educational workshops 2009
DESCRIPTION
EDUCATIONAL WORKSHOPS 2009. CASE PRESENTATION THREE. “He’s got another one, doctor” A difficult case of recurrent MRSA bacteraemia Author: Nick Brown, Addenbrooke’s Hospital. Acknowledgement: Sani Aliyu, Sandwell and West Birmingham Hospitals – now Addenbrooke’s Hospital - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/1.jpg)
EDUCATIONAL WORKSHOPS 2009
CASE PRESENTATION THREECASE PRESENTATION THREE
“He’s got another one, doctor” A difficult case of recurrent MRSA bacteraemia
Author: Nick Brown, Addenbrooke’s Hospital
Acknowledgement:Sani Aliyu, Sandwell and West Birmingham Hospitals – now Addenbrooke’s Hospital
Details of the original case report have been adapted to emphasise particular points
![Page 2: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/2.jpg)
Sponsored through an unrestricted educational grant from Novartis Pharmaceutical Ltd to help support the
cost of developing and hosting this educational workshop series
![Page 3: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/3.jpg)
Background65 y old male
Past history of hypertension and cerebro-vascular disease
July 2003
Aortic aneurysm and complications
Endovascular aortic aneurysm repair (EVAR)
post-operative bleed requiring laparotomy
paraparesis secondary to spinal cord ischaemia
long term suprapubic catheter
longstanding sacral pressure soresAuthor: Nick Brown, Addenbrooke’s Hospital
![Page 4: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/4.jpg)
July 2007Admitted with fever four years after aneurysm repair
Blood cultures MRSA (isolate 1)
X-ray pelvis and transoesophageal echocardiogram (TOE) – normal
2 weeks iv vancomycin plus oral rifampicin, then stopped
Question:
What was the source of infection?
How would you have treated it?
Author: Nick Brown, Addenbrooke’s Hospital
![Page 5: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/5.jpg)
July 20075 days later- pyrexia MRSA again in blood cultures (isolate 2)
Re-started vancomycin plus rifampicin for 4 weeks
Home on doxycycline plus rifampicin for a further 4 weeks
Author: Nick Brown, Addenbrooke’s Hospital
![Page 6: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/6.jpg)
November 2007re-admitted with fever and back pain after 9 days at homeBlood cultures MRSA (isolate 3) Transthoracic echocardiogram (TTE) – normalMagnetic resonance imaging (MRI) spine - normalWCC scan suggestive of increased uptake in lower vertebra1 week vancomycin, then MIC for MRSA strain reported as 3 mg/Lintravenous linezolid for 10 days, then home on further 4 weeks oral
Author: Nick Brown, Addenbrooke’s Hospital
![Page 7: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/7.jpg)
Imaging 1: Indium-111 labelled white cell scan showing localised area of increased uptake in the lower abdomen or perhaps in the vertebrae
Here it is
![Page 8: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/8.jpg)
Population analysis of GISA
0
1
2
3
4
5
6
7
8
9
10
0 2 4 6 8 10 12 14 16
Vancomycin (mg/L)
log
10 c
fu/m
L
Mu3
Mu50
Sensitive S aureus
Patient MRSA
![Page 9: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/9.jpg)
January 2008re-admitted in septic shock, day 38 linezolid
MRSA in blood (isolate 4)
intravenous daptomycin - five fold rise in CK, therefore stopped (was on a statin at the same time)
blood cultures MRSA (isolate 5)
Quinupristin/dalfopristin plus fusidic acid for 12 weeks
Author: Nick Brown, Addenbrooke’s Hospital
![Page 10: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/10.jpg)
Late February 2008Blood cultures sterile by week 3 of quinupristin/dalfopristin plus
fusidic acid
inflammatory markers settling
Computerised axial tomography (CT) scan at week 7 – ‘increased thickness of aneurysm wall compared to previous scans’
Author: Nick Brown, Addenbrooke’s Hospital
![Page 11: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/11.jpg)
Imaging 2: Computerised tomography (CT) scan showing aortic graft in situ with thickening of the aortic wall
![Page 12: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/12.jpg)
April 2008Cardiothoracic review - no surgical intervention indicated
11 weeks into quinupristin/dalfopristin treatmentseptic again ESBL-producing E. coli in urine and femoral line tipmeropenem for 10 daysquinupristin/dalfopristin discontinued end of 12 weeks
blood cultures just before quinupristin/dalfopristin stopped MRSA (isolate 6)
Author: Nick Brown, Addenbrooke’s Hospital
![Page 13: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/13.jpg)
April 2008Quinupristin/dalfopristin re-started (1 week later) plus daptomycin
4mg/kg
CK levels remain normal
2 weeks - Quinupristin/dalfopristin switched to gentamicin and daptomycin dose increased to 10mg/kg
new femoral line
Author: Nick Brown, Addenbrooke’s Hospital
![Page 14: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/14.jpg)
Mid-July 2008Gentamicin stopped after 4 weeks
MRSA bacteraemia persists (isolate 7)
8 weeks into daptomycin treatment - progressive rise in MIC
daptomycin MIC 0.125 mg/L initially, but peaked at 12.0 mg/L
Isolates now also resistant to rifampicin and fusidic acid
Positron emission tomography (PET) scan confirms aortic graft infection
Author: Nick Brown, Addenbrooke’s Hospital
![Page 15: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/15.jpg)
Imaging 3: Positron emission tomography (PET) scan showing increased tracer activity in relation to the aortic graft
![Page 16: EDUCATIONAL WORKSHOPS 2009](https://reader036.vdocuments.us/reader036/viewer/2022062802/568145aa550346895db2a1ee/html5/thumbnails/16.jpg)
End-July 2008Aortic graft replacedCultures of graft are negative, but S. aureus identified by 16s rDNA
PCRGiven iv linezolid, then oral fosfomycin, doxycycline plus
chloamphenicol for 4 weeks
End-August 2008switched to oral doxycycline alone12 sets of blood cultures negative as at 1 Oct 2008
Author: Nick Brown, Addenbrooke’s Hospital