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

64FKuwaitinational

Metastaticpancreatic

adenocarcinomaDx2011

Liver,lung,portalveindeposits

Whipples2012

PMH:T2DM,Sarcoidosis,Asthma

Drughistorypriorto

admission

Nystatin,ranitidine150mgBD,fentanylpatch25mcg/hr,fluconazole50mg,pantoprazole40mgOD,metformin500mgBD,creon70,000Unitsaftermeals,omeprazole20mgBD,

diamicronMRTOD

Recently

completed14thcycleof3rdlinechemotherapy(Folforinox)

• Implantedportlastused17thMay2017

Admittedwithconstipation,pyrexia(39C)anddrowsy

• Bloodpressure95/49.resprate28heartrate128

• WCC25.9,neutrophils25.6CRP33.3

Antibiotics22/05–•  Co-amoxiclav

Microbiology-April2017•  MRSApositive

onscreenResistanttoflucloxacillin,tetracycline,trimethoprim

•  Sensitivetoclindamycin,rifampicin,ciprofloxacin

MAY

22

Antibiotics•  Co-amoxiclav22/05–24/05•  Ciprofloxacin

24/05-•  Gentamicin23/05-

Microbiology-April2017•  MRSApositiveon

screen

22ndMayBloodculture•  KlebsiellaoxytocaRtoAmoxicillinonly•  SerratiamarcescensSensitivetociprofloxacin,gentamicin,temocillin,trimethoprim,ertapenem

Chestdraininserted

MAY

23

Thereisawell-circumscribedlesionintheL1vertebralbody

Thereisaperipherallyenhancingheterogeneousleft-sidedpleuraleffusionwithasingleseptation,mostinkeepingwithempyema.

Multiplepulmonarynodulesarenoted,inkeepingwiththepatient'sknownmetastases.

Atthesiteofpreviousanastomosis,inthecentralmidabdomen,thereisashortsegmentofdilatedsmallbowel.Thesmallboweldistalandproximaltothissegmentiscollapsed.

•  Ongoingissueswithpseudo-obstruction

•  Continuedtospike

Antibiotics•  Co-amoxiclav22/05–24/05•  Ciprofloxacin

24/05-25/05•  Gentamicin

23/05-25/05•  Meropenem

25/05–•  Linezolid28/05-

Microbiology-April2017•  MRSApositiveon

screen

22ndMayBloodculture•  Klebsiellaoxytoca•  Serratia

marcescens

25thMayPleuralFluidBacteroidiesfragilisInitialsensitivitypanelResistanttoClindamycin.,metronidazoleandaugmentin

CRP

Temperature

38MAY

25-28

Neutropaenic–startedonGCSFChestdrainremoved

AntibioticsCoamoxiclav22/05-24/05Ciprofloxacin24/05-25/05Gentamicin23/05-25/05Meropenem25/05–Linezolid28/05–Tigecycline02/06–(50mg)

MicrobiologyApril2017-MRSApositive22ndMayBloodculture-Klebsiellaoxytoca-Serratiamarcescens23rdMayPleuralfluid-Bacteroidesfragilis25thMayBloodcultures-Bacteroidesfragilis4/425thMay2017-Serratiamarcescens

CRP

NeutrophilsMAY

29-31

•  04/06CTCAP-– NewliverlesionsascomparedtoadmissionCT

–  Empyemastillpresent

•  FamilynotkeenforPortacathremoval

•  Discussionwithfamily–  forpalliation

AlkalinePhosphatase

JUNE

4-6

JUNE

9

•  FamilyrepatriatedpatientbacktoKuwaitviaprivatemedicalaircraft

withadoctorinattendance.• Allantibioticsstoppedondischarge

Ourpatient

•  PrevalenceofMDRBacteroidesfragiliswithinKuwaitisunknown

•  Poorresponsetosecondlinetherapy,however; – Delayinappropriatetreatmentinlightofineffectiveempiricaltherapyandneedforreferencelabtesting.

– Significantburdenofdisease– Polymicrobialinfection

CoamoxGentamicinCiprofloxacin Meropenem

Linezolid

Tigecycline

400

300

100

Experiencewithsecondlineagents-Recentcasereports

Report Treatmentsummary

Multi-drugresistantBacteroidesfragilisrecoveredfrombloodandseverelegwoundscausedbyanimprovisedexplosivedevive(IED)inAfghanistan,SherwoodJetal,Anaerobe17(2011)152-155

MDRBacteroidesfragilistraumaticwoundinfectionEffectiveuseofdualtherapyandlinezolidandmoxifloxacin

Multidrug-resistantBacteroidesfragilisBacteraemiainaUSResident:AnEmergingChallenge,MerchanetalCaseReportsinInfectiousDiseases2016

MDRBacteroidesfragilisbacteraemiaassociatedwithparaspinalandpsoasabscessesEffectiveuseoflinezolid,moxifloxacinandcefoxitin

Discussion

•  MultidrugresistantBacteroidesisolatesarerare.•  Metronidazolemainstayofempiricaltreatment

–  SixfoldincreaseinMtzresistance,the%Risstillsmall•  EmergenceandevolutionofaninternationalclusterofMDRBacteroidesfragilisisolates,Sokietal,JAC,2016:71:2441-2448–  IdentifiedaclusterofinternationalclusterofMDRB.fragilisstrainsthatwereresistanttoatleastfivetypesofantibiotics

Questions?