Reactions Weekly | 2021
Cefdinir/ceftriaxone/cotrimoxazole
Abstract
Recurrent right renal abscess due to Extended spectrum β-lactamase-producing Escherichia coli urinary tract infection: case report A 13-year-old girl developed recurrent right renal abscess due to extended spectrum β-lactamase-producing Escherichia coli urinary tract infection (ESBL UTI) following antibiotic therapy with ceftriaxone, cefdinir and cotrimoxazole [dosages not stated; not all routes stated]. The girl presented to the hospital with a right renal abscess. Her medical history was significant for recurrent urinary tract infections since the age of 11 years and chronic constipation. Six months prior to the presentation, she had been hospitalised for the first time for a complicated pyelonephritis with a left renal abscess secondary to pan-sensitive Escherichia coli. The abscess was drained, followed by 1-week therapy of parenteral ceftriaxone and 2-week therapy of oral cefdinir. After completion of the initial antibiotic therapy, she continued to have recurrent left-sided flank pain, decreased appetite and a weight loss of around 6kg over the following 6 months. During that period, she was empirically treated with several courses of cotrimoxazole [trimethoprimsulfamethoxazole] for recurrent febrile urinary tract infections associated with nausea and vomiting. Two weeks prior to the presentation, she had received a 10-day course of cotrimoxazole. Given the chronicity of her symptoms, a contrast-enhanced CT scan of the abdomen was obtained on an outpatient basis. The CT scan showed the presence of a recurrent right renal abscess. She was therefore hospitalised (second hospitalisation). On admission, she was afebrile and tachycardic, but nontoxic appearing, with a HR of 113 beats per minute, RR of 21 breaths per minute, and BP of 110/70mm Hg. Physical examination was significant for bilateral costovertebral angle tenderness. A complete blood count showed normal WBCs, slightly decreased haemoglobin of 11.5 g/dL and an elevated platelet count of 574 000 /mm3. The creatinine level was 0.52 mg/dL. Urinalysis showed rare bacteria, 4–6 RBCs and 18–27 WBCs with few urine epithelial cells. Gram stain revealed rare Gram-positive cocci and Gram-negative rods. Her CRP level was elevated at 29.8 mg/L. On admission, ampicillin and ceftazidime were started empirically. On hospital day 3, the urine culture showed the growth of extended spectrum β-lactamase (ESBL)-producing Escherichia coli [time to reaction onset not stated]. ESBLproducing E. coli are resistance to ceftazidime, but susceptible to imipenem and ertapenem. Therefore, ampicillin and ceftazidime were subsequently changed to meropenem. The blood culture result was negative. A renal ultrasound obtained on hospital day 3 did not show a significant change in the size of the right renal abscess. Because of the lack of significant improvement on meropenem, the girl underwent percutaneous abscess drainage on hospital day 5. The microbiological culture of the drained abscess specimen grew ESBL Escherichia coli. Her clinical symptoms started improving 2 days after abscess drainage and initiation of meropenem therapy. After hospital day 5, meropenem was changed to ertapenem due to its compliant once-daily dosing. She was discharged after 1 week.