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Case of the Month - September 2018

Case presentation

Mrs. MM, a known epileptic patient, was admitted to the burns unit of an Academic Public-Sector facility on the 26th of October 2017, for the treatment of 40% burns that she sustained during an epileptic seizure. She was 26 years old and weighed 55 kg on admission. Her condition rapidly deteriorated (over two days) and she was admitted to the intensive care unit (ICU) on the 28th of October 2017 with a severe sepsis syndrome for which she received empiric intravenous antibiotic therapy.

Her medication on day 5 of ICU admission was as follows:

Medicine Dosage Frequency Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6
Valproate 300mg PO 12 hourly  
Enoxaparin 40mg SC Daily  
Pantoprazole 40mg IVI Daily  
Amikacin 1000mg Daily      
Imipenem 500mg IV 6 hourly      
Vancomycin 1000mg IVI 12 hourly        

Therapeutic drug monitoring was performed:
Drug Concentration
Valproate (random level) 56 µg/ml (Ref range: 50-100µg/ml)
Amikacin trough (Day 2) 9.5 µg/ml (Ref range: 0-10 µ/ml) (taken half an hour before the dose at 08:30 - dose administered at 09:00)
Amikacin peak (Day 2) 45 µg/ml (Ref range: 40 µg/ml) (taken one hour after the dose got administered - taken at 10:00, dose infused over 5 minutes)
Vancomycin trough level (Day 3) 20 µg/ml (Ref range: 15-20 µg/ml) (taken half an hour before the dose got administered at 10:30)
Microbiology report (Blood culture performed on 29th of October 2017):
Acinetobacter baumanni (sensitive only to amikacin, gentamicin and tobramycin); colistin and tigecycline susceptibilities were not reported
AND
Methicillin-Resistant Staphylococcus aureus (MRSA) - vancomycin Minimum Inhibitory Concentrations (MIC) determined by an E-test was 1 mg/L (susceptibility breakpoint 2 mg/L).
Further investigations for disseminated MRSA were not conducted.

Urea  21 (2.5 – 6.7)  mmol/l
Sodium 140 (134 – 147)  mmol/l
Potassium & 4 (3.5 – 5.5)  mmol/l
Chloride 1110 (100 – 112)  mmol/l
Glucose  7  (4 – 8)  mmol/l
Creatinine 4480 (53 – 115)  µmol/l
Albumin 2626 (35 – 55)  g/l
PCT 775 (0.15 - 2)  ng/ml
CRP 3375  (<10)  mg/l


The following antimicrobial stewardship principles were considered:


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