Absolutely fragilis - A case discussion

Transcription

1 Absolutely fragilis - A case discussion Rohma Ghani 1 Giovanni Satta 1 Harriet Hughes 2 James Hatcher 1 1 Imperial College Healthcare NHS Trust 2 UK Anaerobe Reference Unit

2 64F Kuwaiti national Metastatic pancreatic adenocarcinoma Dx 2011 Liver, lung, portal vein deposits Whipples 2012 PMH: T2DM, Sarcoidosis, Asthma Drug history prior to admission Nystatin, ranitidine 150mg BD, fentanyl patch 25mcg/hr, fluconazole 50mg, pantoprazole 40mg OD, metformin 500mg BD, creon 70,000 Units after meals, omeprazole 20mg BD, diamicron MR T OD

3 MAY 22 Recently completed 14 th cycle of 3 rd line chemotherapy (Folforinox) Admitted with constipation, pyrexia (39C) and drowsy Implanted port last used 17 th May 2017 Blood pressure 95/49. resp rate 28 heart rate 128 WCC 25.9, neutrophils 25.6 CRP 33.3 Antibiotics 22/05 Co-amoxiclav Microbiology - April 2017 MRSA positive on screen Resistant to flucloxacillin, tetracycline, trimethoprim Sensitive to clindamycin, rifampicin, ciprofloxacin

4 Antibiotics Co-amoxiclav 22/05 24/05 Ciprofloxacin 24/05- Gentamicin 23/05- Microbiology - April 2017 MRSA positive on screen 22 nd May Blood culture Klebsiella oxytoca R to Amoxicillin only Serratia marcescens Sensitive to ciprofloxacin, gentamicin, temocillin, trimethoprim, ertapenem Chest drain inserted MAY 23

5 At the site of previous anastomosis, in the central mid abdomen, there is a short segment of dilated small bowel. The small bowel distal and proximal to this segment is collapsed. There is a peripherally enhancing heterogeneous left-sided pleural effusion with a single septation, most in keeping with empyema. Multiple pulmonary nodules are noted, in keeping with the patient's known metastases. There is a well-circumscribed lesion in the L1 vertebral body

6 Ongoing issues with pseudoobstruction Continued to spike CRP Antibiotics Co-amoxiclav 22/05 24/05 Ciprofloxacin 24/05-25/05 Gentamicin 23/05-25/05 Meropenem 25/05 Linezolid 28/05 - Microbiology - April 2017 MRSA positive on screen 22 nd May Blood culture Klebsiella oxytoca Serratia marcescens 25 th May Pleural Fluid Bacteroidies fragilis Initial sensitivity panel MAY Temperature Resistant to Clindamycin., metronidazole and augmentin

7 Neutropaenic started on GCSF Chest drain removed MAY Antibiotics Coamoxiclav 22/05-24/05 Ciprofloxacin 24/05-25/05 Gentamicin 23/05-25/05 Meropenem 25/05 Linezolid 28/05 Tigecycline 02/06 (50mg) Neutrophils Microbiology April MRSA positive 22 nd May Blood culture - Klebsiella oxytoca -Serratia marcescens 23 rd May Pleural fluid - Bacteroides fragilis 25 th May Blood cultures -Bacteroides fragilis 4/4 25 th May Serratia marcescens CRP

8 04/06 CT CAP - New liver lesions as compared to admission CT Empyema still present Family not keen for Portacath removal Discussion with family JUNE 4-6 for palliation Alkaline Phosphatase

9 JUNE 9 Family repatriated patient back to Kuwait via private medical aircraft with a doctor in attendance. All antibiotics stopped on discharge

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11 Our patient Prevalence of MDR Bacteroides fragilis within Kuwait is unknown Poor response to second line therapy, however; Delay in appropriate treatment in light of ineffective empirical therapy and need for reference lab testing. Significant burden of disease Polymicrobial infection

12 Coamox Gentamicin Ciprofloxacin Linezolid Meropenem Tigecycline

13 Experience with second line agents - Recent case reports Report Multi-drug resistant Bacteroides fragilis recovered from blood and severe leg wounds caused by an improvised explosive devive (IED) in Afghanistan, Sherwood J et al, Anaerobe 17 (2011) Treatment summary MDR Bacteroides fragilis traumatic wound infection Effective use of dual therapy and linezolid and moxifloxacin Multidrug-resistant Bacteroides fragilis Bacteraemia in a US Resident: An Emerging Challenge, Merchan et al Case Reports in Infectious Diseases 2016 MDR Bacteroides fragilis bacteraemia associated with paraspinal and psoas abscesses Effective use of linezolid, moxifloxacin and cefoxitin

14 Discussion Multidrug resistant Bacteroides isolates are rare. Metronidazole mainstay of empirical treatment Six fold increase in Mtz resistance, the %R is still small Emergence and evolution of an international cluster of MDR Bacteroides fragilis isolates,soki et al, JAC, 2016: 71: Identified a cluster of international cluster of MDR B. fragilis strains that were resistant to at least five types of antibiotics

15 Questions?