Community-acquired, fatal extended spectrum beta lactamase producing Klebsiella pneumoniae splenic abscess and sepsisD Thambu, K Pichamuthu, GM Varghese, S Subramanian
Department of General Medicine, CMC, Vellore, India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 17102566
Source of Support: None, Conflict of Interest: None
Extended-spectrum Beta lactamase (ESBL) producing infections have been previously documented in India in hospital settings., Splenic abscess caused by Klebsiella pneumoniae -mostly hospital acquired-has been reported., Herein we present a rare case of a patient who developed a fatal community-acquired ESBL producing Klebsiella pneumoniae infection causing splenic abscess and sepsis syndrome.
A 34-year-old carpenter was referred from the community health center with a 10-day history of high-grade intermittent fever and vomiting. He had appeared toxic with a mild hepato-splenomegaly. Suspecting typhoid fever, intravenous (IV) ciprofloxacin was started. However, after three days he remained febrile and toxic and was referred to the main hospital.
In childhood he had undergone Bayer's repair of hypospadias and perineal urethrostomy. He had no urinary symptoms presently.
On examination, he was tachypnoeic (SaO 2 56.6%). His WBC count was 7100 with 14% band forms. He also had leukocyturia, hematuria and prolonged prothrombin and activated partial thromboplastin times.
The possibilities of sepsis syndrome, enteric fever, ricketsial infection and leptospirosis were considered. He was given IV ciprofloxacin, penicillin and oral doxiciclin along with supportive therapy. On the second hospital day, he developed ARDS; IV cloxacillin was added in place of penicillin. On the third day, he developed altered sensorium. CSF examination showed only mild pleocytosis.
On further history, a relative admitted that the patient had had possible repeated attacks of urinary infection for which he had received antibiotics from his local general practitioner, the details of which were not available.
Ultrasound abdomen done on day 5, revealed hypoechoeic lesions in the spleen. Considering mellioidosis or lymphoma, IV ceftazidime was started in place of ciprofloxacin; a bone marrow aspirate, trephine and culture were done. His condition worsened and he had a cardio-respiratory arrest on day 6. He was resuscitated and put on mechanical ventilation. A splenic aspirate done revealed numerous gram-negative bacilli that were later found to be ESBL Klebsiella pneumoniae . The same organism was also identified in the blood (day 6) and bone marrow cultures. It was resistant to ampicillin, ceftazidime, cefotaxime, cephalexin, ofloxacin, ciprofloxacin, amikacin, gentamicin, cefpirome, piperacillin, azlocillin and aztreonam. It was sensitive to impepenum, meropenum and isepamicin.
He was started on IV meropenem 1g IV twice daily. However, he did not improve-his brainstem reflexes were not demonstrable. He expired on day 10.
ESBL infections have not been described in India from community settings. This patient had not been to a hospital. He had received different antibiotics from his local general practitioner. Initial blood cultures so vital in choosing appropriate antibiotics were negative, likely due to prior antibiotic usage.
The problem of drug-resistant community-acquired infections is likely to be due to the rampant misuse of antibiotics in the community both by doctors and patients who get antibiotics directly from pharmacies. A recent study describing the quality of prescriptions by medical practitioners in India reveals that a quarter of the prescriptions included an antibiotic. Private practitioners prescribed significantly greater number of medicines and were more likely to prescribe antibiotics. We present this case to highlight the emergence of ESBL organisms in the community and the urgent need for a properly enforced rational antibiotic policy among health professionals.