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Reminder of important clinical lesson
CASE REPORT
Two for the price of one: emerging carbapenemases in a returning traveller to New York City
  1. Jaimie Mittal1,
  2. Wendy A Szymczak1,
  3. Yi Guo1,
  4. Michael H Levi1,
  5. Liang Chen2,
  6. Barry N Kreiswirth2,
  7. Paul F Riska1,
  8. Priya Nori1
  1. 1Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
  2. 2Public Health Research Institute Center, NJMS-Rutgers University, Newark, New Jersey, USA
  1. Correspondence to Dr Jaimie Mittal, jaimie.mittal{at}outlook.com

Summary

We report a case of a complex orthopaedic infection in a patient returning to New York City from Bangladesh where he was involved in a serious motor vehicle accident. He developed extensive osteomyelitis with a carbapenem-resistant Klebsiella pneumoniae. The isolate was unique due to the coexistence of New Delhi metallo-β-lactamase-1 and Oxacillinase type-181 carbapenemases, which are relatively uncommon in North America and were presumably acquired in Bangladesh. Herein, we explore challenges associated with management of carbapenem-resistant Enterobacteriaceae infections, including limited available data on effective antimicrobial therapy. We also highlight the added value of rapid diagnostic technology in guiding clinical management. Ultimately, the patient required both aggressive surgical management and combination therapy with aztreonam and ceftazidime-avibactam for true source control and favourable clinical outcome.

  • infections
  • bone and joint infections

https://doi.org/10.1136/bcr-2018-225440

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    Footnotes

    • Contributors JM, WAS, YG and MHL were actively involved in acquisition of data for the case, drafting the article, producing the figures and collecting and interpreting background research including cases and relevant papers. WAS and MHL were also involved with and performed the synergy testing on the isolate and provided assistance with getting testing performed by the NYSDOH. LC and BNK performed genome sequencing of our isolates, and they were part of drafting, researching and editing this manuscript. Finally, PFR and PN were also integral to the conception of the case, drafting and editing and assisted with background research. They were also the leaders of our group and coordinated our efforts and testing of the isolates. All the authors approve of this final version and agree to be held accountable and ensure that all questions regarding accuracy or integrity of the article are investigated and resolved promptly.

    • Funding This work was in part supported by the following grants from the National Institute of Allergy and Infectious Diseases R01AI090155, R21AI135250 and R21AI117338.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.