IM - CASE RECORD Every cloud has a silver lining Filippo Pieralli 1 • Silvia Baroncelli 1 • Alberto Farese 2 • Antonio Mancini 1 • Fabio Luise 1 • Lucia Sammicheli 1 • Alessandro Bartoloni 2 • Gian Maria Rossolini 3,4 • Carlo Nozzoli 5 Received: 5 April 2017 / Accepted: 28 April 2017 Ó SIMI 2017 Dr. S. Baroncelli (Internal Medicine)— presentation of the case A 54-year-old man was admitted to the Medical Interme- diate Care Unit of Azienda Ospedaliero-Universitaria Careggi in Florence, Tuscany, for a severe septic syndrome. He was healthy since 5 months prior when he underwent elective right hemicolectomy for ascending colon cancer (T2N0M0) at another hospital. The course was complicated by septic shock and diffuse peritonitis due to dehiscence of the surgical suture, requiring multiple surgical interven- tions and debridement. At that time empirical antibiotic treatment with piperacillin/tazobactam (18 g per day) plus ciprofloxacin (1500 mg per day) was initiated. The course was then complicated by severe shock and multiple organ dysfunction syndrome requiring advanced treatment, and on day 32 he was admitted to our tertiary care hospital for continuing care. During clinical stabilization with respira- tory, hemodynamic and renal replacement support, a bladder-cutaneous urinary fistula was documented. Therefore, bilateral percutaneous nephrostomies were set in place on day 62. The course was complicated by critical illness, polyneuromyopathy, and urinary tract infections, sustained by multidrug-resistant (MDR) A. baumannii, E. faecalis, K. pneumoniae and C. albicans. He was treated with several antibacterial lines, including carbapenems, fluoro- quinolones, tigecycline, linezolid and colistin, and anti- fungal therapy including micafungin and fluconazole. The result of the rectal swab was positive for car- bapenem-resistant Klebsiella pneumoniae. After clinical and laboratory improvement, with nor- malization of muscle strength and laboratory parameters, on day 83 from initial surgical intervention, the clinical course was complicated by recurrence of fever, hypoten- sion and severe weakness. Laboratory tests showed marked neutrophilic leukocytosis (34,100 WBC/mm 3 ; neutrophilic count 27,200 cell/mm 3 ), acute renal failure (blood crea- tinine 2.63 mg/dl) and signs of infection supported by procalcitonin and C-reactive protein increase (7.49 and 235 mg/l, respectively). On examination, the temperature was 39.5 °C, the blood pressure 95/55 mmHg, the pulse 88 beats per minute, the respiratory rate 14 breaths per minute, and the oxygen saturation 98% while the patient was breathing ambient air. The heart sounds were regular, without audible murmurs, and lung auscultation was normal. Chest X-ray revealed no consolidation. A contrast enhanced computed tomography (CT) of the abdomen and pelvis did not show abscesses, confirmed the well known urinary bladder fistula, and a trans-thoracic echocardiog- raphy excluded valvular vegetations. Considering the very high risk of MDR bacteria and previous cultural isolates, empirical antibiotic treatment with high dose meropenem (6 g/die), tigecycline (200 mg/ & Silvia Baroncelli silviabaroncelli5@gmail.com 1 Intermediate Care Unit, Careggi University Hospital, Largo Brambilla, 3, 50141 Florence, Italy 2 Infectious Diseases Clinic, Careggi University Hospital, Florence, Italy 3 Department of Medical Biotechnologies, University of Siena, Siena, Italy 4 Clinical Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy 5 Emergency and Internal Medicine Department, Careggi University Hospital, Florence, Italy 123 Intern Emerg Med DOI 10.1007/s11739-017-1675-z