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EDUCATIONAL WORKSHOPS 2009

Sponsored through an unrestricted educational grant from Novartis Pharmaceutical Ltd to help support the cost of developing and hosting this educational workshop series . Background. 65 y old malePast history of hypertension and cerebro-vascular diseaseJuly 2003Aortic aneurysm and complicationsEndovascular aortic aneurysm repair (EVAR)post-operative bleed requiring laparotomyparaparesis secondary to spinal cord ischaemialong term suprapubic catheterlongstanding sacral pressure sores.

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EDUCATIONAL WORKSHOPS 2009

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    2. Sponsored through an unrestricted educational grant from Novartis Pharmaceutical Ltd to help support the cost of developing and hosting this educational workshop series

    3. Background 65 y old male Past history of hypertension and cerebro-vascular disease July 2003 Aortic aneurysm and complications Endovascular aortic aneurysm repair (EVAR) post-operative bleed requiring laparotomy paraparesis secondary to spinal cord ischaemia long term suprapubic catheter longstanding sacral pressure sores

    4. July 2007 Admitted with fever four years after aneurysm repair Blood cultures MRSA (isolate 1) X-ray pelvis and transoesophageal echocardiogram (TOE) � normal 2 weeks iv vancomycin plus oral rifampicin, then stopped Question: What was the source of infection? How would you have treated it?

    5. July 2007 5 days later- pyrexia MRSA again in blood cultures (isolate 2) Re-started vancomycin plus rifampicin for 4 weeks Home on doxycycline plus rifampicin for a further 4 weeks

    6. November 2007 re-admitted with fever and back pain after 9 days at home Blood cultures MRSA (isolate 3) Transthoracic echocardiogram (TTE) � normal Magnetic resonance imaging (MRI) spine - normal WCC scan suggestive of increased uptake in lower vertebra 1 week vancomycin, then MIC for MRSA strain reported as 3 mg/L intravenous linezolid for 10 days, then home on further 4 weeks oral

    8. Population analysis of GISA

    9. January 2008 re-admitted in septic shock, day 38 linezolid MRSA in blood (isolate 4) intravenous daptomycin - five fold rise in CK, therefore stopped (was on a statin at the same time) blood cultures MRSA (isolate 5) Quinupristin/dalfopristin plus fusidic acid for 12 weeks

    10. Late February 2008 Blood cultures sterile by week 3 of quinupristin/dalfopristin plus fusidic acid inflammatory markers settling Computerised axial tomography (CT) scan at week 7 � �increased thickness of aneurysm wall compared to previous scans�

    12. April 2008 Cardiothoracic review - no surgical intervention indicated 11 weeks into quinupristin/dalfopristin treatment septic again ESBL-producing E. coli in urine and femoral line tip meropenem for 10 days quinupristin/dalfopristin discontinued end of 12 weeks blood cultures just before quinupristin/dalfopristin stopped MRSA (isolate 6)

    13. April 2008 Quinupristin/dalfopristin re-started (1 week later) plus daptomycin 4mg/kg CK levels remain normal 2 weeks - Quinupristin/dalfopristin switched to gentamicin and daptomycin dose increased to 10mg/kg new femoral line

    14. Mid-July 2008 Gentamicin stopped after 4 weeks MRSA bacteraemia persists (isolate 7) 8 weeks into daptomycin treatment - progressive rise in MIC daptomycin MIC 0.125 mg/L initially, but peaked at 12.0 mg/L Isolates now also resistant to rifampicin and fusidic acid Positron emission tomography (PET) scan confirms aortic graft infection

    16. End-July 2008 Aortic graft replaced Cultures of graft are negative, but S. aureus identified by 16s rDNA PCR Given iv linezolid, then oral fosfomycin, doxycycline plus chloamphenicol for 4 weeks End-August 2008 switched to oral doxycycline alone 12 sets of blood cultures negative as at 1 Oct 2008

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