Gram-negative Galore and the Gut

An 81-year-old diabetic man with PAF, pleural thickening due to benign fibrous pleuritis and a PPM developed rigors/pyrexia (39°C) with no localising signs of infection. Blood cultures grew Pseudomonas aeruginosa (May 2017) and Enterococcus faecalis (November 2017), MSU was negative and imaging was normal. Readmitted in May 2018 and discharged clinically well with CRP 40 and no acute abnormalities on investigations, he returned with further rigors the following day with E. coli and Enterococcus faecium bacteraemia, treated with Tazocin/Tigecycline. CT colonography revealed a primary recto-sigmoid tumour with high-grade dysplasia on biopsy. In July 2018,he developed a Pseudomonas aeruginosa bacteraemia responding to Tazocin/Ciprofloxacin. Planned surgery was delayed due to anaesthetic instigated pre-operative cardiac rehab optimisation. In August 2018, further rigors/pyrexia were empirically treated with Tazocin/Teicoplanin/Amoxicillin for 3 weeks covering a Staph epidermis/capitis bacteraemia. He underwent an open Hartmann’s with total mesorectal excision two weeks later, complicated by pre-sacral collections drained transcutaneously. Suboptimal antibiotic cover however led to further pseudomonas bacteraemia three weeks later and pseudomonal bacterial peritonitis three months later, managed with prolonged meropenem/ciprofloxacin therapy. TTE two months post-discharge showed a 1cmx0.5cm mass on the RV lead of his pacemaker leading to its removal. Repeat TTE showed tricuspid valve endocarditis with a 2.2cmx0.3cm mobile mass and severe TR. Six weeks of Meropenem therapy achieved sterilisation without further complications. Infectious diseases specialist input should be sought early and can be pivotal in appropriate source control and adequate antibiotic management following organism identification.