pan-resistant pseudomonas

[xiphoid2010]

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Nearing the end of the S-MICU rotation, saw my first case of pan-resistant pseudomonas. Post-op patient, now 2 weeks into the ICU stay, sputum cx grew out pseudomonas that's was initially only sensitive to colistin and intermediate for zosyn (MIC=64). Now it's resistant to both. There is basically nothing to do but to hope his body can somehow fight it off.

Without new antibiotics coming out soon that I'm aware of (besides ceftobiprole), it would antibiotic resistant super bugs are winning. Perfectly healthy looking people coming in for a simple CABG can ends up 6 feet under in matter of days. Makes me want to go home and take a bath in chlorhexidine.


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let's start listing the super bugs you've seen on your rotation. It's the new "my xxx is bigger than yours" contest.

 

[Farmercyst]

Have they tried mulitple abx to try and exploit synergism. I've heard many hospitals are starting to do synergy testing in cases of MDR bugs. We recently discussed the use of Zosyn/Tobi for CFers, perhaps something similar could be done here.

 

[njac]

This is the first I've heard of colistin resistance - but we also don't test for that at our hospital.

Depending on the mechanism, sometimes you can overcome resistance (see high dose Unasyn in Acinetobacter)

 

[xiphoid2010]

Have they tried mulitple abx to try and exploit synergism. I've heard many hospitals are starting to do synergy testing in cases of MDR bugs. We recently discussed the use of Zosyn/Tobi for CFers, perhaps something similar could be done here.

ID is on board already. I'm not sure synergy will help much when the MIC is resistant. I would think it would be more useful when something is of intermediate sensitivity. But I can bright it up on rounds Monday... if he lives that long.

 

[RxWildcat]

I think we had a XDR TB guy at our hospital this month, he wasn't my pt though so I wasn't following him.

 

[StaviZFingerZ]

they need to try multiple drugs even tho each drug may be resistant like farmercyst said. like colistin plus carbapenem plus ag.

 

[StaviZFingerZ]

this is nothing new.

 

[gotdrugs]

As Stavi said, this isn't anything really new....at all. Stick around in the ICU and you'll see it more often.

?'s I have:

I'm assuming he's been on the vent the entire time, does he have actual clinical symptoms of infection?

I've seen several cases of colonization of MDR bugs in long term (i.e. >1week) ventilated patients.

 

[xiphoid2010]

they need to try multiple drugs even tho each drug may be resistant like farmercyst said. like colistin plus carbapenem plus ag.

He was on zosyn and colistin together. Double covering pseudomonas is pretty standard, and ID isn't clueless. But it shrugged them both off and became pan-resistant.

According to the med history, amikacin was tried on also at one point, but colistin+AG was just too much for the kidney, and it was stopped.

 

[njac]

got drugs is onto something - is this just pseudomonas in his sputum or an actual pneumonia. This is where you get to see the great knock down-drag out ID vs pulmonary fights. "Hidden pneumonia" is a term you end up hearing from the pulmonary end.

Your guy sounds pretty screwed. But it's becoming more and more common.

 

[KARM12]

ID is on board already. I'm not sure synergy will help much when the MIC is resistant. I would think it would be more useful when something is of intermediate sensitivity. But I can bright it up on rounds Monday... if he lives that long.

What does it mean when a MIC is labeled as resistant?

Can we still optimize PK/PD parameters in these patients?

 

[StaviZFingerZ]

He was on zosyn and colistin together. Double covering pseudomonas is pretty standard, and ID isn't clueless. But it shrugged them both off and became pan-resistant.

According to the med history, amikacin was tried on also at one point, but colistin+AG was just too much for the kidney, and it was stopped.

Yeah whatever. But was the patient on Carbapenem, Colistin, and AG all together at once?

Let's see...fry the kidneys temporarily or let the patient die of infection?

You hang around CF unit for a while, you'll see MDR ps. A all the time.

 

[xiphoid2010]

As Stavi said, this isn't anything really new....at all. Stick around in the ICU and you'll see it more often.

?'s I have:

I'm assuming he's been on the vent the entire time, does he have actual clinical symptoms of infection?

I've seen several cases of colonization of MDR bugs in long term (i.e. >1week) ventilated patients.

Yeah, he's trached & peged. He's slightly febrile (Tm=101-102), with WBC in the mid-high teens, that's been the same this entire week. When I left, ID hasn't come stopped by today, but the progress notes said that he's considering stopping ABX and see which direction it goes.

 

[StaviZFingerZ]

What does it mean when a MIC is labeled as resistant?

Can we still optimize PK/PD parameters in these patients?

LOL... now now.. stop picking on a student..

They could try continuous infusion of beta lactam to keep the level above MIC...

 

[KARM12]

Yeah, he's trached & peged. He's slightly febrile (Tm=101-102), with WBC in the mid-high teens, that's been the same this entire week. When I left, ID hasn't come stopped by today, but the progress notes said that he's considering stopping ABX and see which direction it goes.

Check a C. diff.

 

[KARM12]

Yeah whatever. But was the patient on Carbapenem, Colistin, and AG all together at once?

Let's see...fry the kidneys temporarily or let the patient die of infection?

You hang around CF unit for a while, you'll see MDR ps. A all the time.

Bcc is my favorite MDR.

 

[StaviZFingerZ]

Check a C. diff.

Did you read the latest?

 

[StaviZFingerZ]

Bcc is my favorite MDR.

I haven't seen much Burkholderia... do you?

 

[KARM12]

Did you read the latest?

Quick skim...I haven't had a chance to do the full read, but that is on the to do list for the next week.

 

[StaviZFingerZ]

Quick skim...I haven't had a chance to do the full read, but that is on the to do list for the next week.

bad bad bad... you're suppose to read all the latest guidelines when the ink is warm..

 

[StaviZFingerZ]

Aight... I have 4 gallons of heavy duty diesel engine oil waiting for me...

bbl.

 

[KARM12]

bad bad bad... you're suppose to read all the latest guidelines when the ink is warm..

I know, but he didnt give me any info if the pt was having diarrhea.. We had a patient just now that the intern never mention the pt was having diarrhea and had some icky c. diff.

 

[xiphoid2010]

Check a C. diff.

c.diff is negative x 3. They thought of that, and even empirically gave flagyl for a while. Besides, usually I see C.diff patients have a lot of diarrhea + foul odor, and get a huge pike in WBC into the 30+.

 

[KARM12]

I haven't seen much Burkholderia... do you?

I had 2 cases this week! Both CF'ers...one they were trying to decide if they could list him for a lung transplant.

 

[StaviZFingerZ]

lung transplant in cf, is it common?

 

[Priapism321]

New C. difficile guideline: nothing special, very heavy on the epidemiology side of things.

Items I liked:

Metronidazole remains the gold standard first line treatment

No glowing recommendation for rifaximin


Item I did not like:

Where the eff is the A-I recommendation for fecal transplant in refractory/severe cases?!?!?!

 

[Praziquantel86]

New C. difficile guideline: nothing special, very heavy on the epidemiology side of things.

Items I liked:

Metronidazole remains the gold standard first line treatment

No glowing recommendation for rifaximin


Item I did not like:

Where the eff is the A-I recommendation for fecal transplant in refractory/severe cases?!?!?!

I didn't even see it mentioned...very depressing, if you ask me.

 

[KARM12]

lung transplant in cf, is it common?

Some what...I would say almost half of our patients were transplanted because of CF. It is usually a last ditch effort. Some patients do well after transplant, but the overall long term survival is still poor.

 

[bigpharmD]

lung transplant in cf, is it common?

3rd most common reason....you have to make every attempt as possible to clear their bugs prior to transplant

 

[johnconner]

Sad to say but MDR gram negatives are something to be worried about now. There are no drugs in the near future that are coming out that will cover MDR gram negatives.

Did his cultures come back with resistant to ALL the other anti-pseudomonals? How about polymixin B, FQ's?, aztreonam?, Timentin, etc? If he starts up on new abx, you gotta really blast it so he doesn't get resistant to whatever you're starting on. It's better to overtreat a little, then to undertreat and then grow resistance.

 

[njac]

anything with an ESBL is going to be resistant to aztreonam and timentin. FQ resistance likely came along about the time it acquired an ESBL.

I don't know of any hospital that test for susceptibility to polymixin B, do they do that regularly?

 

[FAMUPharmD09]

Nearing the end of the S-MICU rotation, saw my first case of pan-resistant pseudomonas. Post-op patient, now 2 weeks into the ICU stay, sputum cx grew out pseudomonas that's was initially only sensitive to colistin and intermediate for zosyn (MIC=64). Now it's resistant to both. There is basically nothing to do but to hope his body can somehow fight it off.

Without new antibiotics coming out soon that I'm aware of (besides ceftobiprole), it would antibiotic resistant super bugs are winning. Perfectly healthy looking people coming in for a simple CABG can ends up 6 feet under in matter of days. Makes me want to go home and take a bath in chlorhexidine.


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let's start listing the super bugs you've seen on your rotation. It's the new "my xxx is bigger than yours" contest.

There is some literature using azithromycin three times a week as adjunctive therapy (reduced biofilm and reduced inflammatory processes) in patients with cf with mdr pseudomonas. Just a thought

 

[smileyangel11]

If MIC = 64 to Zosyn, I suggest it taking it off the therapy. The probablity of target T > MIC is unattainable.

What about the sensitivity to carbapenems? If possible, I would do Doripenem 1000 mg Q 8H (adjust for renal) + Rifampin 600 mg Q12 H + Colistin.

Other things to try may be (1) inhaled AG or colistin; (2) extended doripenem infusion over 4 hrs.

 

[Praziquantel86]

There is some literature using azithromycin three times a week as adjunctive therapy (reduced biofilm and reduced inflammatory processes) in patients with cf with mdr pseudomonas. Just a thought

I was under the impression that this was useful for all CF patients, not just those colonized with MDR pseudomonas.