Infect Chemother.  2018 Dec;50(4):357-361. 10.3947/ic.2018.50.4.357.

Failure of Ciprofloxacin Therapy in the Treatment of Community-Acquired Acute Pyelonephritis caused by In-Vitro Susceptible Escherichia coli Strain Producing CTX-Type Extended-Spectrum β-Lactamase

• Seok H
• Cha MK
• Kang CI
• Cho SY
• Kim SH
• Ha YE
• Chung DR
• Peck KR
• Song JH

• KMID: 2429940
• DOI: http://doi.org/10.3947/ic.2018.50.4.357

Abstract

While carbapenems are the drug of choice to treat extended-spectrum-β-lactamase (ESBL)-producing strains, some alternative carbapenem-sparing regimens are suggested for antibiotic stewardship. We experienced a case of ciprofloxacin treatment failure for acute pyelonephritis caused by an apparently susceptible Escherichia coli. A 71-year-old woman presented the emergency department with fever for 7 days and bilateral flank pain for 2 days. The laboratory results and abdominopelvic computed tomography finding were compatible with acute pyelonephritis. During 3-day ciprofloxacin therapy, the patient remained febrile with persistent bacteremia. After the change in antibiotics to ertapenem, the patient's clinical course started to improve. ESBL-producing E. coli isolates were identified in all three consecutive blood samples. Pulsed-field gel electrophoresis (PFGE) patterns, serotypes, and sequence types showed the three isolates were derived from the identical strain. The isolates produced CTX-M-14 type ESBL belonging to the ST69 clonal group. Despite in vitro susceptibility, the failure was attributed to a gyrA point mutation encoding Ser83Leu within quinolone resistance-determining regions. This case suggests that ciprofloxacin should be used cautiously in the treatment of serious infections caused by ciprofloxacin-susceptible, ESBL-producing E. coli, even in acute pyelonephritis because in-vitro susceptibility tests could fail to detect certain genetic mutations.

Keyword

Extended-spectrum beta-lactamase; Escherichia coli; Ciprofloxacin; Pyelonephritis; CTX-M

MeSH Terms

Aged
Anti-Bacterial Agents
Bacteremia
Carbapenems
Ciprofloxacin*
Electrophoresis, Gel, Pulsed-Field
Emergency Service, Hospital
Escherichia coli*
Escherichia*
Female
Fever
Flank Pain
Humans
In Vitro Techniques
Point Mutation
Pyelonephritis*
Serogroup
Treatment Failure
Anti-Bacterial Agents
Carbapenems
Ciprofloxacin

Figure

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  Figure 1 (A) Abdominopelvic computed tomography finding: diffuse swelling with multifocal ill-defined low density regions in bilateral kidneys (B) Clinical course and treatment of acute pyelonephritis with extended spectrum beta-lactamase-producing Escherichia coli bacteremia.

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