The post-antibiotic era: A case study

Published in the latest issue of the MJA is a case study of a Victorian patient diagnosed with a carbapenem-resistant Klebsiella pneumoniae. The patient, from rural Victoria, had no history or recent overseas travel and no hospital contact for the last 15 years. He was transferred to a metropolitan hospital for intensive care for severe acute pancreatitis secondary to gallstones.

Empirical antibiotics were prescribed, on the advice on the infectious diseases team, for severe pancreatitis. Due to the patients deterioration these antibiotics changed from ceftriaxone to piperacillin-tazobactam to meropenem. At this stage, microbiology did not reveal significant pathogens.

The carbapenem-resistant organism was not found until two months into admission when a pancreatic debridement was performed. During the admission the patient had also been diagnosed with VRE, Candida albicans and Stenotrophomonas maltophilia. These were treated with a combination of piperacillin-tazobactam, fluconazole, co-trimoxazole and linezolid (later teicoplanin). These were ceased after 8 weeks.

In order to treat the resistant Klebsiella gentamicin combined with high-dose prolonged infusions of meropenem three times a day and daily doses of ertapenem. After 3 weeks renal failure and sepsis occurred requiring renal replacement therapy and cessation of gentamicin. Doxycycline was also added to the combination before a request for compassionate access to ceftazidime-avibactam was made. Once available the antibiotic treatment was changed to ceftazidime-avibactam, metronidazole and teicoplanin. Doxycyline was ceased as resistance had developed.

Currently, there is a lack of evidence to guide treatment of these organisms. Based on retrospective observational data dual carbapenems have been shown to be successful in some cases. The clinical value of this practice remains unclear.

Although this patient was treated with eleven different antimicrobials throughout their stay in hospital treatment was unsuccessful. After five months the patient was discharged home for palliation and died soon after.

This case report highlights the growing risk of multi-resistant organisms in our community. Unfortunately, it also highlights that our ability to treat these infections is limited.




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