Diagnostic and Management Challenges in Mixed-Source MDR Sepsis in a Kidney Transplant Recipient with an Infected Sacral Pressure Ulcer Treated with VAC Therapy: A Case Report

Abstract

Background: Kidney transplant recipients are particularly vulnerable to severe infections because of chronic immunosuppression, impaired wound healing, repeated healthcare exposure, and the potential nephrotoxicity of antimicrobial therapy. We report a complex case of multidrug-resistant (MDR) sepsis in a kidney transplant recipient with two concomitant potential infectious sources: an infected sacral pressure ulcer and recurrent urinary tract infection. Case Presentation: A 31-year-old kidney transplant recipient developed traumatic paraplegia following a road traffic accident. Prolonged immobilization was complicated by a progressive sacral pressure ulcer and recurrent urinary tract infections in the setting of neurogenic bladder dysfunction. During hospitalization, wound and urinary cultures identified MDR Gram-negative organisms, including Klebsiella pneumoniae, Acinetobacter baumannii, and Proteus mirabilis. Blood cultures obtained during systemic deterioration were positive for K. pneumoniae. Diagnostic Assessment and Therapeutic Intervention: Severe systemic infection developed with hemodynamic deterioration and markedly elevated inflammatory biomarkers. Because both the urinary tract and infected sacral wound represented plausible infectious reservoirs, the primary source of bacteremia could not be established unequivocally. Management required extensive surgical debridement, negative pressure wound therapy with instillation, culture-directed antimicrobial therapy, and close monitoring of renal allograft function. Gentamicin was used as a culture-directed therapeutic option in the setting of limited antimicrobial alternatives and impaired renal function. Conclusions: This case illustrates the diagnostic and therapeutic complexity of severe MDR infection in kidney transplant recipients when multiple potential infectious sources coexist. Successful management required early source control, microbiological assessment, individualized antimicrobial selection, and multidisciplinary monitoring aimed at controlling infection while preserving renal allograft function.