Successful Management of a Septic Shock Caused by Acinetobacter baumanii XDR in a Young Heart Transplant Patient

Introduction

In recent years, Acinetobacter baumannii (Acb) has emerged as a particularly challenging drug-resistant pathogen, but it has rarely been studied in solid organ transplanted patients.

Case Report

We present the case of a 21-year-old female patient who was admitted to our centre for severe cardiac failure due to post-cardiotomy shock. V-A ECMO and Impella were implanted. On admission, the patient presented a SOFA score of 11, an APACHE II score of 24 and a MODS score of 10, with predicted mortality of 50%. Pre-operative blood cultures resulted positive for Acb XDR, with meropenem MIC of 8 mg/l (R) and colistin MIC of 0.25(S). Specific antibiotic therapy with Colistin (4,5 MU x 2/die) and Meropenem (6g i.c. 12.5 ml/h) was started. As general conditions deteriorated, the patient underwent salvage heart transplant (HT).Before HT, in order to reduce the systemic inflammatory response and prevent the multi-organ dysfunction, a CytoSorb cartridge was mounted in the ECMO circuit for 24 h to remove cytokines from the blood. The following day, PCT, CRP and myoglobin started to decrease whereas WCC remained stable. Seven days after HT, the patient developed septic shock with severe hypotension nonresponsive to vasopressors: endotoxin blood level was high (0.72 at EAA). This time, 2 cycles of Toraymyxin hemo-filtration were applied for 48 h. Clinical conditions started to steadily improve, with the reduction of PCR, PCT, WCC levels and body temperature; vasopressor and inotrope dosages were decreased (Tab.1). After 23 days, the patient was transferred to the ward. On the 45th day, the first negative blood culture was obtained, and 20 days later, antibiotic therapy was interrupted. The patient was discharged 6 months after HT. She is reported fine at 27 months of follow-up.

Summary

In this case report, the combined use of Cytosorb, Toraymixyn, targeted antibiotic therapy based on the antibiogram, and modulation of immunosuppressant therapy proved effective in managing such a complex clinical situation.