Frattari Antonella, Parruti Giustino, Erasmo Rocco, Guerra Luigi, Polilli Ennio, Zocaro Rosamaria, Iervese Giuliano, Fazii Paolo, Spina Tullio
Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy.
Unit of Infectious Diseases, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy.
J Med Case Rep. 2017 Feb 22;11(1):49. doi: 10.1186/s13256-017-1206-6.
In critically ill patients with colonization/infection of multidrug-resistant organisms, source control surgery is one of the major determinants of clinical success. In more complex cases, the use of different tools for sepsis management may allow survival until complete source control.
A 42-year-old white man presented with traumatic hemorrhagic shock. Unstable pelvic fractures led to emergency stabilization surgery. Fever ensued with diarrhea, followed by septic shock. Two weeks later, an abdominal computed tomography scan revealed suprapubic and ischiatic abscesses at surgical sites, as well as dilated bowel. Debridement of both surgical sites, performed with vacuum-assisted closure therapy, yielded isolates of carbapenem and colistin-resistant Klebsiella pneumoniae. Antibiotic treatment was de-escalated after 21 days; 4 days later fever, leukocytosis, hypotension and acute renal failure relapsed. Blood purification techniques were started, for the removal of endotoxin and inflammatory mediators, with sequential hemodialysis. Clinical improvement ensued; blood cultures yielded Candida albicans and multidrug-resistant Acinetobacter baumannii; panresistant carbapenemase-producing Klebsiella pneumoniae grew from wound swabs. In spite of shock reversal, our patient remained febrile, with diarrhea. Control blood cultures yielded Candida albicans, Acinetobacter baumannii and carbapenem-resistant Klebsiella pneumoniae. His abdominal pain increased, paralleled by a right flank palpable mass. Colonoscopy revealed patchy serpiginous ulcers. At exploratory laparotomy, an inflammatory post-traumatic pseudotumor of his right colon was removed. Blood cultures turned negative after surgery. Septic shock, however, relapsed 4 days later. A blood purification cycle was repeated and combination antimicrobial therapy continued. Surgical wounds and blood cultures were persistently positive for carbapenem-resistant Klebsiella pneumoniae. Removal of pelvic synthesis media was therefore anticipated. Three weeks later, clinical, microbiological, and biochemical evidence of infection resolved.
High quality intensive assistance for sepsis episodes needs a clear plan of cure, aimed to complete infection source control, in a complex multidisciplinary interplay of specialists and intensive care physicians.
在多重耐药菌定植/感染的重症患者中，感染源控制手术是临床成功的主要决定因素之一。在更复杂的病例中，使用不同的脓毒症管理工具可能有助于患者存活直至实现完全的感染源控制。
一名42岁的白人男性因创伤性出血性休克入院。不稳定的骨盆骨折导致紧急稳定手术。术后出现发热并伴有腹泻，随后发展为感染性休克。两周后，腹部计算机断层扫描显示手术部位耻骨上和坐骨处有脓肿，以及肠扩张。对两个手术部位进行清创，并采用负压封闭引流治疗，分离出对碳青霉烯类和黏菌素耐药的肺炎克雷伯菌。21天后抗生素治疗降级；4天后发热、白细胞增多、低血压和急性肾衰竭复发。开始采用血液净化技术，通过序贯血液透析清除内毒素和炎症介质。临床症状有所改善；血培养分离出白色念珠菌和多重耐药鲍曼不动杆菌；伤口拭子培养出全耐药产碳青霉烯酶肺炎克雷伯菌。尽管休克得到逆转，但患者仍发热并伴有腹泻。对照血培养分离出白色念珠菌、鲍曼不动杆菌和耐碳青霉烯类肺炎克雷伯菌。他的腹痛加重，右侧腹可触及肿块。结肠镜检查发现散在的匐行性溃疡。在 exploratory laparotomy（此处可能有误，推测为“剖腹探查术”）中，切除了其右结肠的炎性创伤后假肿瘤。术后血培养转阴。然而，4天后感染性休克复发。重复血液净化周期并继续联合抗菌治疗。手术伤口和血培养持续对耐碳青霉烯类肺炎克雷伯菌呈阳性。因此预计要移除骨盆合成介质。三周后，感染的临床、微生物学和生化证据均消失。
对于脓毒症发作，高质量的强化治疗需要一个明确的治疗计划，旨在通过专科医生和重症监护医生复杂的多学科相互协作，实现完全的感染源控制。
