Patient Case: 7-year-old male patient with MDRO

Children’s Hospital Los Angeles

Pediatric hospital in Los Angeles, CA

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Pediatric Kidney Transplant Patient

7 yo male with end stage renal disease, bilateral hydroureter, neurogenic bladder, and recurrent pyelonephritis. Prior P. aeruginosa infection. 12 days after kidney transplant, fever, elevated WBC count.

Empiric therapy Cefepime
ID/AST method Accelerate PhenoTest® BC kit
ID result Escherichia coli
AST results Multi-drug resistance; resistant to 3rd and 4th generation cephalosporins but susceptible to meropenem
Therapy change Escalate to meropenem
Time to AST results 7h 52min post +BC with Accelerate PhenoTest® BC kit
Patient outcome Discharged 37 days post–kidney transplantation

Case Discussion

A 7-year-old male presented with significant past medical history, including end stage renal disease, bilateral hydroureter, neurogenic bladder, and recurrent pyelonephritis. The patient has a history of infections with Pseudomonas aeruginosa. On day 12 status post kidney transplant, he became febrile to 38.8°C with elevated white blood cell (WBC) count of 15.77 K/µL. Urine and peripheral blood were obtained and submitted to the microbiology laboratory for aerobic culture workup. Patient was started empirically on intravenous (IV) cefepime (50mg/kg, Q8H).

Blood culture was positive 12 hours after incubation and Gram-negative bacilli visualized by Gram stain. Provider was notified and results reported in the electronic medical record (EMR) within 1 hour of positivity. Analysis using the Accelerate PhenoTest® BC kit was performed on the positive blood culture and Escherichia coli was reported in 1 hour 15 minutes. In addition to reporting in the EMR, the result was again called to the provider. An additional 6 hours 37 minutes later, susceptibility results from the Accelerate PhenoTest BC kit were reported in EMR and notified to infectious diseases pharmacist. The kit provided early detection of a multi-drug resistant E. coli that was resistant to the 3rd and 4th generation cephalosporins but susceptible to meropenem. The kit’s susceptibility result prompted modification of the patient’s antimicrobial regimen from cefepime to meropenem (20 mg/kg, Q8H) within 4 hours. The patient also grew >100,000 CFU/mL E. coli from the urine after 24 hours incubation and susceptibility testing from colony using the BD Phoenix™ system yielded an identical susceptibility profile as from blood. The susceptibility results using the Accelerate PhenoTest BC kit directly from positive blood culture were available approximately 48 hours faster when compared to conventional urine workup.

The patient was treated with a 14-day course of IV meropenem for E. coli urosepsis. He remained afebrile and relatively well-appearing without dysuria or hematuria. All subsequent blood cultures collected were negative. Due to his extremely complicated comorbidities, he had another urinary tract infection with vancomycin resistant Enterococcus faecium 17 days after initial presentation of the E. coli urosepsis and was treated with linezolid. The patient was discharged 37 days post kidney transplantation.

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