Category: Professional Posters
This case describes a post kidney transplant patient had carbapenem-resistant Klebsiella pneumoniae (CRKP) perirenal infection and Mycobacterium tuberculosis infection, complicated by the diagnosis of TB with inconsistent laboratory test results and the strategy of antimicrobial treatment for CRKP in immunocompromised patients. Patient WZ is a 50-year-old male with renal graft failure, admitted for the second allograft kidney transplant. The donor was intubated in ICU for 5 days with negative blood culture at time of transplant. On postoperative day 13, WZ spiked fever (T 103.1℉) with elevated WBC, CRP and procalcitonin. Chest computed tomography (CT) scan showed increased density in the upper and lower lobes of the right lung and upper lobe of the left lung, and enlarged lymph nodes in the mediastinum and the right hilar area. Empiric antibiotic therapy of imipenem/cilastatin (1g q8h) and voriconazole (First day 400mg q12h, then 200mg q12h) was started. Seven days after the treatment, fever resolved. But nine days later, the patient developed recurrent fever. Blood, sputum and urine cultures were negative. On postoperative day 46, fiberoptic bronchoscopy showed the anterior segment of the right upper lobe and the medial segment of the right middle lobe were distorted and narrowed. Despite the negative result of interferon-gamma release assay (IGRA), WZ was diagnosed TB infection based on immunocompromised state, clinical signs and symptoms, acid-fast bacilli result, and CT result. Therefore, imipenem/cilastatin and voriconazole were discontinued, and isoniazid, rifampicin, ethambutol, and pyrazinamide were initiated. Fever was subsided next day. However, fever reoccurred three days after, and the ultrasound showed significant swelling in the transplanted kidney area. The abscess culture post incision and drainage grew CRKP, resistant to imipenem and meropenem (MIC＞8μg/ml) , and susceptible to tigecycline and chloramphenicol. Although there is a lack of consensus on the treatment of CRKP in renal transplant patients, numerous studies have shown the best outcomes from combination antimicrobial therapy. High dose of tigecycline (200mg loading dosefollowed by 100mg q12h) and imipenem/cilastatin (1g infused over 3 hours q8h) were used in combination therapy for CRKP. Five days after the treatment, fever resolved, but the patient developed nausea and diarrhea, so imipenem/cilastatin was discontinued and tigecycline dose was adjusted to 50 mg q12h. Three days later, labs were normal, wound drainage was removed, repeat chest CT showed improved, and tigecycline was discontinued. The patient was discharged on postoperative day 69 with the continuation of anti-tuberculosis treatment outpatient.