Abstract
Streptococcus intermedius occasionally causes brain abscesses that can be life-threatening, requiring prompt antibiotic and neurosurgical treatment. The source is often dental, and it may spread to the eye or the brain parenchyma. We report the case of a 34-year-old man with signs of apical periodontitis, endophthalmitis, and multiple brain abscesses caused by Streptococcus intermedius. Initial treatment with meropenem and vancomycin was unsuccessful due to subtherapeutic concentrations, despite recommended dosages. Adequate concentrations could be reached only after increasing the dose of meropenem to 16 g/day and vancomycin to 1.5 g × 4. The patient exhibited high creatinine clearance consistent with augmented renal clearance, although iohexol and cystatin C clearances were normal. Plasma free vancomycin clearance followed that of creatinine. A one-day dose of trimethoprim–sulfamethoxazole led to an increase in serum creatinine and a decrease in both creatinine and urea clearances. These results indicate that increased tubular secretion of the drugs was the cause of suboptimal antibiotic treatment. The patient eventually recovered, but his left eye needed enucleation. Our case illustrates that augmented renal clearance can jeopardize the treatment of serious bacterial infections and that high doses of antibiotics are needed to achieve therapeutic concentrations in such cases. The mechanisms for regulation of kidney tubular transporters of creatinine, urea, vancomycin, and meropenem in critically ill patients are discussed.
Highlights
Augmented renal clearance (ARC), defined as a measured creatinine clearance >130 ml/min/1.73 m2, is increasingly being recognized in critically ill patients
The clearance values were normalized to standard body surface area of 1.73 m2 calculated from height and weight according to Dubois and Dubois Reference intervals: Rodvold et al (1988) Clearance of healthy subjects Method: Blood samples for vancomycin concentrations were collected shortly before the dose, immediately after the two hour infusion, and at 3, 4, and 6 hours after the start of the infusion, and as a trough sample before dose
A recent case report described how S. constellatus of dental origin caused endophthalmitis and brain abscesses (Chheda et al, 2011), and endogenous endophthalmitis caused by S. intermedius has been described after routine dental practice (Mali et al, 2015)
Summary
Augmented renal clearance (ARC), defined as a measured creatinine clearance >130 ml/min/1.73 m2, is increasingly being recognized in critically ill patients. The condition can lead to subtherapeutic concentrations of renally excreted drugs. The case-patient presented with low serum creatinine concentrations and high creatinine clearance, leading to the diagnosis of ARC. The pathophysiology of ARC is unknown, but high cardiac output, increased tubular creatinine secretion, and hormonal effects have been suggested. We report a patient with S. intermedius infection, endogenous endophthalmitis, and septic embolization to the CNS, arising from a dental infection. Increased drug elimination due to ARC resulted in subtherapeutic antibiotic drug concentrations until high doses were administered. The purpose of this case report is to illustrate the possible causes for rapid elimination of the drugs
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