Post-ERCP Multi-Drug Resistant Acinetobacter baumannii Bacteremia

Abstract

Introduction: Bacteremia is a rare complication of endoscopic retrograde cholangiopancreatography (ERCP) and biliary stenting. The present report describes fatal bacteremia due to multidrug-resistant A. baumannii in a post-ERCP patient. Case Presentation: An 85-year-old woman with a history of diverticulosis, hypertension, left hip arthroplasty and gout was admitted to our hospital with a 1-week history of jaundice, lethargy, confusion. Her initial vital signs were within normal ranges. Icteric sclera were noted on physical examinations and the rest was unremarkable. Significant findings on laboratory tests were white blood cell count 13,400/μL; total bilirubin 6.2 mg/dL; AST 248U/L; ALT 185 U/L; and alkaline phosphatase 617 U/L. A CT scan of the abdomen revealed a large obstructing stone and ascending cholangitis (Figure 1). Patient was empirically started on antibiotics. Patient underwent two ERCPs to extract stones. Biliary stent was placed during the second procedure. One day after the procedure, patient developed septic shock. Antibiotics were switched to intravenous meropenem and levofloxacin. She was intubated and required maximum vasopressor supports for refractory shock. Five out of 5 sets of blood cultures and bile culture grew multidrug-resistant Acinetobacter baumannii. Intravenous tigecycline was added on day 10 and parenteral colistin replaced meropenem after final sensitivity reports returned. Blood cultures drawn after administration of colistin remained sterile; however, the patient could not recover from septic shock. Discussion: Bacteremia is a rare but well-documented complication following endoscopic retrograde cholangiopancreatography (ERCP). According to a recent prospective, observational study following a total of 2,052 ERCPs, 46 cases of bacteremia were detected after ERCP (incidence rate of 2.24/100). The most commonly isolated pathogens were Enterobacteriaceae and Enterococci. Acinetobacter baumannii is an aerobic gram-negative rod. It is an important pathogen of nosocomial infections including sepsis and ventilator-associated pneumonia. Management of Acinetobacter baumannii infections can be challenging to clinicians because of its resistance to common antibiotics. Colistin and tigecycline have been utilized in the treatment of resistant pathogens. Considering the significant nephrotoxicity of colistin and emerging resistance to tigecycline of A. baumannii as in our case, developing newer antibiotics against multidrug-resistant A. baumannii are needed. Also, gastroenterologists should take into consideration the risk of bacteremia and sepsis caused by hospital-acquired resistant pathogens whenever performing invasive procedures such as ERCP.Figure: [735] Acinetobacter Calocoaceticus Baumanii Complex sensitivity