Anti-Infective Treatment Strategies in Case of Brainstem Hemorrhage Complicated with Pneumonia

Brainstem hemorrhage is the deadliest subtype of cerebral hemorrhage, and the mortality rate rises significantly if combined with pulmonary infection. Anti-infective drugs are of vital importance for treating cerebral hemorrhage combined with pneumonia, but diverse and complex pathogens, including drug-resistant bacteria, pose challenges. This underscores the critical importance of pharmacists who can provide comprehensive consideration and exploration of the appropriate treatment plan.

Pharmacists can provide crucial information when deciding on a treatment regimen | Image credit: ©Julien | stock.adobe.com

Case Presentation

A 41-year-old male was admitted to Zhengzhou People’s Hospital on June, 2022, due to sudden loss of consciousness for 2 hours. He was diagnosed with cerebral infarction at a local hospital and subsequently transferred with loss of consciousness (Glasgow Coma Scale score of 3), nausea, vomiting 4 times, a high fever (102.56°F), and extremely unstable vital signs. After admission, the diagnosis was brainstem hemorrhage. He had limb convulsions, deep coma, and signs of pulmonary infection. Relevant laboratory tests showed elevated white blood cell count and C-reactive protein.¹

At the beginning of treatment, the patient was in a critical state. Therefore, in the initial anti-infection treatment, piperacillin tazobactam sodium for injection was administered in accordance with relevant guidelines and the pathogen distribution and drug susceptibility data. However, 2 days later, relevant examinations and laboratory result showed that the pulmonary infection had worsened, and the possibility of intracranial impact could not to be excluded.¹

The bacteria initially considered for intracranial infection were Pseudomonas aeruginosa (PA) and Methicillin-resistant Staphylococcus aureus (MRSA). Hence, cefoperazone sodium and sulbactam sodium (covering PA) and vancomycin (covering MRSA) were used. They were subsequently combined with levofloxacin injection after PA and Klebsiella pneumoniae were cultured from the patient bronchoalveolar lavage fluid and were sensitive to levofloxacin.¹

Unfortunately, the anti-infection treatment was ineffective. The patient’s body temperature rose intermittently and the infection indicators increased to some extent. Based on the drug sensitivity results, cefoperazone sulbactam and levofloxacin injection were discontinued. The treatment was adjusted to a combined anti-infective therapy of 75 mg polymyxin B every 12 hours plus 1 g meropenem given every 8 hours. Later, the dose of polymyxin B was increased to 100 mg based on the polymyxin B area under the curve 24-hour value of 42.493 (50-100) mg.h/L, and the treatment was stopped after the body temperature returned to normal.¹

Ten days after the patient’s body temperature normalized, he suddenly developed a fever of 101.48°F and infectious shock or septic shock could not be excluded. Therefore, cefoperazone sodium sulbactam sodium was used. Cefoperazone is a third-generation cephalosporin with broad-spectrum antibacterial activity and the ability to penetrate bacterial cell membranes. It is effective against common multidrug-resistant pathogens of hospital-acquired pneumonia and health care-associated pneumonia, and can cover PA. In a study comparing the effects of cefoperazone sulbactam and piperacillin tazobactam in the treatment of gram-negative nosocomial infections, the efficacy and safety of the 2 were comparable.²

After the temperature returned to normal, the patient was transferred back to the neurosurgery department. Two days later the patient suddenly developed a fever again. It was found that the bacteria at the tip of the central venous catheter were Staphylococcus captilis, which was sensitive to vancomycin. At the same time, sputum culture showed that PA was sensitive to ceftazidime. Therefore, an anti-infection treatment regimen was implemented with a combination of vancomycin and ceftazidime. After 1 week the patient’s temperature returned to normal. Eventually, the patient was discharged from hospital for continued rehabilitation.¹

Conclusion

In this case study, the researchers explain that after the patient’s temperature rose repeatedly, polymyxin B and meropenem were used based on the results of the multidisciplinary consultation and the drug sensitivity test.¹ Study show that combining polymyxin B with other antibiotics, especially β-lactam drugs, improves survival rates.³ During the 2-year follow up after discharge, the patient adhered to the prescribed medication, had regular examinations, and underwent intermittent rehabilitation. No adverse or unanticipated event were reported.¹

This research confirms that in the complex and variable anti-infective treatment process, factors such as empirical treatment, drug sensitivity tests, interactions, dosage, and individualized care based on symptoms and drug analysis can significantly affect the patient’s outcome.

Future research could allow pharmacists to explore other similar cases with a focus on precise biomarkers for early infection detection. Researchers could also investigate the optimal combination and timing of antibiotics based on individual characteristics. Furthermore, hospitals should adopt new treatment approaches such as precision medicine based on molecular screening of drug-resistant genes, nanotherapy, and microbiota transplantation therapy.

REFERENCES

1. Wu T, Meng X, Chen N, Wang H, Yang H. Analysis of anti-infective therapy in a challenging case of brainstem hemorrhage complicated with pneumonia. Heliyon. 2024;10(24):e40988. doi:10.1016/j.heliyon.2024.e40988

2. Guclu E, Kaya G, Ogutlu A, Karabay O. The effect of cefoperazone sulbactam and piperacillin tazobactam on mortality in Gram-negative nosocomial infections. J Chemother. 2020;32(3):118-123. doi:10.1080/1120009X.2020.1730087

3. Zhao YC, Wang CY, Liu JY, et al. Factors affecting the effectiveness and safety of polymyxin B in the treatment of Gram-negative bacterial infections: a meta-analysis of 96 articles. Int J Antimicrob Agents. 2024;64(3):107262. doi:10.1016/j.ijantimicag.2024.107262