Treatment of invasive IMP-4 Enterobacter cloacae infection in transplant recipients using ceftazidime/avibactam with aztreonam: A case series and literature review.

Infections caused by carbapenemase-producing Enterobacteriaceae (CPE) are an emerging threat in both solid organ and stem cell transplant recipients. Invasive CPE infections in transplant recipients are associated with a high mortality, often due to limited therapeutic options and antibacterial toxicities. One of the most therapeutically challenging group of CPE are the metallo-ß-lactamase (MBL)-producing Gram-negative bacteria, which are now found worldwide, and often need treatment with older, highly toxic antimicrobial regimens. Newer ß-lactamase inhibitors such as avibactam have well-established activity against certain carbapenemases such as Klebsiella pneumoniae carbapenemases (KPC), but have no activity against MBL-producing organisms. Conversely, aztreonam has activity against MBL-producing organisms but is often inactivated by other co-existing ß-lactamases. Here, we report four cases of invasive MBL-CPE infections in transplant recipients caused by IMP-4-producing Enterobacter cloacae who were successfully treated with a new, mechanism-driven antimicrobial combination of ceftazidime/avibactam with aztreonam. This novel antimicrobial combination offers a useful treatment option for high-risk patients with CPE infection, with reduced drug interactions and toxicity.

Renal safety of short-term empiric gentamicin therapy in aged patients.

OBJECTIVE: To determine the incidence of acute kidney injury (AKI) in aged patients receiving empiric gentamicin therapy. METHODS: Patients aged ≥65 years receiving gentamicin upon admission between 2013 and 2015 at two Australian hospitals were retrospectively studied. AKI was defined as a rise in creatinine by ≥50% and/or ≥26.5 µmol/L. RESULTS: Most patients (95%) received a single dose of gentamicin. The incidence of AKI was 15% (36/242 patients). A composite outcome of persistent kidney injury, requirement for renal replacement therapy or inpatient death in a patient with AKI occurred in 10 (4%) patients. Patients who developed AKI were older (median 80.5 vs 78 years, P = 0.03), had higher Charlson Co-morbidity Index (median 7 vs 5, P = 0.0004) and had more advanced chronic kidney disease at baseline (Stages IV and V) (OR 4.38, 95% confidence interval 1.45-13.2, P = 0.01). CONCLUSION: Empiric gentamicin use in patients with advancing age is associated with low rates of predominantly transient renal impairment.

The longitudinal effects of peritonitis on peritoneal membrane function
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BACKGROUND: The longitudinal effects of peritoneal dialysis (PD) peritonitis on small solute clearance and ultrafiltration are controversial. MATERIALS AND METHODS: We identified 27 patients with PD peritonitis over a 4-year period at a tertiary hospital. Adequacy tests at an "early" (1 - 3 months), "intermediate" (6 ± 2 months), and a "late" (12 ± 2 months) time period after the episode were compared with a pre-peritonitis baseline. The effect of time on serum albumin, weekly creatinine clearance, Kt/V, and net fluid volume removal was assessed. RESULTS: At 12 months, 16/27 (59.3%) patients were no longer on PD. Ten were transferred to hemodialysis, predominantly due to peritonitis (60%). Five patients died, and 1 received a renal allograft. Total daily fluid volume removal significantly decreased over time with an aggregated mean reduction of 523 mL/day between the baseline and 12-month test (1,624 ± 139 mL vs. 1,101 ± 160 mL; p = 0.02). This was due to an equivalent loss of both ultrafiltration and residual urine output, although the separate decline in these individual parameters was not statistically significant. There was no significant change in Kt/V, creatinine clearance, or serum albumin indicating preserved solute transport in those patients with sustained technique survival post peritonitis. CONCLUSION: Peritonitis is a common cause for transfer to hemodialysis. Fluid volume removal is the most significantly affected parameter at 12 months post peritonitis, driven by the combination of both ultrafiltration reduction and loss of residual diuresis. Clinicians should be aware that peritonitis identifies patients at high risk for technique failure. These findings should prompt clinicians to closely surveil volume status and consider backup dialytic strategies as early as 12 months post peritonitis.
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Listeria monocytogenes peritonitis in an HIV-infected patient.

We report the first case of Listeria monocytogenes peritoneal dialysis (PD) peritonitis in a human immunodeficiency virus-infected individual successfully treated with intraperitoneal ampicillin, without the need for catheter removal. Suspicion of listerial infection in at-risk individuals is critical as empiric antimicrobial treatment for PD-associated infections may be ineffective against this organism.

Ibuprofen-induced renal tubular acidosis-a rare cause of rhabdomyolysis: a case report.

Ibuprofen is widely used in the community to manage pain, inflammation and fever. In cases of prolonged and supratherapeutic ingestion of ibuprofen, renal tubular acidosis (RTA) with profound hypokalemia may occur. Although hypokalemia is known to cause rhabdomyolysis, rhabdomyolysis occurring in the setting of ibuprofen-induced RTA is rare. We present an unusual case of a 34-year-old male who presented with rhabdomyolysis in the setting of profound hypokalemia as a result of ibuprofen-induced RTA. The patient was successfully treated with fluid resuscitation, electrolyte replacement and supportive therapy. This case demonstrates a serious complication of ibuprofen and the importance of monitoring in nonprescription medications.