A patient diagnosed as having ventilator associated pneumonia, is on treatment with ceftriaxone and amikacin. Culture and sensitivity turned out to be positive for ESBL producing Klebsiella infection. The most appropriate next action should be:
Klebsiella organisms are resistant to multiple antibiotics. This is thought to be a plasmid-mediated propey. Length of hospital stay and performance of invasive procedures are risk factors for acquisition of these strains. Treatment depends on the organ system involved. In general, initial therapy of patients with possible bacteremia is empirical. The choice of a specific antimicrobial agent depends on local susceptibility patterns. Once bacteremia is confirmed, treatment may be modified. Agents with high intrinsic activity against K pneumoniae should be selected for severely ill patients. Examples of such agents include third-generation cephalosporins (eg, cefotaxime, ceftriaxone), carbapenems (eg, imipenem/cilastatin), aminoglycosides (eg, gentamicin, amikacin), and quinolones. These agents may be used as monotherapy or combination therapy. Some expes recommend using a combination of an aminoglycoside and a third-generation cephalosporin as treatment for non-ESBL-producing isolates. Others disagree and recommend monotherapy. Aztreonam may be used in patients who are allergic to beta-lactam antibiotics. Quinolones are also effective treatment options for susceptible isolates in patients with either carbapenem allergy or major beta-lactam allergy. Other antibiotics used to treat susceptible isolates include ampicillin/sulbactam, piperacillin/tazobactam, ticarcillin/clavulanate, ceftazidime, cefepime, levofloxacin, norfloxacin, moxifloxacin, meropenem, and eapenem. Treatment of Klebsiella pneumonia has discrepant results. For patients with severe infections, a clinically prudent approach is the use of an initial sho course (48-72 h) of combination therapy with an aminoglycoside, followed by a switch to an extended-spectrum cephalosporin when susceptibility is confirmed. REFERENCE: www.medscape.com
Continue same antibiotic but at higher dose
Replace ceftazidime for ceftriaxone
Remove amikacin and add quinolone
Change over to imipenem
Chemotherapy