Patient Case: 2-month-old female patient

Children’s Hospital Los Angeles

Pediatric hospital in Los Angeles, CA

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2-month-old female patient

2-month-old female born at 24 weeks gestation with gastroschisis post silo placement followed by alloderm bio-prosthesis patch for gastrochisis closure. Admitted for surgical evaluation and management. Presented to NICU with episodes of bradycardia and oxygen desaturation. Feeding intolerance. Leukopenia and thrombocytopenia.

Empiric therapyCefepime and vancomycin
ID/AST methodAccelerate PhenoTest® BC kit
ID resultKlebsiella spp.
AST resultsPan-susceptible to all agents tested
Therapy changeDiscontinue vancomycin, de-escalate from cefepime to ceftazidime
Time to AST results9h 51min post +BC with Accelerate PhenoTest® BC kit
Patient outcomePatient recovered from K. pneumonia sepsis but remained hospitalized due to underlying comorbidities

Case Discussion

A 2-month-old female born at 24 weeks gestation with gastroschisis status post silo placement followed by alloderm bioprosthesis patch for closure was admitted for surgical evaluation and management. She presented in the neonatal intensive care unit (NICU) with episodes of bradycardia and desaturation (O2 saturation at 68%) followed by feeding intolerance the next day. Initial laboratory findings revealed leukopenia (white blood cell, 4.07 K/µL), bandemia (27.2%) and thrombocytopenia (83 K/uL). Sepsis evaluation was initiated and empiric intravenous (IV) vancomycin (15 mg/kg, Q12H) and IV cefepime (50 mg/kg, Q8H) was started. As part of the sepsis evaluation, aerobic blood cultures x 2 and cerebrospinal fluid collected via lumbar puncture was submitted to the microbiology laboratory for culture workup.

Aerobic blood cultures collected on day 1 of presentation was positive after 8.3 hours of incubation. Initial Gram stain revealed Gram-negative bacilli and result was called to the provider and reported in the electronic medical record (EMR). Klebsiella species was detected by the Accelerate PhenoTest BC kit 2 hours and 51 minutes later and again the results were called to the provider and reported in the EMR. Further speciation to Klebsiella pneumoniae was completed by MALDI-TOF MS after growth on agar plate 7 hours later. Likewise, susceptibility results by the Accelerate PhenoTest BC kit were also available at approximately 7 hours after initial identification and the organism was found to be pan-susceptible to all antimicrobial agents included in the panel. Based on the identification and susceptibility results provided by the Accelerate PhenoTest BC kit, IV vancomycin was discontinued within 30 hours after availability of results. Importantly, per infectious diseases recommendation, the antimicrobial regimen was de-escalated from cefepime to IV ceftazidime (50 mg/kg, Q8H) within 5 hours of susceptibility results. Blood culture collected on day 2 of presentation was also positive for K. pneumoniae but all subsequent blood cultures were negative. Meningitis was ruled out after 48 hours based on negative cerebrospinal fluid (CSF) culture and normal CSF parameters. The patient clinically recovered from K. pneumoniae sepsis but remained hospitalized due to underlying comorbidities.

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