Title : MDR Pseudomonas prosthetic valve endocarditis successfully treated with Ceftazidime-Avibactam, Meropenem and Colistin combination
Abstract:
Introduction:
Pseudomonas aeruginosa is an uncommon cause of infective endocarditis (IE), accounting for less than 1% of cases, and an extremely rare cause of prosthetic valve endocarditis (PVE). Instances involving multidrug-resistant (MDR) isolates are exceedingly rare, with only a few reported cases. However, its occurrence is rising in healthcare-associated settings, particularly among patients with prosthetic valves, pacemakers, or other cardiovascular devices.
Case report:
A 52 year old female with rheumatic heart disease recently underwent Mitral valve repair with bio-prosthesis and Tricuspid valve annuloplasty. She was admitted again after 6 weeks with sensitive pseudomonas mitral valve endocarditis which was treated with valve replacement along with Ceftazidime, Amikacin and Ciprofloxacin. On day 27 Transesophageal echocardiography (TEE) demonstrated a severe paravalvular leak with early valve dehiscence for that he underwent urgent second redo-MV replacement. After 5 days of the second surgery, TEE showed there is a small mobile mass and the blood culture grew MDR Pseudomonas aeruginosa. A new regimen was initiated which included Ceftazidime-Avibactam, Meropenem and Colistin. This regimen continued for a total of 6 weeks, clinical response was observed, blood cultures became sterile again and all follow up echocardiograms did not show any masses again.
Discussion:
Data shows that over the last two decades, prosthetic valves have emerged as the predominant factor for P. aeruginosa IE. P. aeruginosa endocarditis is typically managed with combination therapy of β-Lactam antibiotic and Aminoglycoside. However, this treatment regimen is less effective against MDR strains. Our patient was treated initially with Ceftazidime, Amikacin and Ciprofloxacin for the susceptible P. aeruginosa. The patient was kept on subtherapeutic doses of antibiotics which led to the progression of the P. aeruginosa to become MDR. The combination of Ceftazidime-Avibactam, Meropenem, and Colistin is known for its synergistic effect in treatment of severe MDR gram negative infection and it has resulted in successful treatment of our patient.
Conclusion:
This report contributes to the existing literature on similar cases, showing that Ceftazidime-Avibactam, Meropenem and Colistin combination therapy is effective for treatment of MDR P. aeruginosa IE.
