EDUCATIONAL WORKSHOPS 2009 CASE PRESENTATION THREE “He’s got another one, doctor” A difficult...

EDUCATIONAL WORKSHOPS 2009

CASE PRESENTATION THREECASE PRESENTATION THREE

“He’s got another one, doctor” A difficult case of recurrent MRSA bacteraemia

Author: Nick Brown, Addenbrooke’s Hospital

Acknowledgement:Sani Aliyu, Sandwell and West Birmingham Hospitals – now Addenbrooke’s Hospital

Details of the original case report have been adapted to emphasise particular points

Sponsored through an unrestricted educational grant from Novartis Pharmaceutical Ltd to help support the

cost of developing and hosting this educational workshop series

Background65 y old male

Past history of hypertension and cerebro-vascular disease

July 2003

Aortic aneurysm and complications

Endovascular aortic aneurysm repair (EVAR)

post-operative bleed requiring laparotomy

paraparesis secondary to spinal cord ischaemia

long term suprapubic catheter

longstanding sacral pressure soresAuthor: Nick Brown, Addenbrooke’s Hospital

July 2007Admitted with fever four years after aneurysm repair

Blood cultures MRSA (isolate 1)

X-ray pelvis and transoesophageal echocardiogram (TOE) – normal

2 weeks iv vancomycin plus oral rifampicin, then stopped

Question:

What was the source of infection?

How would you have treated it?


July 20075 days later- pyrexia MRSA again in blood cultures (isolate 2)

Re-started vancomycin plus rifampicin for 4 weeks

Home on doxycycline plus rifampicin for a further 4 weeks


November 2007re-admitted with fever and back pain after 9 days at homeBlood cultures MRSA (isolate 3) Transthoracic echocardiogram (TTE) – normalMagnetic resonance imaging (MRI) spine - normalWCC scan suggestive of increased uptake in lower vertebra1 week vancomycin, then MIC for MRSA strain reported as 3 mg/Lintravenous linezolid for 10 days, then home on further 4 weeks oral


Imaging 1: Indium-111 labelled white cell scan showing localised area of increased uptake in the lower abdomen or perhaps in the vertebrae

Here it is

Population analysis of GISA

0

1

2

3

4

5

6

7

8

9

10

0 2 4 6 8 10 12 14 16

Vancomycin (mg/L)

log

10 c

fu/m

L

Mu3

Mu50

Sensitive S aureus

Patient MRSA

January 2008re-admitted in septic shock, day 38 linezolid

MRSA in blood (isolate 4)

intravenous daptomycin - five fold rise in CK, therefore stopped (was on a statin at the same time)

blood cultures MRSA (isolate 5)

Quinupristin/dalfopristin plus fusidic acid for 12 weeks


Late February 2008Blood cultures sterile by week 3 of quinupristin/dalfopristin plus

fusidic acid

inflammatory markers settling

Computerised axial tomography (CT) scan at week 7 – ‘increased thickness of aneurysm wall compared to previous scans’


Imaging 2: Computerised tomography (CT) scan showing aortic graft in situ with thickening of the aortic wall

April 2008Cardiothoracic review - no surgical intervention indicated

11 weeks into quinupristin/dalfopristin treatmentseptic again ESBL-producing E. coli in urine and femoral line tipmeropenem for 10 daysquinupristin/dalfopristin discontinued end of 12 weeks

blood cultures just before quinupristin/dalfopristin stopped MRSA (isolate 6)


April 2008Quinupristin/dalfopristin re-started (1 week later) plus daptomycin

4mg/kg

CK levels remain normal

2 weeks - Quinupristin/dalfopristin switched to gentamicin and daptomycin dose increased to 10mg/kg

new femoral line


Mid-July 2008Gentamicin stopped after 4 weeks

MRSA bacteraemia persists (isolate 7)

8 weeks into daptomycin treatment - progressive rise in MIC

daptomycin MIC 0.125 mg/L initially, but peaked at 12.0 mg/L

Isolates now also resistant to rifampicin and fusidic acid

Positron emission tomography (PET) scan confirms aortic graft infection


Imaging 3: Positron emission tomography (PET) scan showing increased tracer activity in relation to the aortic graft

End-July 2008Aortic graft replacedCultures of graft are negative, but S. aureus identified by 16s rDNA

PCRGiven iv linezolid, then oral fosfomycin, doxycycline plus

chloamphenicol for 4 weeks

End-August 2008switched to oral doxycycline alone12 sets of blood cultures negative as at 1 Oct 2008


EDUCATIONAL WORKSHOPS 2009 CASE PRESENTATION THREE “He’s got another one, doctor” A difficult...

Documents

Transcript of EDUCATIONAL WORKSHOPS 2009 CASE PRESENTATION THREE “He’s got another one, doctor” A difficult...