A 68-year-old woman, insulin-dependent, obese and allergic to penicillin, came to the hospital after a traffic accident that caused chest trauma and mild head trauma, requiring an osteomyelitis fracture, with a burn.
After induction for trauma intervention, supraglottic edema and bradycardia requiring atropine administration were observed.
The patient was transferred to the ICU due to the characteristics of the airway. She was admitted to the ICU with stable hemodynamically stable metabolic acidosis, leukocytosis and anemia under pharmacoanesthetic effects.
Treatment was initiated with blood products and electrolyte solutions, corticoids being administered for extubation 24-48 hours later.
At 24 h, a mechanical ventilation disconnection test was performed, but the appearance of an adult respiratory distress syndrome with worsening of the patient's gas exchange and reintubation.
In the following days, extubation was resumed twice unsuccessfully due to the presentation of supraglottic edema and respiratory failure.
In a control of tracheal aspirate to the microbiology laboratory 48 h after admission to the ICU, Haemophilus influenzae (10,000 CFU/ml), epithelial cells x 100 leukocytes and moderate Gram-negative stain 5-10 were isolated.
Despite not meeting clear criteria for ventilator-associated pneumonia, treatment with levofloxacin was discontinued for 6 days (500 mg/ 24 h IV).
At this time interval, the aforementioned extubation attempts were performed, with fever and leukocytosis appearing with the progression of the pulmonary infiltrates on the chest X-ray, so a new tracheal culture was sent.
There were abundant PMNs (> 25/c x100) with extra- and intracellular diphtherimorphic Gram-positive bacilli, increasing 100,000 UFC/ml of amoxicillin-clavulanic acid and ciprofloxacin-sensitive glycopeptides.
With this result, vancomycin 500 mg/ 12 h. i.v. was administered for 7 days, progressed satisfactorily and the orthopedic patient was finally extubated and transferred to the hospitalization ward to continue the orthopedic treatment.
The main characteristics of the three cases are summarized in Table I.
IDENTIFICATION AND SUSCEPTIBILITY FOR ANTIIMICROBIALS
The biochemical characteristics of the three strains were determined using the commercial API Coryne system (bioMèrieux, France).
Antimicrobial susceptibility testing was performed using the Kirby-Bauer disk diffusion method on agar muco-Hinton supplemented with 5% horse sickness, following the recommendations of NCCLS.
