Fleming Erin, Heil Emily L, Hynicka Lauren M
University of Maryland School of Pharmacy, Baltimore, MD, USA.
Ann Pharmacother. 2014 Jan;48(1):123-7. doi: 10.1177/1060028013509974. Epub 2013 Oct 29.
To describe the management strategy for a multidrug-resistant (MDR) Klebsiella urinary tract infection (UTI).
A 69-year-old Caucasian woman with a past medical history of recurrent UTIs and a right-lung transplant presented with fever to 101.4°F, chills, malaise, and cloudy, foul-smelling urine for approximately 1 week. She was found to have a MDR Klebsiella UTI that was sensitive to tigecycline and cefepime. To further evaluate the degree of resistance Etest minimum inhibitory concentrations were requested for cefepime, amikacin, meropenem, and ertapenem. The patient received a 14-day course of amikacin, which resulted in resolution of her symptoms. One month later, the patient's UTI symptoms returned. The urine culture again grew MDR Klebsiella, sensitive only to tigecycline. Fosfomycin was initiated and resulted in limited resolution of her symptoms. Colistin was started, however, therapy was discontinued on day 5 secondary to the development of acute kidney injury. Despite the short course of therapy, the patient's symptoms resolved.
The case presented lends itself well to numerous discussion items that are important to consider when determining optimal treatment for MDR Gram-negative bacilli (GNBs). Susceptibility testing is an important tool for optimizing antibiotic therapy, however, automated systems may overestimate the susceptibility profile for a MDR GNB. Treatment strategies evaluated to treat MDR GNB, include combination therapy with a carbepenem and synergy using polymyxin.
We have described the management strategy for a MDR Klebsiella UTI, the consequences of the initial management strategy, and potential strategies to manage these types of infections in future patients.
描述耐多药（MDR）肺炎克雷伯菌引起的尿路感染（UTI）的管理策略。
一名69岁的白种女性，既往有复发性UTI病史且接受过右肺移植，出现发热至101.4°F、寒战、全身不适以及浑浊、有异味的尿液约1周。她被发现患有对替加环素和头孢吡肟敏感的MDR肺炎克雷伯菌UTI。为进一步评估耐药程度，要求对头孢吡肟、阿米卡星、美罗培南和厄他培南进行Etest最低抑菌浓度检测。患者接受了为期14天的阿米卡星治疗，症状得以缓解。1个月后，患者的UTI症状再次出现。尿培养再次检出MDR肺炎克雷伯菌，仅对替加环素敏感。开始使用磷霉素，症状仅得到有限缓解。随后开始使用黏菌素，但由于急性肾损伤在第5天停药。尽管治疗疗程较短，患者的症状仍得到缓解。
该病例引发了众多在确定耐多药革兰阴性杆菌（GNB）最佳治疗方案时需考虑的重要讨论点。药敏试验是优化抗生素治疗的重要工具，然而，自动化系统可能高估MDR GNB的药敏情况。评估用于治疗MDR GNB的治疗策略包括碳青霉烯类联合治疗以及多黏菌素的协同作用。
我们描述了MDR肺炎克雷伯菌UTI的管理策略、初始管理策略的后果以及未来患者管理这类感染的潜在策略。
