Patient Case: 59-year-old-male-with-acute-myeloid-leukemia

University Hospital Policlinico of Catania

Academic medical center in Catania, Italy

Fever in a Neutropenic Oncohematological Patient

A 59-year-old male with a previous diagnosis of acute myeloid leukemia developed a fever episode (T=38.0°C) and tachycardia with suspicion of sepsis.

Empiric therapy Fluconazole and piperacillin/tazobactam
ID/AST method Accelerate PhenoTest® BC kit
ID result Klebsiella spp.
AST results Amikacin (S), gentamicin (S), meropenem (I), colistin (S), all others (R)
Therapy change Suspended fluconazole and piperacillin/tazobactam, started meropenem and colistin
Time to AST results 6h 30min
Patient outcome Fever and inflammation indices decreased after 2 days

Case Discussion

A 59-year-old male with a previous diagnosis of acute myeloid leukemia developed a fever episode (T=38.0°C) during his hospitalization period in our Oncohematological Unit. A C-reactive protein (CRP) value of 323.41 mg/L and a procalcitonin (PCT) value of 5.00 ng/ml, together with fever and tachycardia, led clinicians to the suspicion of sepsis.

Empiric treatment with fluconazole and piperacillin/tazobactam was started, while peripheral vein and central catheter blood cultures. Blood cultures became positive within 4 hours and an extemporary Gram-stain revealed Gram-negative bacilli.

Identification and antibiotic susceptibility test (AST) with Accelerate PhenoTest® BC kit were performed. Identification results were obtained within 1 hour and 30 minutes: the presence of Klebsiella spp. was detected. A susceptibility panel was produced within 6 hours and 30 minutes.

With these results clinicians were able to optimally modify antibiotic treatment: fluconazole and piperacillin/tazobactam were suspended, while meropenem and colistin were started.

Molecular testing on the isolate revealed the presence of a KPC gene variant (sequencing performed) explaining elevated meropenem and Ceftazidime/Avibactam MICs and resistance. The identification and susceptibility results were also confirmed by alternative routine laboratory methods, but the time to pathogen identification and antibiotic susceptibility requires was considerably longer (additional 5.5-13.5 hours).

Furthermore, newer broad-spectrum antibiotics were tested later using Gradient-test analysis. Following the start of the appropriate antibiotic regimen, the patient’s clinical condition improved: fever and inflammation indices decreased after 2 days; he survived despite his critical oncohematological diagnosis.

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