4CPS-038 Intrapleural colistin for pleural empyema caused by extensively drug-resistant Pseudomonas aeruginosa: a case report

Background and importance

Pleural empyema (PE) is a collection of pus in the pleural space, with high morbimortality if it is caused by multidrug-resistant (MDR) bacteria. The most common cause of empyema is a primary pneumonic process. The intrapleural administration of antimicrobials makes it possible to reach therapeutic concentrations in the pleural cavity, limiting the adverse effects associated with systemic treatment.

Aim and objectives

Our aim was to describe the use of intrapleural colistin (IpC) in one patient.

Material and methods

We describe a 22-year-old woman who was admitted to the Intensive Care Unit after a lung transplant.

Results

She presented a respiratory failure, clinically and radiologically compatible with necrotising pneumonia, for which she underwent retransplantation. Multiple cavitations were observed in the explant and the culture was positive for Pseudomonas aeruginosa; treatment with intravenous (IV) ceftazidime 2 g every 8 hours was initiated. Two weeks later, PE was confirmed by growth of P. aeruginosa resistant to carbapenems in the pleural fluid and treatment was escalated to IV ceftolozane/tazobactam 2 g/1 g every 8 hours. After subsequent microbiological control, P. aeruginosa resistant to ceftolozane/tazobactam and ceftazidime-avibactam (minimum inhibitory concentration (MIC) >250 μg/mL) was observed and, therefore, IV ciprofloxacin 400 mg/12 hours and IV amikacin 15 mg/kg/24 hours were initiated. Nebulised colistin 5 million units (MIU)/8 hours was added. IpC was added due to the persistence of extensively drug-resistant (XDR) P. aeruginosa in the pleural fluid. The decision was based on a case report in which IpC was used for MDR Acinetobacter baumannii PE, with positive results; 0.5 MIU of colistimethate sodium were diluted in 50 mL 0.9% physiological saline and instilled through the pleural drains every 12 hours (clamped for 2 hours). The patient presented episodes of desaturation and sweating associated with the administration of IpC, forcing the suspension of IpC after 9 days of treatment. Finally, she died in the context of infectious disease as a consequence of refractory hypoxaemia.

Conclusion and relevance

The persistence of XDR P. aeruginosa in our patient motivated the search for alternatives and IpC was choosen on the basis of a single case. However, the efficacy could not be determined due to its poor tolerance. Despite the limited amount of published data, the administration of intrapleural antibiotics may constitute a therapeutic option.

References and/or acknowledgements

Conflict of interest

No conflict of interest