Plasma and cerebrospinal fluid concentrations of cefiderocol during successful treatment of carbapenem-resistant Acinetobacter baumannii meningitis.

BACKGROUND: To date, no real-world data are available to describe cefiderocol use in carbapenem-resistant Acinetobacter baumannii (CRAB) meningitis. Furthermore, cefiderocol pharmacokinetic (PK) data to support CNS penetration in human subjects are limited. These gaps pose a significant concern for clinicians who are faced with treating such infections when considering cefiderocol use. OBJECTIVES: To describe cefiderocol CSF and plasma PK and pharmacodynamic (PD) data from two different dosing regimens [2 g IV q6h (regimen 1) and 2 g IV q8h (regimen 2)] during treatment of CRAB meningitis. PATIENTS AND METHODS: A 61-year-old woman with CRAB meningitis was treated with cefiderocol and intraventricular gentamicin. Steady-state plasma and CSF cefiderocol concentrations were evaluated on Day 19 (regimen 1) and Day 24 (regimen 2) during the cefiderocol treatment course. RESULTS: CSF AUC was 146.49 and 118.28 mg·h/L, as determined by the linear-log trapezoidal method for regimens 1 and 2, respectively. Penetration into CSF estimated as the AUCCSF/AUCfree plasma ratio was 68% and 60% for regimens 1 and 2, respectively. Estimated free plasma and CSF concentrations exceeded the MIC of the isolate for 100% of the dosing interval. Microbiological and clinical cure were achieved, and no cefiderocol-associated adverse effects were observed. CONCLUSIONS: Cefiderocol, when given as 2 g q8h and 2 g q6h, attained CSF concentrations that exceeded the organism-specific MIC and the CLSI susceptible breakpoint (≤4 mg/L) for 100% of the dosing interval.

Hypermucoviscous Klebsiella pneumoniae: A Hypervirulent Strain Masquerading as Metastasis.

Hypermucoviscous Klebsiella pneumoniae (HvKP) is a hypervirulent strain of Klebsiella that causes metastatic spread and life-threatening infection. While it is more common among people of Asian descent, it has been increasingly reported globally among people of other ethnicities as well. We report a case of pan-susceptible HvKP infection in a male patient of Asian descent who has been living in the US for 20 years. It caused a liver abscess, perigastric abscess, perisplenic abscess, multifocal pneumonia, septic emboli, and tricuspid valve infective endocarditis. He was treated with ceftriaxone, but his septic shock was refractory, ultimately leading to death. This case highlights the severity of infection caused by this strain, and its ability to present with radiographic signs suggestive of malignancy with metastasis. This case also suggests that this strain can become pathogenic after a very prolonged period of gastrointestinal colonization.

Posterior Reversible Encephalopathy Syndrome (PRES) and Takotsubo: A Heart and Brain Affair!

Takotsubo cardiomyopathy (TC) is characterized by reversible left ventricle systolic dysfunction usually associated with stressors (physiological, psychological) being triggering factors. The increase in sympathetic activity, along with a subsequent surge of catecholamines, has been hypothesized as a possible etiology of TC. Posterior reversible encephalopathy syndrome (PRES), a relatively rare and recently recognized reversible clinico-radiological syndrome, is thought to share the same pathophysiology as TC. We present a case of an 83-year-old female who presented with seizures and was found to have PRES. Within three days of hospitalization, she developed takotsubo. She endorsed being under significant emotional stress that was thought to be the common culprit for both of her syndromes, i.e., PRES and TC.

Acute Coronary Syndrome Presenting With Hiccups.

Acute coronary syndrome can present with atypical symptoms. Hiccups, generally considered benign and self-limiting, can be an indicator of myocardial ischemia if persistent. We present the case of a 62-year-old gentleman with a past medical history significant for hypertension, type II diabetes mellitus, and ischemic stroke who presented with persistent hiccups. Coronary angiogram revealed severe triple vessel disease and he underwent coronary artery bypass graft surgery, following which his hiccups resolved. There are very few cases that report the association of hiccups and myocardial ischemia. To our knowledge, this is the first reported case in which hiccups were a part of the primary symptoms associated with severe triple vessel coronary artery disease. This could be due to irritation of the phrenic nerve from the infarcted myocardium resulting in activation of the hiccup reflex arc. Our case highlights the association between these two common entities and stresses the importance of having a high index of suspicion, especially among high-risk and elderly patients.