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Assistant Professor Department of Pharmacy Health Science Center University of Tennessee 26 South Dunlap Memphis, Tennessee 38163-2111 fax 901/448-6064 cwood{at}utmem.edu
PharmD Student Department of Pharmacy University of Tennessee Health Science Center
Professor Department of Pharmacy University of Tennessee Health Science Center
Research Fellow Department of Pharmacy University of Tennessee Health Science Center
Chair and Professor Department of Surgery University of Tennessee Health Science Center
Professor Department of Surgery University of Tennessee Health Science Center
Published Online, June 1, 2004. www.theannals.com, DOI 10.1345/aph.1D623
Case Report. A 69-year-old white woman was admitted to an intensive care unit with severe thoracic trauma following a motor vehicle collision. The patient had a protracted hospital course, including multiple infections and acute renal failure. On hospital day 94, she developed an Enterobacter cloacae UTI (>100 000 cfu/mL) susceptible only to cefotetan and tobramycin. The urinary catheter was changed and intravenous cefotetan was administered for 5 days. During this time, urine output was approximately 100 mL/day, and the patient was asymptomatic with stable vital signs. Concomitant antimicrobial therapy was vancomycin for Staphylococcus aureus pneumonia that continued throughout UTI therapy.
A follow-up urine culture on day 100 showed persistent E. cloacae (>100 000 cfu/mL) susceptible only to imipenem and tobramycin. Cefotetan was discontinued and a single dose of intravenous tobramycin 100 mg was administered. Imipenem was not used because of the risk of drug-induced seizures. On day 102, the serum tobramycin concentration was undetectable (<1 mg/L). However, intravenous tobramycin was not continued to avoid exacerbating her renal dysfunction as well as uncertainty about drug distribution in the urine during renal failure.1 Instead, a continuous tobramycin bladder irrigation (40 mg in 1000 mL sterile water for injection) was started at 42 mL/h via the multilumen urinary catheter.
The serum tobramycin concentration remained undetectable 3 days later (day 105). A follow-up urine culture (day 106) showed only Candida (>100 000 cfu/mL). That day, the urinary catheter was removed and the irrigation discontinued because of mild bladder wall erosion from the catheter. A urine culture on day 114 showed no organisms. The patient's renal function remained unchanged after bladder irrigation, still requiring dialysis. The patient died on day 121 from septic shock caused by an unrelated episode of Stenotrophomonas maltophilia ventilator-associated pneumonia.
Discussion. Evaluation of this case is complicated because the contribution of each modality (intravenous drug administration, bladder irrigation) to the eradication of E. cloacae is unknown, and the follow-up culture was collected during irrigation (day 106). However, the authors believe the irrigation provided benefit because the duration of therapeutic serum concentrations from the intravenous dose was likely too short to adequately treat a nosocomial UTI (<48 h), and E. cloacae did not return after all antimicrobials were discontinued (day 114). Adverse effects were Candida superinfection and bladder wall erosion from the preexisting catheter. Similar to previous data, there was no appreciable systemic tobramycin absorption.2
As of May 24, 2004, this is the first report of tobramycin bladder
irrigation for UTI in a critically ill patient. The only 3 previous reports of
bladder irrigations for treating bacterial UTIs showed variable efficacy
(
50%) in less ill patients (total n =
25).3-5
In our patient, adjunctive tobramycin bladder irrigation was safe and
effective for treating a lower UTI. Although more data are needed, bladder
irrigation may be an option for localized infections when systemic therapy is
undesirable.
References
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