Tige Cycline Successfully Treats One Case of Relapsed Leukemia-drug-resistant Double Sepsis

Abstract


Background
Nowadays, tigecycline is often used in combination with other antibiotics. To the best of our knowledge, this was the rst documented use tigecycline alone for drug-resistant double sepsis in a patient suffering from leukemia.. The aim of this study is to reduce unnecessary drug combinations associated with tigecycline and use antibiotics reasonably.

Methods
The patient was a relapsed patient with advanced acute leukemia, with severe perianal infection and neutrophil de ciency. At the same time, blood culture suggested Acinetobacter lu (Imipenem resistance) and Enterococcus faecium (vancomycin resistance). The doctor has no other choice according to drug susceptibility results. Tigecycline is used alone, and conventional doses are used .
Results the patient's temperature gradually became normal, blood pressure was stable, blood in the stool stopped, perianal swelling subsided, pain was reduced, and infection improved. Conclusion generally speaking, tigecycline is a bacteriostatic agent; doctors are used to a combination of Tigecycline and other antibiotics in ghting infections.In this case, the patient's immunity is low.Tigecycline is used alone, and conventional doses are used to achieve the effect of curing double sepsis experience.This helps in the rational use of antibiotics.

History
A 29-year-old young man was admitted to the hospital because of "limb right leg, pain for 4 years, fever, blood in the stool, and sudden disturbance of consciousness for 1 week". Four years before admission, there was no cause of claudication and pain in the right lower extremity. MRI showed L5-S1 spinal canal occlusion. Neurosurgery revealed a myeloid sarcoma after surgical removal of the mass. Three years before admission, bone marrow review showed AML-M2, and bone marrow remission was achieved after chemotherapy with DA (daunorubicin + cytarabine) 3 + 7, and the patient stopped chemotherapy after DA × 3 course of consolidation chemotherapy; Local radiotherapy for L5-S1 during breaks .Two years before admission, both eyes had sudden blindness, and cranial MRI showed intracranial metastasis of leukemia; whole brain and spinal cord radiotherapy, vision improved slightly, blood routine deteriorated, and bone marrow reexamination showed recurrence of AML reach relief. After repeated vision loss to complete blindness in both eyes, despite repeated lumbar puncture, vision did not improve. 1 week ago with high fever, chills, and perianal pain; blood test routine HGB 65g / L, PLT 10 × 10 9 / L, WBC 15 × 10 9 / L, white blood cell primitive cells 80%. Blood culture was negative, and panipenem betametholone was used to reduce the pain and infection. At the same time, the dark red blood was relieved several times a day, about 100ml / day. Reduced bleeding after platelet transfusion and intravenous drip of carbsulfonate and tranexamic acid. He had unconsciousness once after bloody stool, without urinary incontinence and convulsions, he recovered after rehydration, red blood cell transfusion support and cooling, and was admitted to the hospital after emergency treatment.

Examination
Temperature was 39℃, Pulse was 110 times per minute, breath was 25 times per minute, and blood pressure was 120/80mmHg .anemia appearance, acute painful face, vision loss in both eyes; super cial lymph nodes not swollen and enlarged; liver and spleen not touched; visible in the anus External hemorrhoids, local swelling and tenderness, a suspicious sinus can be seen.

Auxiliary Examination
Treatment history: Blood test routine HGB 60g / L, PLT 10 × 10 9 / L, WBC 13 × 10 9 / L, white blood cell classi cation primitive cells 90%; bone marrow smear, ow cytometry showed recurrence of AML, and lumbar puncture of CSF 20 × 10 6 nucleated cells were routinely found, and cerebrospinal uid ow cytometry showed AML in ltration. Simultaneous treatment with methotrexate, cytarabine, and dexamethasone triple infusion; sigmoidoscopy was performed due to repeated bloody stools, showing erosion of the mucosa 10 cm from the anus.

Clinical Diagnosis And Treatment And Outcome
After admission to the hospital, he still had blood in the stool after receiving carprosulfuric acid, tranexamic acid intravenous drip, and thrombin enema; and his body temperature improved slightly before IDA (normethorubicin + cytarabine) The 3 + 7 regimen re-induced chemotherapy; granulocyte de ciency in the trough period of chemotherapy, perianal redness, swelling and pain worsened, and the daily redness of the dark red bloody stool continued to be about 50ml. With high fever, anorectal consultation considers perianal infection with high anal stula, re-examination of blood routine HGB 59g/L, PLT 8 × 10 9 /L, WBC 0.14 × 10 9 /L, no primitive cells were found in white blood cell classi cation; empirically selected antibiotics Panipenem and Betamipronwas combined with norvancomycin, but the fever still persisted daily; Check for procalcitonin 2.95ng/ml; blood draw culture at high fever shows Acinetobacter lo (Table 1) growth, according to drug susceptibility results: Acinetobacter lo is resistant to Imipenem, consider carbapenem resistance, select according to drug sensitivity Ceftriaxone combined with levo oxacin; after 2 days still having high fever and bloody stool, blood pressure was measured at 76/34mmHg, considering septic shock; ceftriaxone and levo oxacin were discontinued according to drug sensitivity, and tigecycline was used for treatment. A loading dose of 100mg was given rst, followed by a intravenous infusion of Q12h at 50mg; the body temperature showed a downward trend 2 days after the addition of tigecycline, and another blood culture was drawn showing the growth of Enterococcus faecium Table 2 ; Enterococcus faecium was resistant to vancomycin; Therefore, norvancomycin was discontinued; tigecycline alone was used for anti-infective treatment, and 50 mg Q12h intravenous drip was continued for 3 weeks; the patient's temperature gradually became normal, blood pressure was stable, blood in the stool stopped, perianal swelling subsided, pain was reduced, and infection improved.
The blood routine examination was HGB 78g/L, PLT 114 × 10 9 /L, WBC 6.39 × 10 9 /L, the bone marrow reached CR, and the patients were discharged again after a triple intrathecal injection of methotrexate, cytarabine, and dexamethasone.

Analysis And Evaluation
The patient was a relapsed patient with advanced acute leukemia, with severe perianal infection and neutrophil de ciency. At the same time, blood culture suggested Acinetobacter lu (Imipenem resistance) and Enterococcus faecium (vancomycin resistance). Tigecycline has a relatively short time to market. This patient has a good effect on sensitive bacteria. Tigecycline is a glycylcycline antibacterial drug. It inhibits bacterial protein synthesis by binding to the ribosomal 30S subunit and preventing aminoacylated tRNA molecules from entering the ribosome A site. It is similar in structure to tetracycline antibiotics; generally speaking, tigecycline is a bacteriostatic agent; nowadays, tigecycline is often used in combination with other antibiotics; For example,101 (92%) received tigecycline in combination with an antipseudomonal drug 1 . In a multicenter, open-label, randomized, superiority trial,the combination of piperacillin/tazobactam and tigecycline is more effective than piperacillin/tazobactam alone in febrile, high-risk, neutropenic hematologic patients with cancer 2 . Conclusions Although this study could not conclude that combination therapy with tigecycline was superior to monotherapy, when severe infection leaves no other choice, selection of combination drugs according to infection status and in vitro susceptibility testing is recommended 3. And clinical use of tigecycline to increase the dose; The package insert of the drug shows that the experience of treating patients with the severe underlying disease was limited. in this case, the patient's immunity is low, The doctor has no other choice according to drug susceptibility results. Tigecycline is used alone, and conventional doses are used to achieve the effect of curing double sepsis experience.

Declarations
Ethics approval and consent to participate The study was approved by the Human Ethics Committee of the West China Hospital of Sichuan University of Traditional Chinese Medicine and complied with the Declaration of Helsinki. All data/isolates were analyzed anonymously.

Consent for publication
Not applicable.
All of the authors declare that there are no competing interests in this article.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.