Improving motor and cognitive recovery following severe traumatic brain injury using advanced emotional audio-video stimulation: Lessons from a case report

RATIONALE

It is estimated that about 6 million people suffer from severe traumatic brain injury (TBI) each year (73 cases per 100,000 people). TBI may affect emotional, sensory-motor, cognitive, and psychological functions with a consequent worsening of both patient and his/her caregiver's quality of life. In recent years, technological innovations allowed the development of new, advanced sensory stimulation systems, such as Neurowave, to further stimulate residual cognitive abilities and, at the same time, evaluate residual cognition.

PATIENT CONCERN

An 69-year-old Italian man entered our neurorehabilitation unit with a diagnosis of minimally conscious state following severe TBI. He breathed spontaneously via tracheostomy and was fed via percutaneous gastrostomy. At the neurological examination, the patient showed severe tetraparesis as he showed fluctuating alertness and responsiveness to external stimuli and opened the eyes without stimulation.

DIAGNOSIS

Patient was affected by subarachnoid hemorrhage and frontotemporal bilateral hematoma, which were surgically treated with decompressive craniotomy and subsequent cranioplasty about 6 months before.

INTERVENTIONS

The patient underwent a neuropsychological and clinical evaluation before (T0) and after a conventional rehabilitation cycle (T1), and after a Neurowave emotional stimulation-supported rehabilitative cycle (T2).

OUTCOMES

Following conventional rehabilitation (T1), the patient achieved a partial improvement in behavioral responsiveness; there was also a mild improvement in the caregiver's distress. Conversely, Neurowave emotional stimulation session determined (at T2) a significant improvement of the patient's behavioral responsiveness, cognition, and in the caregiver's distress. The P300 recording in response to the NES showed a significant change of P300 magnitude and latency.

DISCUSSION

Our data suggest that emotional-integrated sensory stimulation using adequate visual stimuli represents a beneficial, complementary rehabilitative treatment for patients in minimally conscious state following a severe TBI. This may occur because stimuli with emotional salience can provide a reliable motivational resource to stimulate motor and cognitive recovery following severe TBI.

The effects of caregiver's burden on dynamic structure in disorder of consciousness families: An observational study

INTRODUCTION

Disorder of consciousness is a clinical condition due to severe brain damage. The impact of consciousness disorder on the family is characterized by a combination of biopsychosocial factors. The burden and suffering perceived by caregivers can cause psychological distress characterized by anxiety, depression, and physical illness. The aim of the study was to investigate the interaction between family dynamics and caregiver burden.

METHODS

We enlisted 35 caregivers of subjects in a minimally conscious state. Two skilled psychologists administered the Olson's Adaptability and Family Cohesion Assessment Scale and the Novak's Burden Inventory Caregiver Scale to assess family function and family burden, respectively.

RESULTS

We found that the caregiver burden correlates with the family adaptability and cohesion, as well as with enmeshment, rigidity, and disengagement.

CONCLUSION

Findings suggest that the traumatic event does not affect the family structure. Families are able to maintain a balanced functioning and control distress.

The impact of the SARS-COV2 infection on the disorder of consciousness rehabilitation unit

BACKGROUND AND OBJECTIVE

Disorders of consciousness include coma (cannot be aroused, eye remain closed), vegetative state-VS (can appear to be awake, but unable to purposefully interact) and minimally conscious state-MCS (minimal but definite awareness). The objective of this study is to assess the impact of the SARS-CoV-2 infection on the Disorder of Consciousness (DOC) Rehabilitation Unit.

METHODS

This is a retrospective, longitudinal, descriptive, observational, pilot study. We consecutively enrolled 18 patients (age range: 40-72 years, 9 females and 9 males), from three to five months after a brain injury. They were grouped into VS (n = 8) and MCS (n = 10). A confirmed case of COVID-19 was defined as a positive result on high-throughput sequencing or real-time reverse-transcription polymerase chain reaction analysis of throat swab specimens. We collected data of lung Computed Tomography (CT) and laboratory exams. DOC patients who were positive for SARS-CoV-2 were classified into severe and no severe infected group, according to the American Thoracic Society guidelines.

RESULTS

A total of 18 hospitalized patients with (16) and without confirmed (2) SARS-CoV-2 infection were included in the analysis. After one month, a follow-up clinical evaluation reported that one patient died, one patient was transferred from Covid Unit to Emergency Unit and 3 patients were resulted negative to double swab and they returned to Rehabilitative Unit. Significant differences were reported about hypertension, cardiac disease and respiratory problems between the patients with severe infection and patients without severe infection (P< 0.001). The laboratory findings, such as blood cell counts (P < 0.001), C-reactive protein, D-dimer, potassium and vitamin D levels, seemed to be considered as useful prognostic predictors.

CONCLUSIONS

To our knowledge, this is the first longitudinal study on a sample of chronic DOC patients affected by SARS-CoV-2. This study may offer important new clinical information on COVID-19 for management of DOC patients. Our findings showed that for the subjects with severe infection due to COVID-19, rapid clinical deterioration or worsening could be associated with clinical and laboratory findings, which could contribute to high mortality rate. During the COVID-19 epidemic period, the clinicians should consider all the reported risk factors to avoid delayed diagnosis or misdiagnosis and to prevent the infection transmission in DOC Rehabilitation Unit.

The role of teriflunamide in multiple sclerosis patient: an observational study

Teriflunomide is a drug with immunosuppressive and selective immunomodulatory action, characterized by anti-inflammatory and antiproliferative properties. Several clinical studies have demonstrated the efficacy and safety of this drug in Multiple Sclerosis, estimating a significant improvement in cognitive performance.The aim of our study is to evaluate the effects of teriflunomide by analysing the correlation between brain atrophy and the general cognitive profile and evaluating long-term changes. The effect of teriflunomide was studied in 30 patients with multiple sclerosis and 30 control subjects. Patients underwent a full cognitive profile assessment using the Brief Repeatable Battery of Neuropsychological Tests and a neuroimaging examination with a 3.0 T working scanner.Our results suggested that treatment with teriflunomide could potentially not only slow down the accumulation of microstructural tissue damage in Grey Matter and With Matter, but also better preserve the cognitive profile, particularly by highlighting the benefits in the memory domain. Thanks to drug therapy, brain volume in our patients has remained constant, leading to improvements in memory, indicating teriflunomide as a neuroprotective potential and further strengthening the evidence of a link between loss of brain volume and cognitive impairment.

The psychometric measures to assess aggressive dimension following traumatic brain injury: A review

BACKGROUND

higher level of aggression and antisocial behavior are frequent following head trauma, due to specific brain alterations. Many tests are used to assess this aspect. A descriptive review was conducted on the main tests used to detect the appearance of aggressive dimensions following traumatic brain injury.

REVIEW SUMMARY

we searched on PubMed and Web of Science databases and screening references of included studies and review articles for additional citations. From initial 723 publications, only 7 met our search criteria. Findings showed that various psychometric tools are used to assess aggressiveness and its subdomains, following head trauma.

CONCLUSIONS

further investigation are necessary to clarify whether these tools ensure a reliable diagnosis in order to make an early intervention and reduce violent behavior and its development.

Refeeding syndrome in a woman with pancreatitis: a case report

Refeeding syndrome can occur in malnourished patients with acute pancreatitis who have electrolyte imbalances. Refeeding syndrome is characterized by severe electrolyte imbalances (mainly hypophosphatemia, hypomagnesemia, and hypokalemia), vitamin deficiency (mainly thiamine deficiency), fluid overload, and salt retention resulting in organ dysfunction and cardiac arrhythmias. We herein report a case involving a patient with severe pancreatitis and gallbladder stones who developed refeeding syndrome with shock and loss of consciousness. The patient was treated by opportune vitamin and electrolyte supplementation therapy and showed substantial improvement after 2 weeks of hospitalization, gaining the ability to eat small bites of solid food orally. Early diagnosis and treatment of refeeding syndrome may reduce morbidity and mortality in patients with acute pancreatitis. Patients should be fasted only if alimentation is contraindicated, and electrolyte values must be closely monitored.

'Online therapy' to reduce caregiver's distress and to stimulate post-severe acquired brain injury motor and cognitive recovery: A Sicilian hospital experience in the COVID era

INTRODUCTION

Severe acquired brain injury(SABI) often results in the deterioration of physical, cognitive and emotional functions in the patient and a significant caregiver's distress syndrome, which is now amplified by the social isolation, depression and financial difficulties related to the COVID-19 pandemic. The use of web-based online-therapy has been shown to be useful to overcome caregiver's distress syndrome and further stimulate cognitive-motor recovery of SABI-patients. Our study aimed to investigate whether a systematic online Skype-therapy(OLST) may be of support in favoring global cognitive and sensory-motor recovery in SABI-patients and reducing caregiver distress.

METHODS

Twenty-five SABI-subjects in inpatient regimen were provided with intensive OLST with the caregiver for 12 weeks in addition to standard neurorehabilitation. Each subject and caregiver was evaluated before and after the treatment by administering an ad hoc battery. Furthermore, 18 of 27 patients were provided with EEG recording in resting state.

RESULTS

We found a significant reduction in caregiver's anxiety (p<0.0001) and burden(p<0.0001). Patients showed significant improvement in trunk control (p<0.0001), functional independence (p = 0.005), functional (p = 0.01) and global communication (p = 0.004), cognitive functioning (p = 0.001), and behavioral responsiveness (p = 0.0004). The training yielded a significant connectivity change within the fronto-centro-parietal areas in the delta frequency band (p<0.0001) and the centro-parieto-occipital areas in the alpha range (p = 0.004).

DISCUSSION

OLST may be a useful and complementary treatment to optimize global cognitive and functional recovery in SABI-subjects and reduce caregivers' concerns in the Covid-era. OLST can foster cognitive-motor recovery potentially by favoring the plasticity-dependent functional recovery. Therefore, OLST could be proposed as a tool allowing social conversations also in the hospital setting.

Multiple Sclerosis lesions detection by a hybrid Watershed-Clustering algorithm

BACKGROUND

Computer Aided Diagnosis (CAD) systems have been developing in the last years with the aim of helping the diagnosis and monitoring of several diseases. We present a novel CAD system based on a hybrid Watershed-Clustering algorithm for the detection of lesions in Multiple Sclerosis.

METHODS

Magnetic Resonance Imaging scans (FLAIR sequences without gadolinium) of 20 patients affected by Multiple Sclerosis with hyperintense lesions were studied. The CAD system consisted of the following automated processing steps: images recording, automated segmentation based on the Watershed algorithm, detection of lesions, extraction of both dynamic and morphological features, and classification of lesions by Cluster Analysis.

RESULTS

The investigation was performed on 316 suspect regions including 255 lesion and 61 non-lesion cases. The Receiver Operating Characteristic analysis revealed a highly significant difference between lesions and non-lesions; the diagnostic accuracy was 87% (95% CI: 0.83-0.90), with an appropriate cut-off of 192.8; the sensitivity was 77% and the specificity was 87%.

CONCLUSIONS

In conclusion, we developed a CAD system by using a modified algorithm for automated image segmentation which may discriminate MS lesions from non-lesions. The proposed method generates a detection out-put that may be support the clinical evaluation.

Twin pregnancy outcome following teriflunomide treatment in a relapsing-remitting multiple sclerosis patient: A case report

RATIONALE

Teriflunomide is a disease-modifying drug that has been approved for treatment of relapsing-remitting multiple sclerosis. Due to its teratogenic effect in animals, however, it is not recommended during pregnancy. For this reason, effective contraception must be used during its administration. When an unscheduled pregnancy occurs during therapy, patients must undergo a cholestyramine procedure for rapid flushing of the drug.

PATIENT CONCERNS

We describe the case of a 35-year-old female patient suffering diagnosed with relapsing-remitting multiple sclerosis at the age of 20. The patient as a result of side effects of previous therapies started taking teriflunomide.

DIAGNOSIS

Despite recommendations for the use of contraceptives, the patient became pregnant during drug therapy. Pregnancy occurred 12 months after initiating teriflunomide treatment.

INTERVENTIONS

Therapy with teriflunomide was immediately suspended and cholestyramine was prescribed (8 g 3 times a day, for 11 days) to flush out any residual drug from the body.

OUTCOMES

Despite an 8-week exposure to teriflumomide during gestation, the patient gave birth to healthy twin girls at 35 week. Controls carried out after birth did not reveal any malformation or genetic and chromosomal abnormality. At a 5-month pediatric specialist check both babies were healthy and growing regularly.

CONCLUSION

This shows that even if there is evidence of teratogenic effects in animals, an 8-week exposure to teraflunomide >0.02 mg/L did not have effects on the newborn.

Nabiximols plus robotic assisted gait training in improving motor performances in people with Multiple Sclerosis

BACKGROUND

Multiple sclerosis (MS) is an autoimmune demyelinating disease of the central nervous system, affecting ambulation even in people with only mild neurological signs. Patients with MS frequently experience spasticity, which contributes significantly to impair their motor functions, including ambulation, owing to muscle stiffness, spasms, and pain.

OBJECTIVES

To clarify the role of delta-9-tetrahydrocannabinol(THC):cannabidiol(CBD) oromucosal spray, coupled to robot-aided gait training (RAGT) using the Lokomat©Pro to improve functional ambulation in patients with MS.

METHODS

We compared 20 patients with MS, who were treated with THC:CBD oromucosal spray in add-on to the ongoing oral antispastic therapy (OAT) (group A), with 20 individuals with MS (matched for clinical-demographic characteristics) who were treated only with OAT (group B). Both the groups underwent RAGT using the Lokomat-Pro (three 45-minute sessions per week). Our primary outcome measures were the Functional Independence Measure (FIM) and the 10 meters walking test (10MWT). As secondary outcome measures we evaluated the brain cortical excitability by using Transcranial Magnetic Stimulation. Both parameters were taken before and after the end of the RAGT.

RESULTS

FIM improved in group A more than in group B (p<0.001). Moreover, 10MWT decreased in group A more than in group B (p<0.001). These clinical findings were paralleled by a more evident reshape of intracortical excitability in both upper and lower limbs, as suggested by motor evoked potential amplitude increase (p<0.001), intracortical inhibition strengthening (p<0.001), and intracortical facilitation decrease (p=0.01) in group A as compared to group B.

CONCLUSIONS

Our results suggest that the combined THC:CBD-RAGT approach could be useful in improving gait performance in patients with MS.

Lethal infective endocarditis due to Streptococcus agalactiae in a man with a history of alcohol abuse: A case report

RATIONAL

Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium.

PATIENT CONCERNS

A 53-years-old man with a history of alcohol abuse was admitted in hospital for fever, paroxysmal atrial fibrillation cardioverted by Amiodarone and pulmonary infection.

DIAGNOSIS

A case of recurrent severe endocarditis, with neurological complications both ischemic and hemorrhagic and heart failure caused by Streptococcus agalactiae in healthy man we reported.

INTERVENTIONS

Surgery was performed 2 weeks after admission.

OUTCOMES

The onset of intracranial hemorrhage delayed second cardiac surgery and the patient died because of end-stage heart failure.

CONCLUSIONS

Infective endocarditis caused by S. agalactiae is very rare, particularly in patients without underlying structural heart disease. This study showed that IE due to S. Agalactiae is a disease with high mortality when associated with neurological complication, heart failure but especially when it is recurrent and hits valve prosthesis.

Recovery of malnutrition in a patient with severe brain injury outcomes: A case report

RATIONALE

Severe brain injury often induces a state of malnutrition due to insufficient caloric and protein input. If left untreated, it will have a negative impact on rehabilitation. Nutritional therapy provides caloric and the nutritional support necessary to cover the daily needs and help contrast hospital infections. Our hypothesis is that integration of natural foods in the daily diet can enhance the recovery of the state of malnutrition and increase rehabilitation outcomes.

PATIENT CONCERNS

We present the case of a young man with traumatic brain injury caused by a car accident. Who underwent tracheostomy and percutaneous endoscopic gastrostomy (PEG) procedures, had severe consciousness disorder, was severely malnourished and therefore underweight.

DIAGNOSIS

He was severely underweight, malnourished, with a severe consciousness disorder that necessitated the tracheostomy and the PEG.

INTERVENTIONS

Our approach included caloric implementation of artificial nutrition and the gradual introduction of semi-liquid natural foods administered through PEG.

OUTCOMES

The patient was followed for a year during which the metabolic/nutritional pattern and the blood tests improved, normal weight restored, and consciousness regained.

CONCLUSION

Nutritional intervention integrated with natural foods, has allowed a gradual increase in weight, a better recovery of the lean mass and the stabilization of the metabolic-nutritional framework.Nutritional approach used has contributed to the reduction of recovery times, making the therapeutic path more effective.

Religious Coping in Caregiver of Patients with Acquired Brain Injuries

Caregivers play a crucial role in physical and psychological management in terms of assistance. For this reason, it is important for caregivers to find better coping strategies to minimize a possible physical and emotional burden. The aim of our study is to demonstrate how the religious coping can influence the burden of caregivers about health care of patients with severe brain injuries. Caregivers were, respectively, divided into two groups: 31 religious believers and 20 unbelievers. We submitted the questionnaires to participants, which investigate the caregiver burden, presence of depressive symptoms and kind of coping strategies adopted. Our results demonstrated that participants with religious belief used avoidance strategies more frequently compared to non-believers' group. We want to improve adaptive coping strategies to upgrade the awareness of caregiver, supporting burden and distress. A problem-solving training might improve quality of life in terms of social and psychological wellness.

Therapeutic adherence and coping strategies in patients with multiple sclerosis: An observational study

Multiple sclerosis (MS) is a chronic demyelinating autoimmune disorder affecting the central nervous system and targets the myelin sheaths around nerves. Local problem: Medical advances have enabled patients to lead a better quality of life (QoL) than before. However, because of its chronicity and unpredictability, it remains a very challenging disease for both patients and their families, as it involves the continued use of medication to slow down progression. The aim of this study is to assess drug adherence in patients with MS. In particular, we will examine how the way drugs are administered (oral or injective) affects compliance with therapy, including the correlation with coping strategies and the QoL of each patient.We enrolled 88 patients with MS, divided into 2 groups according to therapy (injective or oral). The Morisky Medication Adherence scale was administered to evaluate adherence to treatment, the MS QoL 54 to estimate mental and physical health, and Brief coping orientation to problems experienced Inventory for coping strategies.The results showed that in both groups the patients showed a good therapeutic alliance and trust in treatment. In particular, a correlation has been found between therapeutic adherence, adaptive coping strategies, and mental health when drug therapy is administered by injection. In conclusion, this result suggests that for patients receiving injection treatment to have greater adherence to therapy, appropriate coping strategies and good mental health must be developed in order for patients receiving injection therapy to have greater adherence to therapy; they need to develop appropriate coping strategies and good mental health to address this mode of administration successfully.

A complex relation between depression and multiple sclerosis: a descriptive review

BACKGROUND

Multiple sclerosis (MS) is a demyelinating neurodegenerative disease that affects central nervous system (CNS). MS patients are more likely to develop depressive symptoms than patients with other chronic diseases.

OBJECTIVE

In this review, we have analysed if there is a correlation between brain lesions (BL), structural damage (SD) and depressive symptoms (DS).

METHODS

We Searched on PubMed and Web of Science databases and screening references of included studied and some review article for additional citations. From initial 745 studies, only 9 met the inclusion criteria. All studies conducted research on 389 patients with MS associated with DS and 120 HC (healthy controls).

RESULTS

The selected researches highlighted the involvement of limbic system, the role of hippocampus and the impact of brain lesions on the emotional status of MS patients.

DISCUSSION

In the genesis of depression are implicated many mechanisms including genetic, biochemical, immunological and psychosocial factors, even if a prominent role in the onset of DS seem to be associated with structural and functional brain alterations.

Acute exacerbation of Hashimoto's thyroiditis in a patient treated with dimethyl fumarate for multiple sclerosis: A case report

INTRODUCTION

Dimethyl fumarate (DMF) has been recently approved for first-line monotherapy of Multiple Sclerosis (MS). Its effects are due to mechanism modulating the immune system and activating antioxidative and neuroprotective pathways.

PATIENT CONCERNS

A 59-year-old female patient affected by chronic Hashimoto's thyroiditis (HT) from 10 years was diagnosed with relapsing remitting MS in 2013. She started therapy with DMF in November 2016.

DIAGNOSIS

After 2 months of therapy with DMF, the results of thyroid function test were abnormal. Thyroid ultrasonography confirmed the diagnosis of acute exacerbation of HT.

INTERVENTIONS

This condition led to discontinuation of DMF therapy.

OUTCOME

Two months after the interruption of DMF therapy, the findings of thyroid function test were within normal limits.

CONCLUSION

The association of MS with autoimmune thyroid diseases supports a common immune-mediated pathogenic mechanism. We assume that the acute exacerbation of HT in our MS patient is associated not with the immunomodulatory effect of DMF but rather with its antioxidative mechanism.Constant monitoring of thyroid hormone levels should be recommended especially if the MS patients in treatment with DMF are affected by concomitant autoimmune thyroid diseases.

The role of cognitive rehabilitation in limbic encephalitis: A case report

RATIONALE

Limbic encephalitis is a parenchymal inflammation caused by viral, bacterial, or other microbial and postinfectious agents, which is usually expressed by multifocal neurological signs and cognitive impairment.

PATIENT CONCERNS

A 50-year-old female was admitted in postacute phase, at our rehabilitative Center, to undertake neuro-motor treatment for a period of 4 months.

DIAGNOSES

The patient was affected by limbic encephalitis. Clinical presentation revealed attention, memory and executive dysfunctions, as well as behavioral changes, emotional dysregulation and reduction of self-awareness.

INTERVENTIONS

The patients received an intensive cognitive and motor rehabilitation training.

OUTCOMES

Neuropsychological assessment and magnetic resonance imaging were performed before and after rehabilitative training to evaluate the cognitive and cerebral changes induced by treatment. The patient showed an improvement in cognitive performances and behavioral aspects.

LESSONS

The reducing cognitive deficits, especially memory deficits, could improve quality of life by using available cognitive resources.

Coping strategies in caregivers of disorders of consciousness patients

OBJECTIVE

The management of patients with disorders of consciousness (DOC) has raised several important ethical, social, and medical issues. It is also known that families and caregivers are subjected to physical and emotional load due to their assistance activity. The aim of this observational study was to compare distress and coping strategies used among caregivers of two kinds of DOC: vegetative state (VS) and minimally conscious state (MCS).

METHODS

We have enrolled 80 caregivers (mean age 47.87 ± 11-28 years) that were tested with self-administered measures of distress and coping to individuate which coping strategies were adopted by caregivers of DOC patients and to analyze how these have influenced the degree of distress.

RESULTS

Data showed that the reaction to stress was different between two groups of caregivers (VS and MCS); moreover, it may vary according to the coping strategies used.

CONCLUSION

Results showed the importance to develop effective coping strategies aimed to reduce psychological distress and improving caregiver's well-being.

Olfactory dysfunction as a prognostic marker for disability progression in Multiple Sclerosis: An olfactory event related potential study

Multiple sclerosis (MS) is a chronic inflammatory disease and one of the leading causes of disability in young adults. Functional markers able to predict MS progression are still lacking. It is recognized that olfactory dysfunction may be an early symptom in MS. The aim of this study was to investigate whether alterations in olfactory event-related potentials could play a prognostic role in MS. Thirty patients affected by MS relapsing-remitting underwent an olfactory potential examination (T0). Three years after baseline (T1), 28 of 30 patients were clinically evaluated by expanded disability status scale. In addition, the number of Disease Modifying Therapies (DMTs) and the total number of relapses occurred in the last 3 years were collected. At T1, we observed a negative correlation between presence/absence of olfactory potentials and expanded disability status scale scores (rpb = -0.48; p = 0.009). A significant trend for a negative correlation between presence/absence of olfactory potentials and disease duration (rpb = -0.36; p = 0.06) and total number of relapses (rpb = -0.34; p = 0.08) was found. Only patients with olfactory potential absence showed a significant trend in the difference of the disability status scale (p = 0.06) between T0 and T1. In the sub-group of patients with reduced olfactory potential amplitude, we detected a trend for a negative correlation between the disability status scale and the amplitude of N1-P2 components more marked at T1 (r = -0.52; p = 0.06) than T0 (r = -0.47; p = 0.09). This is the first study that evaluated the prognostic role of olfactory event-related potentials in MS. Our results highlighted that olfactory alterations of MS patients were related to disability progression and, to a lesser extent, disease activity. The analysis of olfactory potential parameters confirmed the involvement in olfactory network damage of inflammatory and/or neurodegeneration processes which could predict the progressive course of the disease.

Successful ceftazidime-avibactam treatment of MDR-KPC-positive Klebsiella pneumoniae infection in a patient with traumatic brain injury: A case report

RATIONALE

Carbapenem-resistant Enterobacteriaceae infections are a serious health care problem, because of the high mortality. Carbapenem resistance is mainly caused by carbapenemases production, including Klebsiella pneumoniae carbapenemase (KPC). Ceftazidime-avibactam is a new cephalosporin/β-lactamase inhibitor combination for the treatment of complicated urinary, intra-abdominal infections, and nosocomial pneumonia caused by gram negative, or other serious gram-negative infections.

PATIENT CONCERNS

We showed the case of a 27-year-old patient, hospitalized for traumatic brain injury and chest trauma, with KPC-producing Klebsiella pneumoniae infection.

DIAGNOSES

Blood and bronchial aspirate culture analysis detected an infection caused by MDR Klebsiella pneumoniae, resistant to meropenem, ertapenem, piperacillin/tazobactam, amoxicillin/clavulanic acid, aztreonam, ceftazidime, cefotaxime, cefepime, amikacin, ciprofloxacin, trimethoprim/sulfamethoxazole, colistin while it showed an intermediate sensitivity to gentamicin and was sensitive to ceftazidime-avibactam. Molecular analyses revealed that the isolate belonged to the epidemic clone sequence type 258 (ST258) carrying blaKPC-3, blaTEM-1, and blaSHV-11genes.

INTERVENTIONS

After various combined antibiotic therapies without improvements, he was treated with ceftazidime-avibactam, on a compassionate-use basis.

OUTCOMES

With ceftazidime-avibactam monotherapy clinical and microbiological clearance was obtained. A week after the end of the therapy microbiological analysis was repeated and a positive rectal swab for KPC-Klebsiella pneumoniae was found, becoming negative after 1 month. Moreover, the patient did not show any relapses for up to 18 weeks.

LESSONS

This case indicates that ceftazidime-avibactam monotherapy could be efficacious against KPC positive Klebsiella pneumoniae infections.