estimated prevalence in HAP and VAP from 56-100% in some areas. As their resistance to drugs such as ertapenem increase, we must rely ever more on older more toxic agents to get the job done. Polymyxin B and E (AKA colistin) have become more prevalent, though they bring their greater risks of adverse events. Granted, I would assume losing my hearing may be better than death but I am lucky that I have not had to make that choice.
I really like to hear about new drugs and their trials, combinations are interesting too. There are many synergistic combinations of drugs in use from oncology to diabetes and infectious diseases. This is great, do not get me wrong, but you can only combine so many ways before every permutation has been used. Preserving our weapons is just as important as finding new ones to use.
Anyways, love y'all. Check out the podcast which I have been neglecting. Peace.
References
Acinetobacter baumannii Antibiotic Resistance Mechanisms by Kyriakidis et al., in Pathogens 2021
ESBL, klebsiella pneumonea, klebsiella oxytoca, polymyxin B, colistin, A. baumannii all from the NIH website
Image of colistin from wikipedia
Klebsiella from www.antimicrobe.com
Klebsiella oxytoca: an emerging pathogen? by Signh et al., from the Medical Journal of the Armed Forces, India in 2016
The global prevalence of multidrug-resistance among Acinetobacter baumannii causing hospital-acquired and ventilator-associated pneumonia and its associated mortality: A systematic review and meta-analysis by Lim et al., in J Infect. 2019
The PDR for the above mentioned drugs
Treatment of a meningitis due to an Enterobacter aerogenes producing a derepressed cephalosporinase and a Klebsiella pneumoniae producing an extended-spectrum beta-lactamase by de Champs et al., in Infection 1991
Comments
Post a Comment