A 46-year-old woman was admitted to the Neurosurgery Department due to a brain hematoma secondary to a ruptured left middle cerebral artery aneurysm.
Emergency aneurysm clipping was performed to evacuate the hematoma and left frontotemporal craniectomy was performed, leaving external ventricular drainage.
Since the day of the intervention, the patient has persistent fever, being diagnosed with Responsive Syndrome A possible Nonsystemic Symptom with suspected pulmonary focus, possibly due to aspiration pneumonia.
She received antibiotic treatment with vancomycin 1,000 mg/12 h for 7 days and meropenem 1,000 mg/8 h for 14 days.
Two weeks after surgery, the patient was diagnosed with an infection by Enterococcus faecalis from the craniectomy wound and 7 days later a brain magnetic resonance imaging (MRI) was performed. The result was compatible with negative meningoencephalitis CSF cultures.
The patient was treated with vancomycin 1000 mg/8 h and cefepime 2000 mg/8 h for 23 days.
Forty-five days after surgery, a ventriculomegaly associated with external h. faecalis was diagnosed after extraction of new CSF cultures and treated with meropenem 1000 mg/24000 mg/24000 mg for 13 days.
After 59 days of admission Candida albicans was isolated in CSF with associated candidaemia and fluconazole 400 mg/12 h for 17 days was added.
Posterior CSF and blood cultures for the above mentioned pathogens are negative, so resolution of prior infections is inferred; however, the patient returns to high fever and on day + 70 multicasttin-susceptible coliMI-C.
Also due to day +73 isolation in CSF Stenotroph used poorly sensitive Acinetobacter coli, resistant to beta-lactams EUL2/ amino acid sequestrum, and fluoroquinolone (≤ 2 mg/Lazole).
After treatment with intravenous cotrimoxazole 800/160 mg/12 h and with ceftazidime iv 2,000 mg/8 h, on day +75 the patient continues with fever, so colistin IV/120,000 h.
After 7 days with this treatment, day +82 is growing in CSF, S. maltophilia sensitive to min (CMIBC ≤ 4 mg/L, CLSI-2012) and colis resistant (CLSI-2012).
After confirming this value using a strip of preformed gradient of IMC, it is observed that it is due to the growth of a subpopulation different from the majority.
This situation was resolved with the administration of intravenous cotrimoxazole 600/320 mg/12 h.
Subsequently, when absolute diet is required due to gastrointestinal bleeding, day +94 is suspended and tige iv regimen 50 mg/12 h is prescribed.
Finally, the patient died 95 days after admission due to intercurrent infections.
