Acinetobacter baumannii bacteremia, a rare complication of endoscopic retrograde cholagiopancreatography!
The present case report is about an 85-year-old female patient with a history of diverticular disease, hypertension, left hip arthroplasty and gout was admitted to our hospital with a 1-week history of jaundice, lethargy, confusion and multiple episodes of falls. She denied any fever or abdominal pain.\nHer initial vital signs were: Blood pressure 92/68 mmHg, temperature 98.0°F and pulse rate 86/min. Icteric sclera was noted. The rest of the physical examination including neurological system, skin, throat, chest and abdomen was normal. Murphy's sign was absent.\nSignificant laboratory findings included white blood cell count, 13,400/μL (4-11/μL) (differential counts of 81% neutrophils, 8% lymphocytes, 6% monocytes); hemoglobin, 13.8 g/dL (12-15.3 g/dL); platelet count, 268,000/mL (150-450/mL); blood urea nitrogen 39 mg/dL (6-26 mg/dL); creatinine 1.57 mg/dL (0.5-1 mg/dL); total bilirubin 6.2 mg/dL (0-1 mg/dL); aspartate aminotransferase 248 U/L (0-32 U/L); alanine aminotransferase 185 U/L (0-40 U/L); and alkaline phosphatase 617 U/L (35-104 U/L).\nA computed tomography scan of the abdomen [Figures and ] revealed a 1.8 cm obstructing stone in a distal common bile duct. The patient was empirically started on intravenous levofloxacin and metronidazole. Two days after her admission, she underwent ERCP. The procedure was terminated due to profuse bleeding following papillotomy. The stone was not extracted. Initial blood cultures did not grow any pathogen.\nAt 4 days after her hospitalization, the patient underwent a second ERCP []. Pieces of stones were extracted and a stent was placed in the common bile duct. One day later, the patient became lethargic and developed a fever of 100.8F. The next morning, the patient deteriorated further with a blood pressure of 76/46 mmHg, pulse rate of 104 beats/min, respiratory rate of 25 breaths/min and oxygen saturation was 94% on 6 L nasal cannula with other clinical evidence of shock believed to be secondary to sepsis.\nAntibiotics were switched to intravenous meropenem 500 mg twice daily with intravenous levofloxacin 750 mg. The next day, blood cultures revealed Gram-negative rods.\nOn day 9, she required intubation and mechanical ventilation for respiratory failure with the addition of maximum vasopressor support for refractory shock. Percutaneous cholecystostomy was performed on day 10 and 5 mL of thick brown fluid was aspirated.\n5 out of 5 sets of blood cultures as well as culture of biliary fluid grew A. baumannii, resistant to almost all antibiotics including piperacillin/tazobactam, meropenem and levofloxacin. Intravenous tigecycline 50 mg every 12 h was added and parenteral colistin 75 mg every 12 h replaced meropenem based on the final sensitivity reports. Blood cultures drawn after the administration of colistin remained sterile. However, the patient did not recover from septic shock. After discussing the goals of care, her family opted for withdrawing medical management and pursuing comfort measures instead.