Persistent Bacteremia from Pseudomonas aeruginosa with In Vitro Resistance to the Novel Antibiotics Ceftolozane-Tazobactam and Ceftazidime-Avibactam
Table 1
Significant events in the patient’s hospital course.
Hospital day
Significant event
max (°F)
WBC (cells/mm3)
Antibiotics
1
Admission to the medical ICU, being started on norepinephrine for hypotension Blood cultures drawn Right radial A-line and left femoral central line inserted
103.0
4.61
Piperacillin-tazobactam 4.5 g IV every 8 hours Vancomycin IV
2
Noncontrast CT scan of abdomen and pelvis showed bilateral pleural effusion, moderate ascites, generalized anasarca, no abscess
100.7
11.16
3
Day 1 blood cultures grew P. aeruginosa Stool C. difficile enzyme immune-assay positive
99.8
15.60
Cefepime 2 gm IV daily
4
Rising creatinine (1.8 mg/dL) Urinary catheter removed Femoral line removed PICC line inserted
98.3
17.07
5
Hemoglobin decreased from 7.2 to 6.8 g/dL Platelets decreased from 27 to 16 × 103/microliter 1 unit of packed RBC transfused Repeat blood cultures drawn
97.7
14.29
6
Blood pressure stable off vasopressor, arterial line removed Repeat blood culture negative to date Transferred to general medical floor
97.8
6.38
7
Repeat blood culture × 1, no growth Minimal bleeding from nares, platelets transfused
97.8
12.4
8
Blood culture from Day 5 resistant to cefepime
98.2
11.93
Meropenem 1 g IV every 8 hours
9
1 unit of packed RBC transfused
99.0
9.68
10
Transthoracic 2D ECHO showed possible valvular vegetations HIDA scan, negative Intubated for decreased respiratory rate and apnea, hypotension (75/50), altered mental status Repeat blood cultures were drawn Transferred back to the medical ICU
98.4
5.96
Meropenem 1 g IV every 8 hours + tobramycin
11
Hypotension despite fluid resuscitation Phenylephrine started
98.0
6.29
12
Transesophageal echocardiogram did not reveal vegetations PICC line removed and sent for culture Stable respiratory status; patient extubated
98.3
4.35
13
Worsening renal function and oliguria Blood culture from Day 10 grew P. aeruginosa resistant to meropenem; -test performed for P. aeruginosa isolate from Day 10 showed resistance to ceftazidime-avibactam and ceftolozane-tazobactam
99.3
3.84
Tobramycin 1.7 mg/kg every 12 hours
14
Increasing tachypnea, tachycardia, lethargy
98.5
1.54
15
Absolute neutrophil count dropped to 590 cells/mm3 Reintubated for respiratory distress Hypotension despite fluids; patient on three vasopressors (norepinephrine, phenylephrine, vasopressin) Repeat blood cultures drawn
98.5
2.53
Tobramycin 1.7 mg/kg every 12 hours Anidulafungin 200 mg IV Cefepime 2 gm IV daily Vancomycin IV
16
Family decided to change the patient’s code status from full interventions to comfort measures only
He was extubated and expired
Tobramycin and vancomycin doses were adjusted by pharmacy based on peak and trough blood levels. Patient was on oral vancomycin empirically for C. difficile since Day 1 of hospitalization. HIDA scan: hepatobiliary iminodiacetic acid scan; IV, intravenous; PICC: peripherally-inserted central catheter; and max, maximum temperature.
