title: Recurring septic shock in a patient with blunt abdominal and pelvic trauma: how mandatory is source control surgery?: a case report.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy. antofrattari@gmail.com.
authors.forename: Antonella
authors.initials: A
authors.lastname: Frattari
authors.affiliation: Unit of Infectious Diseases, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy.
authors.forename: Giustino
authors.initials: G
authors.lastname: Parruti
authors.affiliation: Unit of Orthopedics and Traumatology, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy.
authors.forename: Rocco
authors.initials: R
authors.lastname: Erasmo
authors.affiliation: Unit of Orthopedics and Traumatology, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Guerra
authors.affiliation: Unit of Infectious Diseases, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy.
authors.forename: Ennio
authors.initials: E
authors.lastname: Polilli
authors.affiliation: Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy.
authors.forename: Rosamaria
authors.initials: R
authors.lastname: Zocaro
authors.affiliation: Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy.
authors.forename: Giuliano
authors.initials: G
authors.lastname: Iervese
authors.affiliation: Unit of Microbiology, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Fazii
authors.affiliation: Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy.
authors.forename: Tullio
authors.initials: T
authors.lastname: Spina
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D003422:Critical Care / Q000379:methods; D006464:Hemoperfusion / Q000379:methods*; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D010384:Pelvic Bones / Q000000981:diagnostic imaging / Q000293:injuries*; D011859:Radiography; D012008:Recurrence; D012772:Shock, Septic / Q000188:drug therapy / Q000382:microbiology / Q000601:surgery*; D013530:Surgical Wound Infection / Q000188:drug therapy / Q000382:microbiology* / Q000601:surgery; D014949:Wounds, Nonpenetrating / Q000150:complications
chemical_list: D000900:Anti-Bacterial Agents
keywords: Case report; Control surgery; Intensive assistance; Septic shock