INT J TUBERC LUNG DIS 23(9):1042–1045 Q 2019 The Union CORRESPONDENCE Correspondence A multidrug resistant tuberculosis case treated with continuous infusion of meropenem in outpatient care Multidrug-resistant tuberculosis (MDR-TB) repre- sents an emerging threat to TB control and elimina- tion. 1 MDR-TB management is a research, clinical and public health priority also in low TB incidence, high-income countries. Encouraging results have been published about the in vitro and in vivo combined anti-tuberculosis activity of b-lactam anti- biotics and b-lactamase inhibitors, such as a combi- nation of meropenem and clavulanate. 2 The main restrictions to the extensive use of meropenem is the need for continuous intravenous administration, which requires prolonged hospitalisation, with sub- sequent high costs. Continuous infusion is considered more effective than intermittent infusion for attaining optimal plasma exposure, which in turn ensures clinical efficacy and lowered risk of resistance selection. 3 In July 2014, an Australian group reported the successful utilisation of cooled elastomeric infusion devices to administer meropenem in non- TB outpatients. 4 Here, we report a MDR-TB patient who was successfully treated using a meropenem- containing second-line regimen, administered using continuous infusion in outpatient care. A 41-year old HIV-negative Italian man with a history of alcohol abuse was diagnosed with MDR- TB at the tertiary teaching hospital, St Orsola- Malpighi, Bologna, Northern Italy. In July 2014, the patient was admitted to hospital due to acute liver and renal failure (estimated creatinine clearance, 52.3 ml/min), presence of ascites and a flare up of chronic multifactorial anaemia. At admission, high-resolu- tion computed tomography scan of the chest revealed the presence of a cavity in the left upper lobe. The lesion showed an increased 18F-fluorodeoxyglucose uptake on positron emission tomography (PET), with a maximum standardised uptake value (SUV) of 8.3 (mean hepatic, SUV 1.3). The interferon-gamma release assay (IGRA) yielded positive results. All respiratory (including lung biopsy) and non-respira- tory samples (ascitic fluid) were negative on smear microscopy and Xpert w MTB/RIF (Cepheid, Sunny- vale, CA, USA). The pathological examination of lung biopsy showed the presence of granulomatous lesions suggestive of TB. The diagnosis of TB was then bacteriologically confirmed by the isolation of Mycobacterium tuberculosis on ascitic fluid culture. Drug susceptibility testing indicated resistance to rifampicin, isoniazid, ethambutol, streptomycin and second-line injectable agents. Conversely, susceptibil- ity was documented for pyrazinamide, fluoroquino- lones and linezolid (LZD). The patient was started on a second-line regimen comprising moxifloxacin, cycloserine, prothiona- mide, aminosalicylic acid and pyrazinamide. After 2 weeks, the patient developed a severe adverse event (mental confusion), attributed to cycloserine and prothionamide, which were then discontinued. Thrice-daily meropenem infusion, coupled with amoxicillin/clavulanic acid and LZD were added to the regimen; however, LZD was stopped a few weeks later due to the rapid progression of anaemia, and replaced with clofazimine. The patient was discharged after 1 month and intravenous continuous infusion of meropenem was continued using a 1% solution meropenem (3 g/day in 300 ml of normal saline, 12 ml/h) in a cooled elastomeric infusion device (Baxter Multi-rate Infu- sors LV 12; Deerfield, IL, USA) administered through a peripherally inserted central catheter. The infuser was carried over the shoulder for the whole day in a cooled bag, and the ice packs were changed every 8 h. Therapeutic drug monitoring always showed steady- state concentrations for meropenem of .2 mg/l. 5 Consistent decrease of SUV uptake was documented on 18F/FDG PET after 8 months of intensive treatment, when meropenem and amoxicillin/clavulanate were stopped. SUV uptake returned to full normalcy at the end of MDR-TB treatment (20 months). No TB relapse was documented at 2 years follow-up. This experience confirms the safety and efficacy of meropenem and amoxicillin/clavulanate use in MDR- TB treatment. The use of cooled elastomeric infusion devices can be an option for selected outpatient cases, particularly when no other therapeutic options are available. E. VANINO* M. TADOLINI* L. ATTARD* A. CASCAVILLA* F. PEA †‡ P. VIALE* *Infectious Diseases Unit, Department of Medical and Surgical Sciences St Orsola-Malpighi Hospital Alma Mater Studiorum University of Bologna Bologna † Department of Medicine University of Udine Udine ‡ Institute of Clinical Pharmacology