Pyogenic liver abscess secondary to Streptococcus anginosus in an adolescent

Pyogenic liver abscess in the pediatric population is a rare entity and can be difficult to manage. Surgical infections caused by Streptococcus anginosus are exceedingly rare. Here we present a case of pyogenic liver abscess caused by S anginosus in an adolescent presenting with fever, nausea, emesis, and right upper quadrant abdominal discomfort.     

Enterobius vermicularis (pinworm) infection of the liver mimicking malignancy: Presentation of a new case and review of current literature

INTRODUCTIONEnterobius vermicularis or “pinworm” infection of the liver is an extremely rare condition with only five cases previously reported in literature. It is characterized by the presence of granulomas in the liver with a necrotic core, containing adult helminthes or their ova. Because of the relatively mild symptomatology associated with this disease, prior to the arrival of modern imaging methods hepatic enterobiasis was an incidental intra-operative finding during abdominal surgery for other conditions. In recent years however, with high-resolution abdominal imaging readily available and the improved safety of hepatic resection, a lower threshold for treating suspicious hepatic nodules aggressively with surgery is being adopted.PRESENTATION OF CASEWe present the second case in international literature, where E. vermicularis of the liver was mistaken for malignancy and led to hepatic resection and perform a literature review of the five previously documented cases of hepatic enterobiasis.DISCUSSIONOur report identifies certain trends in this condition's aetiology and clinical behaviour, but due to its rarity definitive answers cannot yet be established.CONCLUSIONWe do not advocate a change in the current approach of suspicious hepatic nodules, but we do feel that better understanding of the mechanisms involved with hepatic enterobiasis could, in the future, prevent unnecessary surgery.     

Pyogenic liver abscess complicated by endogenous endophthalmitis

Background: Endogenous endophthalmitis is an inflammation of ocular tissues that can lead to deterioration of and loss of vision. Rarely, this can complicate the course of a patient with pyogenic liver abscess. Methods: Over an 18‐month period, 68 patients were treated for pyogenic liver abscesses. Three patients, all of whom were male and with diabetes, were diagnosed with a Klebsiella pneumoniae liver abscess complicated by endogenous endophthalmitis. Open surgical or percutaneous drainage of the liver abscess was undertaken and the symptomology and outcome of the endophthalmitis reviewed. Results: There was no mortality in our series. Two patients presented with simultaneous abdominal and ocular symptoms and one patient had ocular symptoms 3 days after surgical drainage of the liver abscess. Despite aggressive treatment, all patients had permanent deterioration of visual function with one patient becoming blind and requiring evisceration of the infected eye. Conclusion: Ocular symptoms in patients treated for pyogenic abscesses must be dealt with urgently with an ophthalmologic consultation. Increased awareness of this complication and a high index of suspicion are paramount for salvage of visual function.     

Spinal epidural abscess with myelitis and meningitis caused by Streptococcus pneumoniae in a young child

Background

Spinal epidural abscess (SEA) in children is a rare infectious emergency warranting prompt intervention. Predisposing factors include immunosuppression, spinal procedures, and local site infections such as vertebral osteomyelitis and paraspinal abscess. Staphylococcus aureus is the most common isolate.

Design

Case report and literature review.

Findings

A 2.5-year-old boy with tetraparesis was found to have an SEA in the posterior lumbar epidural space with evidence of meningitis and myelitis on MRI spine in the absence of any local or systemic predisposing factors or spinal procedures. Streptococcus pneumoniae was isolated from the evacuated pus.

Conclusions

Definitive treatment of SEA is a combination of surgical decompression and iv antibiotics. Timely management limits the extent of neurological deficit.     

Fatal skin and soft tissue infection of multidrug resistant Acinetobacter baumannii: A case report

INTRODUCTION

Acinetobacter baumannii is usually associated with respiratory tract, urinary tract and bloodstream infections. Recent reports suggest that it is increasingly causing skin and soft tissue infections. It is also evolving as a multidrug resistant organism that can be difficult to treat. We present a fatal case of multidrug resistant A. baumannii soft tissue infection and review of relevant literature.

PRESENTATION OF CASE

A 41 year old morbidly obese man, with history of alcoholic liver disease presented with left superficial pre-tibial abrasions and cellulitis caused by multidrug resistant (MDR) A. baumannii. In spite of early antibiotic administration he developed extensive myositis and fat necrosis requiring extensive and multiple surgical debridements. He deteriorated despite appropriate antibiotic therapy and multiple surgical interventions with development of multi-organ failure and died.

DISCUSSION

Managing Acinetobacter infections remains difficult due to the array of resistance and the pathogens ability to develop new and ongoing resistance. The early diagnosis of necrotizing soft tissue infection may be challenging, but the key to successful management of patients with necrotizing soft tissue infection are early recognition and complete surgical debridement.

CONCLUSION

A. baumannii is emerging as an important cause of severe, life-threatening soft tissue infections. Multidrug resistant A. baumannii soft tissue infections may carry a high mortality in spite of early and aggressive treatment. Clinicians need to consider appropriate early empirical antibiotic coverage or the use of combination therapy to include MDR A. baumannii as a cause of skin and soft tissue infections.     

Comparison of pathogens and antibiotic resistance of burn patients in the burn ICU or in the common burn ward

Background

This study aims to compare pathogens and their antibiotic resistances of burn patients from burn intensive care unit (ICU) or common burn ward. Of 2395 clinical samples from 63 patients in burn ICU, pathogens were detected in 1621 samples, in which 1203 strains (74.2%) were Gram negative bacteria, 248 strains (15.3%) were Gram positive bacteria, 170 strains (10.5%) were fungi. Top-4 microorganisms isolated from patients in burn ICU were Bauman's Acinetobacter (557, 34.4%), Pseudomonas aeruginosa (287.17.7%), Staphylococcus aureus (199, 12.3%) and Klebsiella pneumoniae (171, 10.5%). Of 512 clinical samples from 235 patients in common burn units, pathogens were detected in 373 samples, in which 189 (50.6%) strains were Gram negative bacteria, 150 strains (40.2%) were Gram positive bacteria, 34 strains (9.2%) were fungi. Top-4 microorganisms isolated from patients in common burn units were S. aureus (103, 27.6%), P. aeruginosa (46, 12.3%), K. pneumoniae (38, 10.2%) and Escherichia coli (32, 8.6%). Antibiotic resistance rates of pathogens isolated from clinical samples of burn patients from ICU was significantly higher than those from common units.

Conclusions

Pathogens and their antibiotic resistances are significantly different between burn ICU and common burn units. This finding has great implication for infection control in burn patients.     

Prevalence of multidrug-resistant organisms recovered at a military burn center

Infections caused by multidrug-resistant (MDR) pathogens are associated with significant morbidity and mortality in patients with burn injuries. We performed a 6-year antibiotic susceptibility records review from January 2003 to December 2008 to assess the prevalence of MDR isolates by pathogen at the US Army Institute of Surgical Research Burn Center. During the study period Acinetobacter baumannii (780 isolates [22%]) was the most prevalent organism recovered, followed by Pseudomonas aeruginosa (703 isolates [20%]), Klebsiella pneumoniae (695 isolates [20%]), and Staphylococcus aureus (469 isolates [13%]). MDR prevalence rates among these isolates were A. baumannii 53%, methicillin-resistant S. aureus (MRSA) 34%, K. pneumoniae 17% and P. aeruginosa 15%. Two isolates, 1 A. baumannii and 1 P. aeruginosa, were identified as resistant to all 4 classes of antibiotics tested plus colistin. A. baumannii isolates recovered from patients with burns greater than 30% of total body surface area (TBSA) were more likely to be MDR (61%) with no significant difference for P. aeruginosa and K. pneumoniae. A higher proportion of MDR P. aeruginosa isolates were recovered from respiratory specimens compared to blood specimens (24% vs. 9%) while the opposite was true for MRSA (35% vs. 54%). A comparison of A. baumannii recovered during hospitalization days 1–5 and 15–30 revealed higher MDR levels as length of stay increased (48% vs. 75%) while no significant trends were observed for P. aeruginosa and K. pneumoniae. A similar pattern was observed for MDR A. baumannii levels for the facility between 2003 and 2005 and 2006–2008 (39% vs. 70%), with no significant increase in MDR P. aeruginosa and MDR K. pneumoniae. Increasing antibiotic resistance patterns of the most prevalent isolates recovered during extended hospitalization, impact of % TBSA and other clinical parameters may affect empirical antimicrobial therapy and patient management decisions during treatment.     

Living donor liver transplantation with replacement of vena cava for Echinococcus alveolaris: A case report

INTRODUCTION

There is no medical treatment for alveolar echinococceal disease (AED) of liver till now. Curative surgical resection is optimal treatment but in most advanced cases curative resection can’t be done. Liver transplantation is accepted treatment option for advanced AED. AED in some case invade surrounding tissue especially inferior vena cava (IVC). Advanced AED with invasion to IVC can be treated with deceased liver transplantation. Although living donor liver transplantation is very difficult to perform in patients with advanced AED with resected IVC, it come into consideration, since there is very few cadaveric liver.

PRESENTATION OF CASE

Here we present a case with advanced stage of AED of liver which cause portal hypertension and cholestasis. AED invaded surrounding tissue, right diaphragm, both lobes of liver and retrohepatic part of IVC. Invasion of IVC forced us to make resection of IVC and reconstruction with cryopreserved venous graft to reestablish blood flow. After that a living donor liver transplantation was done.

DISCUSSION

Curative surgery is the first-choice option in all operable patients with AED of liver. Advanced stage of AED like chronic jaundice, liver abscess, sepsis, repeated attacks of cholangitis, portal hypertension, and Budd-Chiari syndrome may be an indication for liver transplantation. In some advanced stage AED during transplantation replacement of retrohepatic part of IVC could be done with artificial vascular graft, cadaveric aortic and caval vein graft.

CONCLUSION

Although living donor liver transplantation with replacement of IVC is a very difficult operation, it should be considered in the management of advanced AED of liver with IVC invasion because of the rarity of deceased liver.     

Prosthetic joint infections due to Mycobacterium tuberculosis: A report of 5 cases

INTRODUCTIONTubercular infection of prosthetic joint arthroplasty is sporadically described, but its incidence is rising. Misdiagnosis is common because of disparate clinical presentation.PRESENTATION OF CASEWe describe 1 hand, 2 hip and 2 knee prosthetic-joint infections due to Mycobacterium tuberculosis in patients without a previous history of tuberculosis. All of them were initially misdiagnosed as bacterial infections and unsuccessfully treated with antibiotic for a long period of time. Diagnosis was made by means of culture of periprosthetic tissues and histolopathological examination. Tuberculosis was cured in all patients, but two of them have had a permanent functional damage (one arthrodesis of the knee and one loss of hand function).DISCUSSIONAn aggressive diagnostic approach is required to make diagnosis of periprosthetic tubercular infection. The identification of the pathogen is advisable to test drug susceptibility.CONCLUSIONThe low index of suspicion of periprosthetic tubercular infection could delay a correct diagnosis with risk of permanent damage due to a late treatment. During any surgical revision of prosthetic joints with suspect infection culture for tuberculosis should be taken into consideration.     

Higher rate of colorectal cancer among patients with pyogenic liver abscess with Klebsiella pneumoniae than those without: an 11‐year follow‐up study

Aim Pyogenic liver abscess (PLA) has been reported as an early manifestation of colorectal cancer (CRC) in adults, but few studies have investigated this relationship. It is unclear if patients with Klebsiella pneumoniae PLA are at increased risk of subsequent CRC. Our aims were to estimate the incidence of CRC among patients with PLA and to compare the incidence of CRC between K. pneumoniae PLA and non‐K. pneumoniae PLA groups. Method We conducted a retrospective study of patients with PLA diagnosed between 2000 and 2009 at a medical centre in northern Taiwan. CRC status and survival status were determined until December 2010. Incidence data from the general population were retrieved from the Taiwan Cancer Registry. Outcome measures were defined as standardized incidence ratio and the incidence rate per 100 000 person‐years. Results This study included 2294 patients, of whom 1194 (52%) had K. pneumoniae infection. During the follow‐up period, 54 (2.3%) patients were diagnosed with CRC, corresponding to an overall incidence rate of 669.1 (95% CI, 490.7–847.6) per 100 000 person‐years. The adjusted hazard ratio of CRC was 2.68 times greater for patients with K. pneumoniae PLA than for those with non‐K. pneumoniae PLA (95% CI, 1.40–5.11). Conclusion Patients with K. pneumoniae PLA had a significantly higher rate of subsequent CRC than did patients with non‐K. pneumoniae PLA. Colonoscopy is recommended to detect occult colonic malignancy in patients with PLA, particularly for patients over 60 years of age and with K. pneumoniae.     

嗜酸性肝脓肿的影像表现:与病理对照

目的 探讨嗜酸性肝脓肿的影像和病理表现.方法 回顾性分析8例经病理证实的嗜酸性肝脓肿的资料,分析其影像表现.结果 8例行CT增强扫描,表现为3种强化方式:动脉期病变边缘轻度强化,静脉期及延迟期呈分隔状强化3例;动脉期病变边缘轻度强化,静脉期及延迟期呈蜂窝状强化4例;动脉期病变表现为连续的环状强化,静脉期及延迟期呈低密度1例.MR检查2例,平扫病灶均呈T1WI等、T2WI高信号,DWI表现为高信号;MR增强扫描动脉期病变呈蜂窝状强化,静脉期及平衡期持续强化.结论 了解嗜酸性肝脓肿的影像表现对于提高该病的诊断准确率具有重要意义.     

Description of Streptococcus pneumoniae infections in burn patients

Background

Longer survival in burn patients has resulted in more infectious complications, typically with Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, and Staphylococcus aureus. Although Streptococcus pneumoniae infections are common in the community and can cause nosocomial infections, the incidence and risk factors for pneumococcal infections in burn patients is unclear.

Methods

We performed an electronic retrospective chart review to collect rates of and risk factors for S. pneumoniae infections in patients with thermal burns from March 2003 through June 2008.

Results

Of the 1838 patients admitted to the burn center, 10 were infected (0.54% incidence). Patients presented with pneumonia (seven patients, 0.38% incidence) and bacteremia (three patients, 0.16% incidence) within a week of initial burn (median 1 day, range 0–8), often in the setting of bacterial co-infection (five patients). This group was mainly young males with median 28.8% total body surface area burns; 60% had concomitant inhalational injury. Most did not have traditional risk factors for pneumococcal infection but had objective signs of infection at time of positive culture and were treated with appropriate antibiotics. Two patients in this series died, although no mortality was attributed to S. pneumoniae.

Conclusions

Pneumococcal disease is not common in burn patients and generally occurs early on in hospitalization after burn making it more likely to be a community-acquired pathogen rather than nosocomial in the burn population. It should be considered in the setting of sepsis or new pulmonary infiltrates within a week after burn, but typical empiric antibiotics against the usual burn pathogens should be adequate to also treat for pneumococcal infection.     

Incidence and bacteriology of burn infections at a military burn center

Considerable advancements in shock resuscitation and wound management have extended the survival of burned patients, increasing the risk of serious infection. We performed a 6-year review of bacteria identification and antibiotic susceptibility records at the US Army Institute of Surgical Research Burn Center between January 2003 and December 2008. The primary goal was to identify the bacteria recovered from patients with severe burns and determine how the bacteriology changes during extended hospitalization as influenced by population and burn severity. A total of 460 patients were admitted to the burn ICU with 3507 bacteria recovered from 13,727 bacteriology cultures performed. The most prevalent organisms recovered were Acinetobacter baumannii (780), Pseudomonas aeruginosa (703), Klebsiella pneumoniae (695) and Staphylococcus aureus (469). A. baumannii was most often recovered from combat-injured (58%) and S. aureus the most frequent isolate from local (46%) burn patients. Culture recovery rate of A. baumannii and S. aureus was highest during the first 15 hospital days (73% and 71%); while a majority of P. aeruginosa and K. pneumoniae were recovered after day 15 (63% and 53%). All 4 pathogens were recovered throughout the course of hospitalization. A. baumannii was the most prevalent pathogen recovered from patients with total body surface area (TBSA) burns less than 30% (203) and 30–60% (338) while P. aeruginosa was most prevalent in patients with burns greater than 60% TBSA (292). Shifting epidemiology of bacteria recovered during extended hospitalization, bacteriology differences between combat-injured and local burn patients, and impact of % TBSA may affect patient management decisions during the course of therapy.     

Subdural Empyema Due to Lactococcus lactis cremoris: Case Report

Lactococcus lactis cremoris (L. lactis cremoris) infections are very rare in humans. Only three case reports of brain abscess have been reported and the infectious routes and pathological features are still unknown. We experienced a subdural empyema due to L. lactis cremoris in an immunocompetent adult. A 33-year-old man was admitted with fever, right facial pain, left hemiparesis, and left hemianopsia. Computed tomography demonstrated low density fluid collection in the right falcotentorial subdural space. Magnetic resonance (MR) images revealed a high signal lesion on a diffusion-weighted image (DWI) and fluid attenuated inversion recovery (FLAIR) images in the right paratentorial and parafalcine subdural space, right maxillary sinus, and bilateral ethmoidal sinus. He underwent two sequential open surgeries for removal and drainage of empyema and was treated with antibiotics including meropenem and ampicillin. To our knowledge, this is the first report of subdural empyema caused by L. lactis cremoris infection. We report the case and discuss the pathological features with the previous literature.     

Pneumoperitoneum caused by ruptured gas-containing liver abscess

An 84-year-old woman was admitted to our hospital with high fever, and she suddenly complained of severe abdominal pain the next day. Computed tomography revealed a gas-containing abscess in the lateral segment of the liver, with spontaneous pneumoperitoneum. An emergency lateral segmentectomy was performed, and Klebsiella pneumoniae was cultured from the liver tissue, abscess, and blood. The patient made a satisfactory recovery and was discharged on the thirty-first postoperative day. Pneumoperitoneum caused by the rupture of a gas-containing liver abscess is rare, and to our best knowledge, this is the first report, in the English-language literature, of a patient who has undergone successful hepatectomy for such a condition.     

Growth factor modulation of hepatic inflammation: a novel approach to the management of total parenteral nutrition-associated liver disease

Purpose

Dependence on total parenteral nutrition in intestinal failure or short bowel syndrome patients can lead to many complications. The most significant complication is progressive liver injury leading to liver failure. This study assesses the potential of hepatocyte growth factor (HGF) in modulating the hepatic response in a rat cholestatic liver injury model.

Methods

Female Sprague-Dawley rats were divided into 3 groups: control (n = 5), chronic liver injury (α-naphtylisocyocyanate [ANIT] every 3.5 days at 75 mg/kg; n = 5), and chronic liver injury plus HGF (ANIT + HGF at 250 μg kg⁻¹ d⁻¹; n = 5). The rats initially underwent massive (80%) small bowel resections. Seven days later, they were given intraperitoneal injections of saline (control) or ANIT and implantation of an osmotic minipump for continuous intravenous saline or HGF. Intraperitoneal saline or ANIT injections were subsequently administered every 3.5 days to create a chronic cholestatic model. After 14 days, the animals were euthanized, and liver biopsies were obtained. The liver biopsies were evaluated by histology, immunofluorescence staining for interleukin-6 and tumor necrosis factor α, and assessment of apoptosis by terminal dUTP-transferase-mediated nick end labeling (TUNEL) technique.

Results

In this chronic liver injury model, HGF did not effect the grade of inflammation. However, HGF did induce retention of the ductal structures and avoided ductal proliferation, damage, and evidence of primary sclerosing cholangitis (P < .05). Hepatocyte growth factor induced less interleukin-6 (P < .011) and tumor necrosis factor α (P < .01) expression. Apoptotic activity was also significantly less in the HGF group (P < .01).

Conclusion

Hepatocyte growth factor preserved the hepatic ductal system, modulated the hepatic inflammatory response, and reduced the apoptotic index in this chronic cholestatic liver injury model. It may diminish or prevent liver damage in patients with total parenteral nutrition-induced liver injury.     

Diagnosis of parapneumonic pleural effusion by polymerase chain reaction in children

Purpose

Most pleural effusions are associated with bacterial pneumonia, and the identification of the pathogen will assist the therapeutic decision. A specific method that is not affected by previous antibiotic therapy is sought to detect the main causative agents of pneumonia in infants and children (Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus). The aim of the present study was to compare the polymerase chain reaction (PCR) technique with standard culture methods in identifying bacterial infections in infants' and children's pleural effusion.

Methods

Samples obtained from pediatric patients (n = 37) with a diagnosis of pneumonia associated to pleural effusion, submitted to thoracentesis, were analyzed by PCR with specific primers.

Results

The PCR technique identified the presence of bacterial infection in a larger proportion (95.2%) than the standard culture method (33.3%) on complicated pleural effusion samples. The microorganism detection on uncomplicated pleural effusion samples was positive only by the PCR method (31.3%). The frequencies of microorganisms identified on complicated pleural effusion were 57.1% of all patients for methicillin-resistant Staphylococcus; 52.4%, S pneumoniae; 28.6%, S aureus; and 23.8%, H influenzae. The previous use of antibiotics interferes with standard culture method, but it did not interfere with the PCR results.

Conclusions

The molecular diagnosis by PCR method could improve the etiologic diagnosis and might help to guide the treatment of parapneumonic effusion in children.     

Triparesis caused by gas-containing extensive epidural abscess secondary to Aeromonas hydrophila infection of a thoracic vertebroplasty: a case report

Background context

Aeromonas hydrophila is a motile gram-negative non-sporeforming rod with facultative anaerobic metabolism. Except for gastrointestinal disease, skin and soft-tissue infections represent the second most common site of human Aeromonas infections. However, to our knowledge, A. hydrophila infection of the spine has not been reported to date.

Purpose

To report the first case of A. hydrophila spinal infection of the T7 vertebra after vertebroplasty.

Study design

Case report.

Methods

A 72-year-old man was transferred to our emergency department with chief complaints of severe midthoracic pain and triparesis. He had undergone vertebroplasty for a painful vertebral fracture at T7 5 weeks before transfer. Magnetic resonance imaging showed an infection of the T7 vertebroplasty and an extensive epidural abscess. The epidural abscess originating from the infected T7 vertebroplasty extended from the T8 to the C4 epidural space. Computed tomography demonstrated sparsely scattered gas in the epidural abscess, strongly suggestive of an anaerobic infection.

Results

Emergency multilevel laminectomies from C5 to T8 and a posterior instrumentation from T3 to T10 were performed. A. hydrophila was isolated from the blood cultures. The patient was treated with intravenous ampicillin/sulbactam. Posterior decompression and stabilization in combination with appropriate antibiotic treatment completely resolved the neurologic deficit and infection without the need for further anterior corpectomy of the infected T7 vertebroplasty.

Conclusions

This is the first reported case of spine infection caused by A. hydrophila. The infection developed after vertebroplasty for the management of a painful vertebral fracture. Triparesis occurred rapidly due to an extensive epidural abscess containing gas. Emergency decompression and stabilization in combination with appropriate antibiotic treatment achieved a successful clinical outcome.     

Propionibacterium acnes infection after shoulder surgery

Propionibacterium acnes has been implicated as a cause of infection following shoulder surgery, may occur up to 2 years after the index operation and has been shown to be responsible for up to 56% of shoulder infections after orthopedic implant. Male patients within the population undergoing shoulder surgery are particularly at risk, especially if their shoulder surgery involved prosthesis or was posttraumatic. P. acnes infection can be difficult to diagnose clinically and laboratory techniques require prolonged and specialized cultures. Usual inflammatory markers are not raised in infection with this low virulence organism. Delayed diagnosis with P. acnes infection can result in significant morbidity prior to prosthesis failure. Early diagnosis of P. acnes infection and appropriate treatment can improve clinical outcomes. It is important to be aware of P. acnes infection in shoulder surgery, to evaluate risk factors, to recognize the signs of P. acnes infection, and to promptly initiate treatment. The signs and symptoms of P. acnes infection are described and discussed. Data were collected from PubMed™, Web of Science, and the NICE Evidence Healthcare Databases - AMED (Ovid), BNI (Ovid), CINAHL (EBSCO), Embase (Ovid), HMIC: DH-Data and Kings Fund (Ovid), Medline (Ovid), and PsycINFO (Ovid). The search terms used were “P. acnes,” “infection,” “shoulder,” and “surgery.” In this review, we summarize the current understanding of the prevention and management of P. acnes infection following shoulder surgery.     

Klebsiella pneumoniae carrying blaNDM-1 gene in orthopedic practice

Emergence and spread of carbapenemases in Enterobacteriaceae is a cause of concern worldwide, the latest threat being New Delhi metallo-β-lactamase (NDM-1). This report is of an orthopedic case with fracture femur managed with internal fixation and bone grafting, who subsequently developed secondary infection with Klebsiella pneumoniae harboring bla_NDM-1 gene. Minimum inhibitory concentration (MIC) of imipenem was ≥8 μg/ml by E-test, suggestive of carbapenemase production. Phenotypic and further genotypic detection confirmed the presence of bla_NDM-1 gene. The isolate remained susceptible only to tigecycline, colistin, and polymyxin B.