CASE REPORT

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Innovations in STEAM: Research & Education

ISSN (print): 3105-7071; ISSN (online): 3105-708X

Volume 1; Issue 2; Article No. 23010201

https://doi.org/10.63793/ISRE/0006

Case Report on Multi-Drug Resistance Urosepsis in 19-Year-Old Female

Noor Ul Ain¹, Aqsa Shakoor², Razzia Tehreem², Eman Aftab², Javeria Akhtar¹, Eman Fatima¹, Seerat Iftikhar¹

¹Department of Pharmacology, Government College University Faisalabad, Pakistan

²Department of Pharmacy, The University of Faisalabad, Pakistan

METADATA Paper history Received: 20 February 2023 Revised: 21 May 2023 Accepted: 15 August 2023 Published online: 28 September 2023 Corresponding author Email: ananoorkhan105@gmail.com (Noor Ul Ain) Keywords Colistin UTI MDR Urine culture Bacteria Citation Noor Ul Ain, Shakoor A, Tehreem R, Aftab E, Akhtar J, Fatima E, Iftikhar S (2023) Case report on multi-drug resistance urosepsis in 19-year- old female. Innovations in STEAM: Research & Education 1: 23010201. https://doi.org/10.63793/ISRE/0006

ABSTRACT Background: Multiple drug resistance (MDR) has emerged as a serious consequence of the overuse of antibiotics. Kidney stone disease results from the formation of crystalline aggregates of urinary solutes within the kidney or urinary tract. In some cases, the stone moves into the ureter, requiring a ureteral stent replacement procedure for management. However, the use of unsterilized equipment during such procedures can lead to urinary tract infections (UTIs). Objective: This case study highlights the development of MDR Pseudomonas aeruginosa following the treatment of a UTI in a patient undergoing ureteral stent replacement. Method: The patient developed a UTI post-procedure, confirmed through urine culture, which identified Pseudomonas aeruginosa as the causative agent. Multiple antibiotics were administered to control the infection. Results: Despite antibiotic therapy, the patient's condition did not improve. A subsequent urine culture revealed the development of MDR due to the excessive use of antibiotics. Most antibiotics tested showed resistance, with only colistin remaining effective. Treatment with colistin was initiated and continued for 14 days. Follow-up results indicated complete bacterial inhibition and no further infection progression, leading to the patient's stable condition. Conclusion: This case underscores the importance of rational antibiotic use and proper sterilization techniques to prevent MDR infections, especially in patients undergoing invasive procedures such as ureteral stent placement.

INTRODUCTION

The emergence of multidrug-resistant (MDR) bacterial infections has become a critical global health concern, posing serious challenges to healthcare systems. MDR infections are associated with prolonged hospital stays, increased healthcare costs, and higher mortality rates (Wartu et al. 2019). Of particular concern is MDR urosepsis, a life- threatening condition that originates in the urinary tract and spreads into the bloodstream (Porat et al. 2023). This condition is difficult to manage due to the resistance of the causative bacteria to multiple antibiotics, leaving limited treatment options. Although carbapenems remain the cornerstone of current treatment strategies, their overuse has resulted in growing resistance. Alternative therapeutic options such as beta-lactam/beta-lactamase inhibitor

combinations, cefiderocol, polymyxins, aminoglycosides, and fosfomycin have been explored as potential treatments (Kunz Coyne et al. 2022).

The rise of antibiotic-resistant microorganisms represents one of the greatest threats to modern medicine. The overuse and misuse of antibiotics, combined with the rapid spread of resistance genes among bacterial populations, have significantly contributed to the global burden of MDR infections. Previously, antibiotic-resistant strains were largely confined to nosocomial (hospital-acquired) infections; however, these resistant strains have now become widespread in both community and healthcare settings, infection control measures to prevent the spread of resistant pathogens affecting both Gram-positive and Gram-negative bacterial species (McKinnon et al. 2018; Walker et al. 2022).

Kidney stone disease, also known as nephrolithiasis or

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urolithiasis, is a common urological disorder characterized by the formation of crystalline aggregates of urinary solutes within the kidney or urinary tract. The pathogenesis, risk factors, and management options for kidney stones vary considerably. They may put a stent into one or both ureters, depending on the reason for the stenting. Allow urine to bypass a kidney stone (renal calculi) that slows or stops urine flow (Guliciuc et al. 2021). This stenting procedure Prevent a new blockage from developing after kidney stone treatment. Prevent a blockage from postoperative swelling after the removal of kidney stone. Due to nonsterile instruments used during procedure may lead to MDR urosepsis. It is caused by multidrug-resistant bacteria, is a very serious medical condition where a urinary tract infection (UTI) spreads to the bloodstream. MDR bacteria are resistant to multiple antibiotics, making treatment more challenging and potentially increasing the risk of severe complications like organ failure, sepsis-induced shock, and death. It poses a significant Danger due to the difficulty in finding effective antibiotics to treat the infection. Treatment options may involve using a combination of antibiotics or newer antimicrobial agents. Diagnosis was made in 2107 (7.7%) cases amongst 27,542 patients screened. Microbiological proof of infection was available in 1606 (5.8%) cases. In total,

408 patients had microbiologically proven urosepsis (Petrosillo et al. 2020).

Cases were registered from Europe (n: 311–76%), Asia (n: 66–16.1%), Africa (n: 21–5.1%) and USA (n: 10–2.4%).

Type of hospital cases were registered from university (n: 228– 56%), teaching (n: 107–26%), district (n: 69–17%) and others (n: 4–1%). Mean age of patients with urosepsis was 63 ± 17 years, and the female-to-male ratio was 3:7. An intervention prior to the episode of urosepsis was reported in 324 (79%) cases (clean: n: 77–24%, clean contaminated: n: 99–31%, clean contaminated with bowel segments opened: n: 57–18%, contaminated: n: 28–9%, infected: n: 63–19%, missing: n: 2). A urinary catheter at the time of diagnosis was present in 287 (70%) cases, and urinary tract obstruction was reported in 234 (57%) cases. Urolithiasis was reported in 20% (n: 76, missing n: 21) of cases (Rozwadowski and Gawel 2022).

Given the growing burden of MDR urosepsis, particularly among patients with underlying urological conditions such as kidney stones, there is an urgent need to promote rational antibiotic use and implement stringent.

CASE PRESENTATION

A 20 year old female presented in emergency department of private setup with symptoms of high-grade fever, chill, nausea, vomiting. And difficulty in urinating and from last 3 days there is moderate obstruction in urinating. Also, she had Right flank pain radiating to the groin from last 4 days. Patients’ past history has shown that the patient is suffering from kidney stones from the last 4 years. According to the physical examination the patient’s blood pressure is 140/90 mmHg, pulse 112 bpm, and body temperature is more than

37.5^oC. A ureteral stent was placed to relieve the obstruction of urine and allow the urine to pass from the kidney to the bladder. The stone is removed, and the discomfort of the patient was reduced. But after 3 days of ureteral stent placement the patient had high grade fever, and also have symptoms includes: nausea chill and vomiting. She was again presented to the same setup and was admitted to hospital again due to her severe condition. Empirically she was treated with paracetamol (infusion 1 g/100 mL) and some other antibiotics. After few days when she was not recovered Ultrasound and X-ray imaging examination again perform and show that infection begin in the ureter where the ureter stent placement performs. The reason behind is that during stent placement the equipment that are used are not fully sterilize. So, due to no sterility of the equipment the UTI infection begins. According to the abdominal examination there is tenderness in the right flank and costovertebral angle. Ultrasound and X-ray imaging examinations shows that there is a 13mm stone in her right kidney and in left kidney there is 11mmstone at start she was treated with the pain management and hydration. Alpha blockers were prescribed to facilitate the the stone passage. The patient was subsequently treated with Cefixime 400 mg, paracetamol (1 g/100 mL infusion), diclofenac, amikacin sulfate, ceftriaxone sodium, meropenem, multivitamins, antiemetics, and moxifloxacin. She showed partial improvement and was discharged home. However, a few months later, she presented to the emergency department again in a worsened state.

A urine culture was performed, which after 48 h of incubation, identified Pseudomonas species (Fig. 1–2). Her condition had significantly deteriorated, and due to the excessive and prolonged use of antibiotics, she had developed multiple drug resistance (MDR). Only a limited number of antibiotics showed susceptibility. Her treatment was adjusted based on the antibiotic susceptibility results, which initially produced some improvement. However, a repeat urine culture revealed that only Colistin remained effective against the isolated bacterial strain. The patient was started on Colistin, and iron supplementation (Sangobian) was prescribed to support her overall health. Despite this, her condition remained suboptimal.

Investigations

Laboratory investigations confirmed complete resistance to several antibiotics, including Amikacin, Aztreonam, Ciprofloxacin, Imipenem, Meropenem, Ceftazidime, and Levofloxacin. The urine culture indicated that Colistin was the only remaining effective option. To further assess the extent of the infection, a CT-KUB (Kidney, Ureter, and Bladder) scan was performed (Fig 3). The scan revealed the presence of infectious material and pus accumulation, prompting the recommendation for another ureteral stent placement to relieve the obstruction. Additional laboratory results showed a significantly elevated serum parathyroid hormone (PTH) (Fig. 4) level of 649 pg/mL. A parathyroid

Fig. 1: Ultrasound reports of renal calculi

Fig. 2: Culture report and repeated antibiotic sensitivity for P. aeruginosa

Fig. 3: Report of CT-KUB and serum PTH (649)
Fig.4: Parathyroid scan
Fig. 5: Pre-operative CBC reports	Fig. 6: Post-operative urine report
Fig. 7: Post-operative urine report	Fig. 8: Post-operative medications

Fig. 9: Culture report for Pseudomonas aeruginosa after medication alteration

scan confirmed parathyroid dysfunction

Treatment

During her hospital stay, the patient received Colistin (2 mg) twice daily for 14 days. Follow-up laboratory tests showed significant improvement, with bacterial growth successfully inhibited. Renal function improved, as reflected by normalization of creatinine levels and estimated glomerular filtration rate (eGFR). Her white blood cell (WBC) count decreased from 17,000 to 9,000. The treatment plan was continued, and based on her laboratory and imaging results, a multidisciplinary approach was adopted. A stepwise treatment protocol was implemented, which included surgical removal of the overactive parathyroid gland, responsible for hypercalcemia and recurrent kidney stone formation. In the same surgical session, laser lithotripsy was performed to remove the kidney stones, both procedures conducted under a single anaesthesia. Following surgery, the patient showed gradual clinical improvement (Fig. 5–9).

DISCUSSION

Multi drug resistance is a sever condition in which the patient develop resistance to the antibiotic because of the excessive use. Multidrug resistance (MDR) is a kind of acquired resistance of microorganisms and cancer cells to chemotherapeutic drugs that are characterized by different chemical structures and different mechanisms of action (Linhares et al. 2015). Urolithiasis is a disorder that is characterized by the development of solid crystalline aggregates of urinary solutes within the urinary space of the kidney. Her are the number of treatments to treat the kidney stone. For the ureteral obstruction the ureteral stent placement is used now day other procedures are also used to treat ureteral obstruction (Parajuli et al. 2017). Here we discuss the case report of a patient who had ureteral obstruction. Ureteral stent placement is used for treatment but due to non-sterile conditions of the equipment’s the patient develops Urosepsis. And due to excessive use of the antibiotics the patient develops antibiotic resistance. Patient is badly affected and in critical condition. From this case

presentation we can assure that the effect of colistin has shown to the bacteria without any severe adverse effects leading to a progressive treatment (Babar et al. 2021).

Overall, this case illustrates the growing threat of MDR in urological settings and highlights the significance of infection control practices and antibiotic stewardship in preventing such complications.

CONCLUSIONS

This case highlights the serious complications that can arise from inadequate sterilization and excessive antibiotic use, leading to multidrug-resistant urosepsis. Strict aseptic techniques and rational antibiotic use are essential to prevent such infections. Colistin proved effective in managing the MDR infection, demonstrating its potential as a last-resort treatment option in similar cases.

AUTHOR CONTRIBUTIONS

All the authors contributed equally to the write up.

CONFLICTS OF INTEREST

The authors affirm that they possess no conflicts of interest.

DATA AVAILABILITY

Not applicable

ETHICS APPROVAL

Informed consent was obtained from patient.

FUNDING SOURCE

No funding was acquired for this work.

REFERENCES

Babar ZU, Dodani SK, Nasim A (2021) Treatment outcome and adverse effects of colistin in adult patients with carbapenem-resistant Gram- negative bacteremia from Pakistan. International Journal of Infectious Diseases 106: 171–175. https://doi.org/10.1016/j.ijid.2021.03.004.

Guliciuc M, Maier AC, Maier IM, Kraft A, Cucuruzac RR, Marinescu M, Şerban C, Rebegea L, Constantin GB, Firescu D (2021) The urosepsis—a literature review. Medicina 57: 872. https://doi.org/10.3390/medicina57090872.

Kunz Coyne AJ, El Ghali A, Holger D, Rebold N, Rybak MJ (2022) Therapeutic strategies for emerging multidrug-resistant Pseudomonas aeruginosa. Infectious Diseases and Therapy 11: 661–682. https://doi.org/10.1007/s40121-022-00591-2.

Linhares I, Raposo T, Rodrigues A, Almeida A (2015) Incidence and diversity of antimicrobial multidrug resistance profiles of uropathogenic bacteria. BioMed Research International 2015: 354084. https://doi.org/10.1155/2015/354084.

McKinnon J, Chowdhury PR, Djordjevic SP (2018) Genomic analysis of multidrug-resistant Escherichia coli ST58 causing urosepsis. International Journal of Antimicrobial Agents 52: 430–435. https://doi.org/10.1016/j.ijantimicag.2018.06.017.

Parajuli NP, Maharjan P, Parajuli H, Joshi G, Paudel D, Sayami S, Khanal PR (2017) High rates of multidrug resistance among uropathogenic Escherichia coli in children and analyses of ESBL producers from Nepal. Antimicrobial Resistance & Infection Control 6: 9. https://doi.org/10.1186/s13756-016-0168-6.

Petrosillo N, Granata G, Boyle B, Doyle MM, Pinchera B, Taglietti F (2020) Preventing sepsis development in complicated urinary tract infections. Expert Review of Anti-infective Therapy 18: 47–61. https://doi.org/10.1080/14787210.2020.1700794.

Porat A, Bhutta BS, Kesler S (2023) Urosepsis. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. https://doi.org/10.1186/s13756-016-0168-6.

Rozwadowski M, Gawel D (2022) Molecular factors and mechanisms driving multidrug resistance in uropathogenic Escherichia coli—an update. Genes 13: 1397. https://doi.org/10.3390/genes13081397.

Walker MM, Roberts JA, Rogers BA, Harris PN, Sime FB (2022) Current and emerging treatment options for multidrug resistant Escherichia coli urosepsis: A review. Antibiotics 11: 1821. https://doi.org/10.3390/antibiotics11121821.

Wartu JR, Butt AQ, Suleiman U, Adeke M, Tayaza FB, Musa BJ, Baba J (2019) Multidrug resistance by microorganisms: A review. Science World Journal 14: 49–56.