Abdominal surgical site infection due to Klebsiella pneumoniae carbapenemase‐producing K. pneumoniae

Dear Editors, Recently, an immunocompetent febrile 34-year-old woman was referred for an exploratory laparoscopy with abdominal flushing and drainage for acute purulent peritonitis sustained by a sigmoid diverticular abscess. Ten days after the intervention, the antibiotic regimen with cefepime, teicoplanin and fluconazole was withdrawn because of the occurrence of profound neutropenia (absolute neutrophil count below 100/μl); after another 5 days, the patient became septic, and an abdominal computed tomography (CT) scan documented intraperitoneal free air together with a left subphrenic abscess. During laparotomy after treating the subphrenic collection, the sigmoid colon, which was found ecchymotic in two different points, was resected, creating a terminal-descending colostomy. After this operation, the patient was commenced on intravenous meropenem, tigecycline, metronidazole and caspofungin acetate. Despite this, she remained pyrexial (39∘C), and a purulent discharge was observed from the abdominal surgical wound. An abdominal CT scan showed a dehiscence of the surgical site extending to the subcutaneous and suprafascial planes (Figure 1). Cultures from the surgical site yielded an extensively drug-resistant strain of carbapenemase-producing Klebsiella pneumoniae, showing susceptibility only to fosfomycin on antibiogram. A 1-month course of intravenous fosfomycin (2 g thrice daily), ertapenem (1 g daily) and wound irrigations with polymyxin E (2 million international units daily) made the patient afebrile; the discharge stopped and the surgical site culture became sterile. Three months on, the patient is in good condition, and her wound dehiscence is being resolved with topic medications in an outpatient setting (Figure 2).