advised to be continued till clinical cure of the patient. On day 30, patient had sudden onset of multiple episodes of seizure for which symptomatic treatment was started and she developed hypoten- sion for which ionotropic support was started. On day 31, patient deteriorated on Glasgow Coma Scale and became febrile, patient was later intubated and investigations suggested sepsis. Patient was on ventilator with FiO2 100% and ionotropic support. On day 32, patient had bradycardia and severe hypotension and despite Cardiopulmonary Resuscitation she could not be revived and death was declared.
Discussion: n this case, despite administration of appropriate antibiotic therapy the patient did not attain complete clinical cure.
However, in a similar case reported by Cascio et al., a 5-year old boy who was successfully operated for astrocytoma, got admitted to hospital 4 days after the intervention, because of CSF leak from the surgical wound with fever. After wound revision, culture of CSF yieldedE. cloacae subsp. cloacae, which was sensitive to fosfomycin, tigecycline, and colistin. As definitive therapy, combination of intravenous colistin methanesulfonate 2 million IU/12 h and intravenous rifampin 400 mg/day were started. But, as the patient continued to be febrile and CSF cultures were positive even after 6 days, intraventricular colistin methanesulfonate 10 mg/day was started. The patient became afebrile 48 h after beginning intraventricular colistin and serial CSF cultures were sterile. After 13 days, ventricular drainage was removed. On further follow-up the authors reported that there were no similar complaints. Another case, a 17-year old patient of meningitis by XDR Enterobacter cloacae, after removal of neurocytoma reported by He Z et al., the patient responded to treatment with high dose meropenem along with intravenous and intraventricular amikacin.
he treatment suggested by drug information services was based on these two case reports, which reported good outcomes with intraventricular therapy. As in this case, the isolate was sensitive to gentamicin and intermediate to colistin, intraventricular therapy with gentamicin and colistimethate sodium was added to intravenous therapy, which resulted in microbiological cure with serial CSF cultures being negative, but patient deteriorated suddenly.
Conclusion: In this case, despite administration of appropriate antibiotic therapy by both intraventricular and intravenous routes, attainment of microbiological cure and apparent improvement in clinical condition, the patient did not attain complete clinical cure.
These carbapenem resistant enterobacteriaceae are threatening public health due to limited treatment options and unfavorable prognosis. There is therefore an urgent need to develop effective treatment regimens to combat such life threatening infections and take necessary precautions to prevent the emergence of resistant isolates with judicious use of antimicrobial agents.
PCC-008
Risk of infection with multiple pathogen in post liver transplantation patient in referral centre in Jakarta, Indonesia Fadrian Fadrian1*, Erni Juwita Nelwan1,2, Juferdy Kurniawan1,3, Herdiman T. Pohan1,2.1Department of Internal Medicine;2Division of Tropical and Infectious Disease;3Division of Hepatology Faculty of Medicine Universitas Indonesia, Ciptomangunkusumo Hospital, Jakarta, Indonesia
Introduction:Liver transplantation survival and success rates are increasing due to availability of potent immunosuppressive agents but mortality from infectious diseases complications remains a major problem besides the complication due to the surgical procedure itself. Immunosuppression puts recipients at risk for de novo infection and reactivation of latent infection. The most common types of infection were bacterial (48%), fungal (22%), and
viral (12%) but concomitant bacterial, fungal and viral co-infections were rarely reported.
Case report:A 46-year-old male patient with a history of liver transplantation 5 months ago and currently on immunosuppres- sant therapy came with high fever since 2 days before admission.
Physical examination revealed icteric. Chest x-ray revealed para- cardial infiltrate. The abdominal MRI shows a septate cyst, intrahepatic fluid collection. Laboratory examinations revealed Hb 10.9 g/dl, Ht 32.8%, leukocytes 7890/ul, platelets 29 000/ul, elevated liver enzymes, galactomannan serum titre >1,0 equal to positive and PCR CMV 4.5.104copies/ml. The patient was diagnosed with post-liver transplant infection due to biloma, pneumonia, aspergillosis, and CMV infections. The patient received initial empiric Meropenem which then be switched for Tigecycline after ID consultation. The surgical correction for biloma will be performed after the patient clinically stable, definitive antifungal therapy for Aspergillosis was initiated after receiving laboratoty result including the CMV medication.
Discussion:Infected collections of liver fluid (biloma) are one of several major infectious complication of liver transplantation.
Opportunistic infections (OI) such as Aspergillus and CMV infections often occur 1 to 6 months post-transplant because of the highest degree of immunosuppression. The screening strategy applied to determine the risk of infection after transplantation and the use of prophylactic antimicrobial therapy can reduce post- transplant infection.
Keywords: post liver transplantation infection, biloma, CMV, aspergillosis.
PCC-009
Aggregatibacter aphrophilus chronic rheumatic heart disease: A case report
Sharifah Aisyah Sayed Hitam1*, Alyaa Farhan Zulkefli2.1Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan, Malaysia;2Hospital Sultan Ismail Petra, Kuala Krai, Kelantan, Malaysia
Background:The HACEK group referring toHemophillusspecies, Aggregatibacterspecies,Cardiobacterium hominis, Eikenella corro- densandKingellaspecies are found as part of the normal human oral flora. They are fastidious Gram negative organisms responsible for approximately 3% of cases of native valve infective endocarditis.
HACEK infection, although rare, can be extremely serious, but outcomes are generally successful if the organism is identified early and treated appropriately.
Case Presentation:We are presenting a 36 years old lady with chronic rheumatic heart disease presented with typical infective endocarditis symptoms. Transthoracic echocardiography upon admission showed severe aortic stenosis, moderate aortic regurgi- tation, mild tricuspid regurgitation, and mild mitral regurgitation.
No vegetation seen. Blood investigation showed no leucocytosis with raised erythrocyte sedimentation rate and C reactive protein.
Blood culture sent was positive with difficult identification and finally came out Aggregatibacter aphrophilus. Initially, she was empirically started on iv Ampicillin 2 g 4 hourly and iv Gentamycin 80 mg tds for 1 week. Then was changed to iv Unasyn 3 g qid for 4 weeks. Two weekly transthoracic echocardiography during hos- pital admission showed no vegetation. Patient improved and had no more of fever in ward. The patient recovered completely and was discharged home.
Conclusion:This case highlights the importance of identifying rare causes of endocarditis and recognizing that treatment may not differ from the standard treatment for typical presentations. HACEK group is known to cause infective endocarditis, however rare and difficult to be identified. Prompt treatment with antibiotic has better outcome.
Abstracts from the 13th ISAAR 2021 / International Journal of Antimicrobial Agents 58S1 (2021) 106421
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