Key factors around successful management of CPE infection in a patient with pancreatic collection

Carbapenemase-Producing Enterobacterales (CPE) are threat to public health as they are resistant to one of the broad-spectrum antibiotic classes (Carbapenems) in clinical use.

In this report we highlight the need for optimal choice and duration of antimicrobial therapy in combination with source control for successful management of CPE infection.

A 52-year old male was admitted under general surgery with CT confirmed severe pancreatitis. He was commenced on cefuroxime and metronidazole for associated cholecystitis based on local guidelines. Treatment was gradually escalated to Meropenem due to intermittent pyrexia and inadequate response to standard antimicrobial therapies with no obvious source control solution. Following 39 days of Meropenem the fifth CT scan showed drainable peri-pancreatic collections. The drained pus sample grew Escherichia coli and Bacteroides species. The Escherichia coli were confirmed to be CPE gene (KPC) positive by PCR and sensitive to Tigecycline and Gentamicin but resistant to Meropenem and Ciprofloxacin based on MicroScan automated sensitivity panel.

Initially Tigecycline was commenced, however, due to unsatisfactory clinical progress treatment escalated to Ceftazidime/Avibactam and Co-Trimoxazole and patient completed a three-week course. The percutaneous drain was upgraded twice to facilitate drainage. Follow-up CT showed reduction of collection and patient discharged after 115-day stay.

This case demonstrated that CPE infection should be suspected in patients with persistent fever after a prolonged course of carbapenem treatment. A prompt laboratory diagnosis and effective multidisciplinary collaboration among microbiologists, surgeons and radiologists proved to be successful in achieving source control of CPE infection in this case.