Case 37

Patient #37 is 52 years old (Covid19 negative) with a past medical history of type 2 diabetes mellitus, obesity, hyperlipidemia and hypertension who was tracheostomy dependent and had multiple previous hospitalizations for diabetic foot ulcers. Upon presentation to the emergency department chest x-ray showed no acute disease. On 12Oct2020 a wound culture and sputum culture were positive for CRAB resistant to all antibiotics but demonstrated intermediate susceptibility to trimethoprim and tigecycline. Phage therapy was started on 17Oct2020 IV twice a day for 36 days. Multiple sputum cultures were positive for MDR P. aeruginosa from 22Oct2020 to 31Oct2020 and sputum culture was positive on 30Oct2020 for CRAB. Nebulized phage therapy was initiated on 02Nov2020 for five days. All phage therapy was stopped on 06Nov2020 after multiple cultures were negative for CRAB. However, sputum cultures were again positive starting on 10Nov2020 prompting re-initiation of phage therapy (IV and nebulized) on 13Nov2020 which continued until 27Nov2020. A single positive blood culture for CRAB was also noted on 02Nov2020 but 9 other blood cultures were negative from 28Sep2020 to 3Dec2020. While on the second course of phage therapy 7 sputum cultures were positive for CRAB from 07Nov2020 to 26Nov2020. Phage therapy was discontinued on 27Nov2020 after two sputum cultures were negative for CRAB on 27Nov2020 and 03Dec2020. No adverse events were reported as related to phage therapy. Liver enzymes AST/ALT/ALP/TB were elevated prior to the start of phage therapy and mostly normal on 25Nov2020 (slightly elevated ALP level), two days prior to discontinuation of phage therapy on 27Nov2020. The last AST/ALT/ALP values reported were on 07Dec2020 when they had once again increased beyond normal limits.