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Abstract

Introduction: Hospital-Acquired Pneumonia: Is ceftaroline a viable option in critically ill patients? Chad Cannon, Calvin Tucker, Kevin Epps Ceftaroline is a fifth-generation cephalosporin and the first cephalosporin that has shown activity against MRSA. Cephalosporins work by inhibiting penicillin-binding proteins (PBPs), which inhibit the third and final stage of transpeptidation. Ceftaroline has strong affinity for PBP2a and PBP2x contributing to its spectrum of activity against Methicillin-Resistant Staphylococcus aureus (MRSA) and Streptococcus pneumonia. Ceftaroline is approved by the FDA for treatment for community-acquired pneumonia and complicated skin and skin structure infections. We report a case of a 37-year-old woman who complains of lower extremity swelling that has gradually progressed over the past week, shortness of breath, and dizziness. Patient has past medical history significant for diastolic heart failure and asthma. Previous hospital records show last hospitalization of more than a year in which patient received no antibiotics. Patient went into respiratory failure on second day of hospitalization and thus required intubation. Patient had blood cultures and sputum cultures that were negative during first week of intubation. However, a second set of sputum cultures that were taking four days later were positive for gram-positive cocci and gram-negative rods. Also, chest x-ray showed increasing opacities in the right mid and lower lung region. Patient had persistent fever of 38.2° C, elevated WBC of 13.9 k/mcl, with increasing ventilator setting of volume support with FIO2 50%. Patient was empirically started on vancomycin loading dose 2 grams intravenous (iv) and then maintenance dose 1250 mg iv q12hrs, piperacillin/tazobactam 4.5 gram iv q8hr extended infusion over 4 hours, and meropenem 500 mg iv q6hr. Sputum cultures sensitivities two days later found to have "pan-resistant' Pseudomonas aeruginosa, MRSA with vancomycin MIC 1 mcg/ml, and Klebsiella pneumonia that was "pan-sensitive". Patient still had persistent fevers 38.1 °C and increasing WBC 21.3 k/mcl. Infectious disease was consulted and ordered ceftaroline 600 mg iv q12hrs and amikacin 1400 mg iv q24hr. Therapy was changed before dose received to linezolid 600 mg iv q12h, colistimethate 125 mg iv q12hrs, and meropenem 2 gm iv q8hrs extended infusion over 3 hours. Microbiology performed E-test on colistin, vancomycin, and ceftaroline. Pseudomonas aureginosa was found to have MIC 1.5 mcg/ml to colistin, vancomycin MIC 1.5 mcg/mL to MRSA, and ceftaroline MIC > 32 mcg/mL to MRSA. After, five days of therapy, patient was afebrile; WBC 11.1 k/mcl, x-ray showed slight improved aeration of the left upper lung, ventilator support decreased to assist control with FIO2 40%, and sputum culture with no growth. This case report brings into question whether ceftaroline should be an option for patients who are critically ill in the intensive care unit (ICU). We present a patient, from previous hospital records, with no known antibiotic history or hospitalization in the previous year. This case shows the importance of performing MICs on all antibiotics to determine organisms' sensitivities. To our knowledge, this is the first case of resistant ceftaroline and the first E-test resistance confirmed by the microbiology lab to ceftaroline in our hospital. This case may bring into question practitioners usage of ceftaroline for hospital-acquired pneumonia in critically ill patients.