Department of Anaesthesia and Critical Care, Maulana Azad Medical College and Lok Nayak Hospital, Bahadur Shah Zafar Marg, New Delhi 110002, IndiaIndia
Department of Anaesthesia, Safdarjang Hospital, New Delhi 110029, IndiaIndia
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The risk of acquisition of multi-drug resistance remains a major hurdle in management of patients with sepsis. Owing to limita tion in availability of antibiotics and increasing surge of multi-drug resistant organisms, the major aim still remains at prevention of the growth of organism. Various guidelines prevent against the routine change of urinary catheter at fixed interval unless there are clinical predictors of infection or obstruction. But there are at times, when despite all the measures, once infection oc cur, it may be resistant to all the available antibiotics, as had been seen in our case. This case report highlights yet another instance of multi-drug resistance organism, where the importance of preventive measures needs to be over emphasized.
Keywords: Providencia sepsis; Renal parenchyma
Sepsis is defined as life threatening organ dysfunction caused by dysregulated host response to infection. 1 Providencia is a class of enterobacteriaceae family, with 8 recognized species and P. stuartii is the most frequent. It is commonly found in soil, water and sewage, but is a notorious opportunistic pathogen in patients who have long-term indwelling urinary catheters, diabetics, immunocompromised or severe burns. The most common source of sepsis is via urinary route as P. stuartii adheres directly to the urinary catheters, and adheres to uroepithelial cells via fimbriae. Godebo et al2 suggested that 75% of Providencia isolates were multidrug resistant and Linhares et al 3 identified Providencia species as the most common cause of multi drug resistant urinary tract infection. Over 90% of isolates were resistant to aminoglycosides, cephalo sporins, 20% to other penicillins, quinolones, sulphonamides. Ten percent were resistant to II-III generation cephalosporins and 5% to aztreonam.
Carbapenems (Imipenem and Meropenem) are considered as the best choice for empirical therapy in life threatening outbreaks caused by P. stuartii, but our patient did not respond to all of these. Amikacin and beta lactamase inhibitors such as piperacillin/ tazobactum are preferred in non-life threatening infections. There were various factors which could have resulted in the nososcomial infection of P. stuartii in our patient. Our patient had alleged history of injury to renal parenchyma during his percutaneous nephrolithotomy (PCNL) procedure, initial drain culture sensitivity was suggestive of acenitobacter which was sensitive to colistin. He initially responded to three day course of the same, but owing to surge of pyrexial episode, we extended the course of colistin for further 5 days. Hayakawa et al 4 suggested increased use of colistin can be associated with increase in infection of P. struatii. Surgical drains were subsequently removed, but the drain source could have resulted in Providencia infection. Secondly he had catheter in situ which could have been a nidus of infection. Thirdly, knowing that he was diabetic, provision of nutritional requirement by total parenteral nutrition led to persistently high blood sugar and required high dose of insulin infusion. Because of strong association of providencia urinary tract infection with chronic urinary catheterization, removal and change of the same was done. Prevention is the best cure in dealing with these organisms, as far as possible. Urinary catheters, drains, tracheostomy tubes in chronic debilitated patients especially who are diabetics or immunocompromised, should be changed contrary to the norms.
Urinary Tract Infections,5 recommend against changing indwelling catheters or drainage bags at routinely fixed intervals unless there are clinical indicators like infection, obstruction or when closed system is compromised, seems questionable in our case. Considering this scenario, changing the catheter every 15 days should be undertaken in patients who are chronically immunocompromised, diabetics especially with uncontrolled blood sugars and elderly. Control of blood sugars in the normal range should be a norm and as far as possible, blood glucose levels should be less than 180 mg/dL as suggested by sepsis guidelines in 2016. 1 Enteral route should be preferred for nutrition except in circumstances such as in ours where parenteral is the only way left to provide nutrition. This is yet another instance where the importance of preventive measures cannot be over emphasized. Chasing infection by escalating antibiotics or discovering newer ones seems to be rather futile. Hand hygiene and strict aseptic precautions are still of paramount importance and most effective standalone measures. Clinical guidelines may be best for patients overall but may be inappropriate for all individuals. Hence bedside clinical judgement still supersedes clinical guidelines.
The authors declare that they have no conflicts of interest.
Campaign: International guidelines for the management of sepsis and septic shock: 2016. Intensive Care Med . 2017; 43(3): 304-377. doi: 10.1007/s00134-017-4683-6 2. Godebo G. Kibru G, Tassew H. Multidrug-resistant bacterial isolates in infected wounds at Jimma University Specialized Hospital, Ethiopia. Ann Clin Microbiol Antimicrob. 2013; 12: 17. doi: 10.1186/1476-0711-12-17 3. Linhares I, Raposo T, Rodrigues A, Almeida A. Frequency and antimicrobial resistance patterns of bacteria implicated in community urinary tract infections: A ten-year surveillance study (2000-2009). BMC Infect Dis. 2013; 13: 19. doi: 10.1186/1471-2334- 13-19 4. Hayakawa K, Marchaim D, Divine GW , et al. Growing prevalence of Providencia stuartii associated with the increased usage of colistin Figure 1. Specific Note Can be Made of Change in Color of Urine, Suggestive of Pus and Pinkish Purple Hue in T ubing’s and Uroflowmeter, and Simultaneously Urine Culture Suggested of Growth of Providencia Organism
Figure 2. Bed Side Chest X Ray is Suggestive of Bilateral Infiltrates in Middle and Lower Zones with Blunting of Bilateral Cardio-Phrenic Angles at a tertiary health care center. Int J Infect Dis . 2012; 16: e646-e648.
doi: 10.1016/j.ijid.2012.05.1029 5. HICPAC. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Web site. https://www.cdc.gov/ infectioncontrol/pdf/guidelines/cauti-guidelines.pdf. Accessed February 15, 2017.
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