RESUMO
PURPOSE: A patient with carbapenem-resistant Klebsiella pneumoniae infection is described, and treatment options are discussed. SUMMARY: Few antibiotics to treat carbapenem-resistant Enterobacteriaceae (CRE) infection are available, and treatment is further complicated by the limited ability of many antibiotics to penetrate into the cerebrospinal fluid (CSF). Currently, there is a lack of clinical data on the treatment of central nervous system CRE infections, and therapy is based on case reports, case series, and small retrospective studies. A patient was admitted to the emergency department with intracranial hemorrhage and ventriculitis due to traumatic injury. A ventriculostomy and, subsequently, a ventriculoperitoneal (VP) shunt were placed. After approximately a month of treatment with various antibiotic regimens, the patient's VP shunt was externalized, and a CSF culture speciated carbapenem-resistant K. pneumoniae and Pseudomonas aeruginosa. The patient was then switched to i.v. ceftazidime-avibactam and intrathecal amikacin therapy. His CSF cultures were sterile 3 days after initiation of those antibiotics, and subsequent CSF cultures resulted in no growth. After the patient was treated with intrathecal amikacin 30 mg daily for 4 weeks and i.v. ceftazidime-avibactam 2.5 g every 8 hours for 6 weeks, the ventriculitis resolved, the external ventricular drain was removed, and he was transferred to a long-term care facility for rehabilitation. CONCLUSION: A man with ventriculitis caused by P. aeruginosa and carbapenem-resistant K. pneumoniae was successfully treated with i.v. ceftazidime-avibactam and intrathecal amikacin.
Assuntos
Amicacina/uso terapêutico , Antibacterianos/uso terapêutico , Compostos Azabicíclicos/uso terapêutico , Ceftazidima/uso terapêutico , Ventriculite Cerebral/tratamento farmacológico , Infecções por Klebsiella/tratamento farmacológico , Klebsiella pneumoniae , Infecções por Pseudomonas/tratamento farmacológico , Pseudomonas aeruginosa , Adulto , Amicacina/administração & dosagem , Antibacterianos/administração & dosagem , Compostos Azabicíclicos/administração & dosagem , Enterobacteriáceas Resistentes a Carbapenêmicos , Ceftazidima/administração & dosagem , Ventriculite Cerebral/microbiologia , Ventriculite Cerebral/cirurgia , Combinação de Medicamentos , Quimioterapia Combinada , Humanos , Injeções Intravenosas , Injeções Espinhais , Infecções por Klebsiella/complicações , Infecções por Klebsiella/microbiologia , Masculino , Infecções por Pseudomonas/complicações , Infecções por Pseudomonas/microbiologia , Derivação Ventriculoperitoneal , VentriculostomiaRESUMO
BACKGROUND: Studies on the implantation of care routines showed reduction on EVD catheter-related infections rates; however zero tolerance is difficult to be achieved. The objective of this study was to assess the impact of an educational intervention on the maximal reduction on rates of EVD-related infections. METHODOLOGY/PRINCIPAL FINDINGS: The quasi-experimental (before-after intervention) study occurred in two phases: pre-intervention, from April 2007 to July 2008, and intervention, from August 2008 to July 2010. Patients were followed for 30 days after the removal of the EVD, and EVD-related infections were considered as only those with laboratorial confirmation in the CSF. Observations were made of the care of the EVD and compliance with Hygiene of the Hands (HH), a routine of care was drawn up, training was given, and intervention was made to reduce the time the EVD catheter remained in place. RESULTS: during the study, 178 patients were submitted to 194 procedures, corresponding to 1217 EVD catheters-day. Gram-negative agents were identified in 71.4% of the infections during the pre-intervention period and in 60% during the intervention period. During the study, EVD-related infection rates were reduced from 9.5% to 4.8% per patient, from 8.8% to 4.4% per procedure, and the incidence density dropped from 14.0 to 6.9 infections per 1000 catheters-day (p = 0.027). The mortality reduced 12% (from 42% to 30%). CONCLUSIONS/SIGNIFICANCE: During one year after the fourth intervention, no microbiologically identified infection was documented. In light of these results, educational intervention proved to be a useful tool in reducing these rates and showed also impact on mortality.