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
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