Because of an increased prevalence of infections with resistant Gram-negative bacteria, finding optimal treatment regimens for these cases is one of the major healthcare concerns. Carbapenems were an important treatment option in these cases, but with the growing incidence of multi-drug-resistant (MDR) strains, finding an appropriate treatment course has become an issue (1).
Due to the global importance of drug resistance, in 2018, WHO recommends the development of novel antibiotics against carbapenem-resistant
Although, some studies have been conducted to evaluate effective treatment regimens against resistant species of
Because of
To the best of our knowledge, there are no available reports of ventilator-associated pneumonia (VAP) with PDR
We had an outbreak due to PDR
In two cases with bacteraemia and meningitis due to PDR
The course of treatment was different for the remaining patients. One of the patients received a combination of two antibiotics—meropenem and amikacin. We administered high doses of meropenem intravenously (2 g every 8 h) together with intravenous amikacin (20 mg/kg) and inhalation of amikacin (250 mg every 6 h) via mesh nebulizer. In this case, the treatment course proved to be successful, with clinical improvement and bacterial eradication; thus, we decided to report it.
In this general context, we present the case of a 74-year-old woman brought to the hospital after losing consciousness. She received initial treatments in the emergency ward but following respiratory distress, reduced oxygen saturation and loss of consciousness; was intubated and was transferred to the ICU. On the first day of admission, there was no significant lung parenchymal involvement.
At the 17th day of ICU admission, we diagnosed VAP based on clinical signs, including fever and increased pulmonary secretions, leucocytosis and alveolar infiltrations on the chest X-ray (CXR). Sputum cultures revealed the presence of an Acinetobacter strain, which was sensitive to ampicillin-sulbactam and colistin. Considering the results of the antibiogram, on the 17th day of hospitalisation, the patient began receiving a course of ampicillin-sulbactam.
After 3 days of treatment, the patient still presented fever and leucocytosis with an increase in procalcitonin (PCT) levels from 0.11 to 21.48 and serum creatinine levels from 1.4 mg/dl to 4 mg/dl. The patient also started showing signs of septic shock—the blood pressure dropped from 120/80 mmHg to 80/50 mmHg, and we administered norepinephrine.
According to isolation of Klebsiella strain, in sputum, which was sensitive only to colistin, we administered colistin as intravenously plus oral inhalation. Repeated sputum cultures, was PDR
Based on these findings, we changed the treatment regimen. We administered high-dose intravenous meropenem (1 g every 12 h), infused over 4 h, intravenous amikacin (1500 mg every 48 h) and nebulised amikacin (250 mg every 6 h) by mesh nebuliser. The doses were calculated based on the patient's weight and renal function [Cockcroft–Gault estimated creatinine clearance by using lean body weight (13.69 ml/min/1.73)].
We defined a clinical response as the resolution of pneumonia-related signs and symptoms for at least 48 h, including fever and reduced bronchial secretions. We considered a clinical failure based on the presence of one of the following signs: fever (
After 23 days, following improvement in clinical signs (including fever), a drop in leucocytes counts, a higher than 80% reduction in PCT levels (0.12), together with confirmed microbial eradication (negative sputum cultures), the antibacterial regimen was discontinued.
Hospital-acquired pneumonia (HAP), including VAP, the most common infection in the ICU, is associated with prolonged hospital and ICU stays, high costs and poor outcomes (11). Studies, including a prospective 1-year microbiological study, showed that antibiotic-resistant bacteria are one of the proven causes of high mortality rates in pneumonia (12).
Although patients received several treatment regimens, as part of specially designed studies, with the desire of obtaining favourable outcomes, there are no definite recommendations for treating infections caused by resistant
In 2018, Abdallah published the results of a meta-analysis. According to that paper, the prolonged infusions of carbapenems in high doses (meropenem 2 g every 8 h, infused over 3–4 h) are effective against carbapenemase-producing Enterobacteriaceae, including carbapenem-resistant
Douka et al. designed an antimicrobial synergy test using 15 isolated samples of PDR
Combined therapy was effective in our case; the patient showed clinical improvement and sputum culture conversion. In conclusion, when dealing with an infection with a pan-resistant microorganism, using combinations of antibiotics in high doses can be an option. These treatment regimens have the potential of overcoming