title: Successful treatment of a Carbapenem-resistant Klebsiella pneumoniae carrying bla OXA-48 , bla VIM-2 , bla CMY-2 and bla SHV- with high dose combination of imipenem and amikacin.
abstract: We describe a case of 58-year-old man with septic shock due to Carbapenem-resistant Klebsiella pneumoniae (CR-Kp) bloodstream infections (BSI) who was successfully treated with a high dose association of amikacin and imipenem combined with continuous venovenous hemodiafiltration (CVVHDF). A Klebsiella pneumoniae (Kp) was isolated from the catheter culture and from two blood samples, drawn from the catheter before removal and from a peripheral vein. The Kp was intermediate to Amikacin (MIC = 16 μg/ml) and was resistant to all other antibiotics including Imipenem (MIC = 4 μg/ml), Colistin (MIC = 16 μg/ml) and Tigecycline (MIC = 4 μg/ml) according to the Clinical and Laboratory Standards Institute (CLSI) published in 2011. PCR amplification and sequencing verified the presence of blaOXA-48, blaVIM-2, blaCMY-2 and blaSHV-1 genes. Amikacin was given at a dose of 30 mg/kg (2.5 g) in a 30 min infusion and the dose of imipenem was increased to 1 g every 6 h despite patient's altered renal function (Creatinine Clearance = 25 ml/min). To avoid amikacin nephrotoxicity and to allow the use of high doses of imipenem, continuous venovenous hemodiafiltration (CVVHDF) (blood flow, 200 ml/h; dialysate, 1000 ml/h; ultrafiltrate, 2000 ml/h) was initiated 1 h after the start of the amikacin infusion and continued thereafter. The patient improved hemodynamically and norepinephrine was stopped five days after antibiotherapy adaptation.
authors.affiliation: Intensive Care Unit, Military Hospital of Tunis, Montfleury, 1008 Tunis, Tunisia.
authors.forename: Zied
authors.initials: Z
authors.lastname: Hajjej
authors.affiliation: Intensive Care Unit, Military Hospital of Tunis, Tunisia.
authors.forename: Hedi
authors.initials: H
authors.lastname: Gharsallah
authors.affiliation: Military Hospital of Tunis, Tunisia.
authors.forename: Habiba
authors.initials: H
authors.lastname: Naija
authors.affiliation: Laboratory of Research "resistance to antibiotics" Faculty of Medicine of Tunis, Tunisia.
authors.forename: Ilhem
authors.initials: I
authors.lastname: Boutiba
authors.affiliation: Intensive Care Unit, Military Hospital of Tunis, Tunisia.
authors.forename: Iheb
authors.initials: I
authors.lastname: Labbene
authors.affiliation: Head of Department of Intensive Care Unit, Military Hospital of Tunis, Tunisia.
authors.forename: Mustapha
authors.initials: M
authors.lastname: Ferjani
keywords: Bloodstream infections; Carbapenem-resistant Klebsiella pneumoniae; Continuous venovenous hemodiafiltration