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Case Reports
. 2016 Feb;95(7):e2243.
doi: 10.1097/MD.0000000000002243.

Severe Bloodstream Infection Due to KPC-Producer E Coli in a Renal Transplant Recipient Treated With the Double-Carbapenem Regimen and Analysis of In Vitro Synergy Testing: A Case Report

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Free PMC article
Case Reports

Severe Bloodstream Infection Due to KPC-Producer E Coli in a Renal Transplant Recipient Treated With the Double-Carbapenem Regimen and Analysis of In Vitro Synergy Testing: A Case Report

Alessandra Oliva et al. Medicine (Baltimore). .
Free PMC article

Abstract

Transplant recipients are at high risk of infections caused by multidrug resistant microorganisms. Due to the limited therapeutic options, innovative antimicrobial combinations against carbapenem-resistant Enterobacteriaceae causing severe infections are necessary.A 61-year-old woman with a history of congenital solitary kidney underwent renal transplantation. The postoperative course was complicated by nosocomial pneumonia due to Stenotrophomonas maltophilia and pan-sensitive Escherichia coli, successfully treated with antimicrobial therapy. On postoperative day 22, diagnosis of surgical site infection and nosocomial pneumonia with concomitant bacteremia due to a Klebisella pneumoniae carbapenemase-producer E coli was made. The patient was treated with the double-carbapenem regimen (high dose of meropenem plus ertapenem) and a potent synergistic and bactericidal activity of this un-conventional therapeutic strategy was observed in vitro. Despite a microbiological response with prompt negativity of blood cultures, the patient faced a worse outcome because of severe hemorrhagic shock.The double-carbapenem regimen might be considered as a rescue therapy in those subjects, including transplant recipients, in whom previous antimicrobial combinations failed or when colistin use might be discouraged. Performing in vitro synergy testing should be strongly encouraged in cases of infections caused by pan-drug resistant strains, especially in high-risk patients.

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

FIGURE 1
FIGURE 1
(A) MICs distribution of KPC Escherichia coli by VITEK-2 system. Values in brackets refer to MIC determination by broth macrodilution method (BMD). (B) Time–kill studies for ertapenem, meropenem, and ertapenem plus meropenem against KPC E coli. The horizontal line represents a reduction of 3 log10 CFU/mL compared with the initial bacterial count. Bactericidal activity was defined as a ≥3-log10 CFU/mL reduction of the initial bacterial count at each time point whereas synergy was defined as a ≥2-log10 decrease in CFU/mL between the combinations and its most active constituent after 24 h. ERT = ertapenem, GC = growth control, KPC = Klebsiella pneumoniae carbapenemase, MEM = meropenem, MIC = minimal inhibitory concentration, TMP/SMX = trimethoprim/sulfamethoxazole.
FIGURE 2
FIGURE 2
Timeline of clinical condition, interventions, and outcome. BAL = bronchoalveolar lavage, TMP/SMX = trimethoprim/ sulfamethoxazole, PO = postoperative.

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