ENTERAL ANTIBIOTIC FOR PATIENT WITH RESPIRATORY

FAILURE AND SEPTIC SHOCK IN INTENSIVE CARE UNIT: A

CASE REPORT
Mayasari 1*, Wiwi Jaya 2, Arie Zainul Fatoni 3
1
Resident of Anesthesiology & Intensive Care, Faculty of Medicine, Brawijaya University,
Saiful Anwar General Hospital, Malang, Indonesia
2
Intensivist and Anesthesiologist, Faculty of Medicine, Brawijaya Univesity, Saiful Anwar
General Hospital, Malang, Indonesia
3
Intensivist and Anesthesiologist, Faculty of Medicine, Brawijaya Univesity, Saiful Anwar
General Hospital, Malang, Indonesia
*0341-351386,maia_fk-06@yahoo.co.id

Abstract
Pneumonia is lung infection involving the lung alveoli and can be cause by microbes, including
bacteria, viruses, and fungi. It is leading infectious cause of hospitalization and death in the world
wide and exacts an enormous cost in economic and human term. American Thoracic Society
(2016) recommend, patients with Hospital-Associated Pneumonia (HAP) and Ventilator-
Associated Pneumonia (VAP) to get intravenous antibiotic. Study to asses clinical outcomes for
critically-ill patient treat with enteral antibiotic for bacterial pneumonia is still limited. We report
a case of pneumonia that cause respiratory failure and septic shock in intensive care unit treat
with enteral antibiotic and had the good outcomes.
Keyword: pneumonia, respiratory failure, septic shock, enteral antibiotic

Introduction
Despite advances in the understanding of contributing cause and prevention, HAP and

VAP continue to be frequent complications of hospital care. These infections negatively

impact important patient outcomes. Serious complication occur in HAP and VAP,

including respiratory failure, pleural effusion, septic shock, renal failure and empyema.

Optimal antibiotic management appears to one of method to safe the patient from these

diseases.
Case
A 68 years old, 75 kg man with Cancer pain ec Pancreatic Caput Carcinoma with Diabetes

Mellitus type 2 and Hypertension stage 1 was admitted at Saiful Anwar General Hospital.

Unfortunately, after 2 weeks of hospital treatment, he got worse and transferred to ICU

with pneumonia, respiratory failure and septic shock. We gave this patient empiric

antibiotic intravenous Meropenem. After a few days, culture of patient’s sputum revealed,

Klebsiella Pneumonia which was sensitive to Meropenem, Tygecyclin, Amikacin and

Cefepime, and we decided to continue intravenous Meropenem as a definitive therapy.

After 3 days evaluation, patient got worse, his antibiotic replaced with intravenous

Amikacin but no improvement of patient condition and his renal function test got worse.

Repeated sputum’s culture discovered, Acinetobacter Baumanii which was sensitive to

Amikacin and Cotrimoxazole. We decided to give this patient cotrimoxazole per enteral

than intravenous amikacin because of his renal impairment. After 48 hours cotrimoxazole

therapy, the condition of patient got better. He was extubate after 72 hours and discharge

from ICU after 5 days of cotrimoxazole therapy.

Discussion
The American Thoracic Society and Infectious Disease Society of America Guidelines

for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP)

recommend all patients be initiated on intravenous therapy. The purpose of this

intravenous therapy in critically-ill patient are for instance outcomes, and when patient

have poor oral absorption. The more rapidly achieved peak antibiotic level in blood after

intravenous dosing is an advantage when treating rapidly progressing infections such as

pneumonia with septic condition.

For most commonly antibiotic such as beta-lactams, glycopeptides or macrolides,

antimicrobial killing is not dependent on the peak levels in blood but rather on the period

of time during which antibiotic level are above the minimum inhibitory concentration.

Even allowing for the higher doses that can be given intravenously, the time above

minimum inhibitory concentration is similar for well-absorbed oral antibiotic, in this case

is co-trimoxazole, compared with intravenous antibiotics.

Enteral antibiotic in this case is co-trimoxazole was being used for treat pneumonia HAP.

It is active against many respiratory tract pathogens, including the pneumococcus,

haemophilus species, Moraxella catarrhalis, and Klebsiella pneumonia, making it a

potentially useful alternative to beta-lactam drugs for treatment of upper respiratory tract

infections and bacterial pneumonia. Co-trimoxazole well absorbed from gastrointestinal

tract and distributed widely in body fluids and tissues, including cerebrospinal fluid.

Infections with P jiroveci and some other pathogens can be treated orally with high doses

of the combination (dosed on the basis of the trimethoprim component at 15–20 mg/kg).

In this case, we choose to use enteral antibiotic to treat the patient because of his renal

impairment condition and no improvement of the condition after administration of

intravenous Amikacin.

Conclusion
Pneumonia can cause respiratory failure and septic condition. It is a human and economic

burden. Optimal antibiotic management is one of method to solve this pneumonia

problem. Benefit of utilizing enteral antibiotic are substantial and may be appropriate in

certain patients, citing the proven effectiveness and bioavailability of certain antibiotics.

In this case we choose to use it for patient safety and minimize the side effect of the
intravenous drug. And it can be the way out for remote area with minimum facility and

limited the type of drugs.

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