Acinetobacter Pneumonia

Patient Presentation:
A.G. , a 40 year old Afghan National Army male s/p IED (improvised explosive device) blast to face, chest and limbs,  was being treated in a combat ICU for devastating facial and extremity injuries.  Pt has been mechanically ventilated via tracheostomy since his admission due to the extent of his face wounds.  A.G. is becoming increasingly febrile, difficult to wean from the ventilator and has worsening x-ray imaging studies.

VITAL SIGNS: Heart Rate: 110, Blood Pressure: 92/64, SpO2: 88, Axillary Temperature: 39.0
CBC: WBC: 22, RBC: 5, HCT: 8, HGB:26, PLT: 200
ABG: pH: 7.19, PaCO2: 65, PaO2: 55, HCO3: 28

DIFFERENTIAL DIAGNOSES:
Klebsiella pneumonia, MRSA pneumonia, Acinetobacter pneumonia

DIAGNOSIS:
Chest x-ray was performed and revealed large areas of consolidation in both lungs indicative of pneumonia.  A.G. underwent multiple bedside bronchoscopies to take sputum samples and to wash out the copious amounts of secretions that he could not clear on his own.  A bronchoscopy is a procedure in which the doctor uses an endoscope to look at the patient’s airway, starting with the mouth and down to the lower lobes of each lung.  The sputum results came back positive for multi-drug resistant Acinetobacter.  Acinetobacter is a bacterium common to soil around the world, which in the past has not been a worrisome pathogen.  However, in recent years, this bacterium has been causing problems in the war wounded and particularly those with IED blast injuries due to the amount of soil and dirt becoming engrained in the wounds.

TREATMENT:
A.G. was becoming increasingly tachypneic and his O2 saturations were consistently in the high 80’s.  Consequently, A.G. was placed on APRV.  This is ventilation setting is reserved for patients with severe lung injury and is meant to be lung protective.  APRV, an inverse ratio ventilation, only allows for a very short exhalation time while maintaining an almost constant positive airway pressure in an effort to protect the lungs from further injury and ensure adequate ventilation.  A.G. was also started on inhaled colistin 80mg every 12 hours to fight the infection.  This specific strain of Acinetobacter had become resistant to many more common antibiotics.  Being in a war zone meant limited access to many medications and this specific drug was delivered from a nearby base.  Therapeutic bronchoscopies were performed at the bedside in the ICU in an effort to clear some of the copious secretions from A.G.’s lungs.

OUTCOME:
A.G. stayed in the combat hospital for a month until his respiratory status improved, however marginally.  Although his chest and limb wounds healed, A.G. was left permanently blind after the blast.   A.G. was eventually transferred to a hospital in his native country to continue recovery.
Case created by Alison Groome, 2012.