Simultaneous post-neurosurgical ventriculitis and bacteraemia by two different strains of KPC-producing K. pneumoniae successfully treated with meropenem/vaborbactam and high dose of fosfomycin.

OBJECTIVE: A case of post-neurosurgical ventriculitis caused by a KPC-producing Klebsiella pneumoniae (KPC-Kp) with a ceftazidime/avibactam-resistant, meropenem-susceptible phenotype is reported. METHODS AND RESULTS: The patient had a concomitant bloodstream infection with a wild-type KPC-Kp with a ceftazidime/avibactam-susceptible, meropenem-resistant phenotype. Prolonged treatment with intravenous fosfomycin and meropenem/vaborbactam achieved clinical success. Therapeutic drug monitoring performed during the first days of treatment showed for the first time that vaborbactam efficiently penetrates cerebrospinal fluid. In contrast, meropenem was undetectable in cerebrospinal fluid at each sampling, suggesting that additional doses of meropenem may be required to appropriately prescribe meropenem/vaborbactam for central nervous system infections. Plasma and cerebrospinal fluid levels of fosfomycin were adequate, confirming the potential of this agent possibly even in the fight against multidrug-resistant organisms. CONCLUSIONS: This case highlights the need for therapeutic drug monitoring as a crucial tool for optimizing treatment in complicated cases where the pharmacokinetic behaviour of antibiotics is difficult to predict.

Dedicated endotracheal tube for percutaneous tracheostomy.

BACKGROUND AND OBJECTIVE: Percutaneous dilational tracheostomy (PDT) is an accepted method in intensive care patients. In our neurosurgical ICU, we routinely perform PDT. We have performed 130 PDT procedures and have often observed previously reported difficulties/complications: dislocation of the endotracheal tube (ETT); frequent puncture of the ETT cuff; difficult visualization of the entire procedure because the ETT is often in the way; and risk of damaging the posterior tracheal wall due to needle puncture or rotating dilator. We believe that the rate of complications is directly related to the ability and experience of the anaesthetist carrying out the PDT. Because our hospital is a university teaching centre, PDT is often carried out by residents who are not experienced with the technique. In order to guarantee the patient's safety and to optimize the learning curve, we propose, in such circumstances, the use of a modified standard ETT. METHOD: We developed a prototype tube for percutaneous tracheostomy procedures modifying a commercially available ETT. The idea was to create a protection shield for the tracheal wall, greater stability of the ETT in the trachea and improved vision during the whole procedure. We tested the effectiveness of the prototype on a manikin model. CONCLUSION: The dedicated ETT eliminates puncturing of the ETT, rupture of the cuff and difficult direct vision. We report an optimal stability of the tube during the whole procedure and improvement in the efficacy and safety of the procedure. When residents attempt PDF for the first time, we believe that it would be safer and more practical to perform such a technique with the dedicated ETT.