Candida glabrata infection of a pancreatic pseudocyst in a COVID-19 patient: A case report and review of the literature

Abstract

Introduction
Pancreatic pseudocysts remain a feared complication of acute or chronic pancreatitis and are often characterized by collections of fluids due to underlying damage to the pancreatic ducts, culminating in a walled-off region bereft of an epithelial layer but surrounded by granulation tissue. While fungal infections of pancreatic pseudocysts are rarely encountered, candida albicans remains the most frequently implicated organism.

Case presentation
A 55-year-old male presented with pain in the left-hypochondriac region, accompanied by non-bilious emesis and nausea. Interestingly, the patient also tested positive for a COVID-19 infection. Investigative workup divulged enhancing pancreatic walls with a radiologic impression consistent with a pancreatic pseudocyst. An ultrasound-guided external drainage was performed; the drainage was conducted unremarkably, with the resultant fluid collection revealing the presence of Candida Glabrata. The patient was commenced on antifungal therapy and continues to do well to date.

Discussion
Infectious ailments of pancreatic pseudocysts remain a widely known complication of acute pancreatitis. While it is rare, fungal infection is a crucial consideration for patients with pancreatic pseudocysts, especially in the context of a lack of an adequate response to antibiotics, deterioration, comorbidities, and immunocompromised states.

Conclusion
Rapid identification of the microbe responsible for pancreatic pseudocyst infection is vital for time-sensitive treatment and a more rapid recovery, curbing associated morbidity and mortality.

Full text

Annals of Medicine and Surgery 77 (2022) 103648
Available online 19 April 2022
2049-0801/© 2022 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
Case Report
Candida glabrata infection of a pancreatic pseudocyst in a COVID-19
patient: A case report and review of the literature
Mohammad Aasim Khan
a
, Talal Almas
b
, Muneeb Ullah
c
,
*
, Maha Alkhattab
d
, Fathema Shaikh
e
,
Sufyan Shaikh
e
, Isha Bagwe
f
, Meetty Antony
g
, Tarek Khedro
b
, Vikneswaran Raj Nagarajan
b
,
Joshua Ramjohn
h
, Reema Alsufyani
b
, Dana Almubarak
b
, Abdulla Hussain Al-Awaid
b
,
Majid Alsufyani
b
, Dhineswaran Raj Nagarajan
i
, Muhammad Omer Khan
b
, Helen Huang
b
,
Mert Oruk
b
, Arjun Samy
b
, Nagi Alqallaf
b
, Adil Sha
c
, Aqsa Adeel
c
, Muhammad Kashif Khan
c
,
*
a
Khyber Medical College, Peshawar, Pakistan
b
RCSI University of Medicine and Health Sciences, Dublin, Ireland
c
Department of Surgery, Maroof International Hospital, Islamabad, Pakistan
d
Department of Surgery, Galway University Hospital, Galway, Ireland
e
University of Toronto, Toronto, Canada
f
Mercy University Hospital, Cork, Ireland
g
Jawaharlal Nehru Medical College, Belgaum, India
h
Sligo University Hospital, Sligo, Ireland
i
Sunway University School of Medicine and Health Sciences, Subang Jaya, Malaysia
ABSTRACT
Introduction: Pancreatic pseudocysts remain a feared complication of acute or chronic pancreatitis and are often characterized by collections of uids due to un-
derlying damage to the pancreatic ducts, culminating in a walled-off region bereft of an epithelial layer but surrounded by granulation tissue. While fungal infections
of pancreatic pseudocysts are rarely encountered, candida albicans remains the most frequently implicated organism.
Case presentation: A 55-year-old male presented with pain in the left-hypochondriac region, accompanied by non-bilious emesis and nausea. Interestingly, the patient
also tested positive for a COVID-19 infection. Investigative workup divulged enhancing pancreatic walls with a radiologic impression consistent with a pancreatic
pseudocyst. An ultrasound-guided external drainage was performed; the drainage was conducted unremarkably, with the resultant uid collection revealing the
presence of Candida Glabrata. The patient was commenced on antifungal therapy and continues to do well to date.
Discussion: Infectious ailments of pancreatic pseudocysts remain a widely known complication of acute pancreatitis. While it is rare, fungal infection is a crucial
consideration for patients with pancreatic pseudocysts, especially in the context of a lack of an adequate response to antibiotics, deterioration, comorbidities, and
immunocompromised states.
Conclusion: Rapid identication of the microbe responsible for pancreatic pseudocyst infection is vital for time-sensitive treatment and a more rapid recovery, curbing
associated morbidity and mortality.
1. Introduction
Pancreatic pseudocysts remain a feared complication of acute or
chronic pancreatitis. They are often characterized by collections of uids
due to underlying damage to the pancreatic ducts, culminating in a
walled-off region bereft of an epithelial layer but surrounded by gran-
ulation tissue [1]. The reported incidence rate of acute pseudocysts as
post-pancreatitis complications hovers around 6–18%, with chronic
pseudocyst reported in upwards of 20–40% of cumulative cases [2].
They frequently present with a vague constellation of symptoms,
typied by abdominal pain, distension, covert bleeding, nausea, and
vomiting [3]. Clinically, pseudocysts pose a diagnostic conundrum and
are often mistaken for recurrent or chronic pancreatitis [3]. Infectious
ailments of pseudocysts present an additional challenge, with the
mainstay of treatment being endoscopic or external drainage [1–3].
While fungal infections of pancreatic pseudocysts are rarely encoun-
tered, candida albicans remains the most frequently implicated organ-
ism [4]. Nevertheless, infection with candida glabrata remains
exceedingly rare. In the present paper, we elucidate the case of a
55-year-old male who presented with pain in the left-hypochondriac
* Corresponding authors. Department of Surgery, Maroof International Hospital, Islamabad, Pakistan.
E-mail address: Talalalmas.almas@gmail.com (T. Almas).
Contents lists available at ScienceDirect
Annals of Medicine and Surgery
journal homepage: www.elsevier.com/locate/amsu
https://doi.org/10.1016/j.amsu.2022.103648
Received 16 February 2022; Received in revised form 15 April 2022; Accepted 15 April 2022

Annals of Medicine and Surgery 77 (2022) 103648
2
region, accompanied by non-bilious emesis and nausea. Interestingly,
the patient also tested positive for a COVID-19 infection. Investigative
workup by employing a computed tomography (CT) scan divulged
enhancing pancreatic walls with a radiologic impression consistent with
a pancreatic pseudocyst. An ultrasound-guided external drainage was
performed; the drainage was conducted unremarkably, with the resul-
tant uid collection sent for further culture and sensitivity examination,
revealing the presence of Candida Glabrata. The patient was
commenced on antifungal therapy and continues to do well to date.
2. Case Presentation
A 55-year-old male presented to the emergency department with a
three-day history of dull aching, gradually worsening left hypochon-
driac region pain accompanied by non-bilious emesis and profound
nausea. Pertinently, the patient reported that the pain had no temporal
association with eating or drinking, and further stated that physical
activity would exacerbate the pain intensity, resulting in immobility and
ambulatory dysfunction over the past three days.
The patient initially sustained an episode of acute pancreatitis of
unknown etiology 18-months ago, which promptly responded to con-
servative medical management. Consequently, the patient developed a
pancreatic pseudocyst as a complication of his recurrent bouts of
pancreatitis. The pseudocyst continued to enlarge in size until the pa-
tient presented to the emergency department three months prior to the
current presentation. Gastroenterology was consulted at the time and a
cystogastrostomy was performed to facilitate drainage into the stomach
cavity. A computed tomography (CT) scan at the time divulged
enhancing pancreatic walls with a radiologic impression consistent with
a pancreatic pseudocyst. Radiological imaging at the time further
revealed an unremarkable liver and a gallbladder replete with gallstones
within the gallbladder lumen. The gallbladder otherwise appeared
normal and no biliary ductal dilation was noted; however, there was
appreciable fatty inltration of the pancreas along with wall thickening
consistent with a pancreatic pseudocyst in the setting of recurrent bouts
of acute pancreatitis. Interestingly, the patient had tested positive for a
COVID-19 infection four days prior to the onset of his symptoms.
In order to better elucidate the etiology underlying the patient’s
current presentation, amylase and tumor marker levels, including CEA
and CA-19-9, were ordered to exclude an underlying malignancy pro-
cess. All tumour markers and amylase levels were unremarkable.
Following cystogastrostomy, the patient was discharged in a stable state.
However, two days later, the patient returned with a constellation of
symptoms including spiking fevers to 101.3◦fahrenheit, dull aching
pain in the right upper quadrant, and nausea and vomiting. Considering
the presence of an infectious process, intravenous antibiotics were
started and resulted in downtrending C-reactive protein levels from 420
μ
g/mL to 322
μ
g/mL over three days. Concurrently, the leukocytosis
also abated, resulting in downtrending levels of 16000 cells/mL on day
1–11000 cells/mL on day 3 of admission. Given the patient’s history of
pancreatitis, a CT scan of the abdomen was performed and revealed a
large pancreatic pseudocyst (Fig. 1).
Furthermore, an infected pancreatic pseudocyst communicating with
the posterior stomach wall, consistent with an intact cystogastrostomy,
was noted (Fig. 2, Fig. 3).
The upper and lower limits of the pancreatic pseudocyst were also
delineated by the CT scan and reveal exorbitant proportions consistent
with a diagnosis of a huge infected pseudocyst (Fig. 4, Fig. 5).
A multidisciplinary team meeting was thus conjured in order to
facilitate optimal management. Input from the infectious disease, gen-
eral surgery, gastroenterology, and interventional radiology teams was
considered and a decision to proceed with ultrasound (US)-guided
external drainage was made. The drainage was conducted unremark-
ably, with the hemorrhagic uid collection sent for further culture and
sensitivity examination. Following US-guided drainage, the patient
returned to his baseline afebrile state, and the CRP downtrended to 130
μ
g/mL. Interestingly, the culture turned out positive for heavy growth of
Candida glabrata, which was noted to be susceptible to uconazole and
amphotericin B; however, it was intermediately resistant to caspofungin.
At this point, the differentials included an infected pseudocyst,
pancreatic abscess, and various subcategories of neoplasms. Thereafter,
a decision to commence uconazole and meropenem in order to curb
residual infection was made. The drain output continued to drain
200–300 mL of uid. Post-operatively, the patient continued to do well
with thorough abatement of his symptoms after surgery. The present
paper was reported in accordance with the SCARE guidelines [5]. The
patient received supportive treatment postoperatively within the hos-
pital for three days thereafter, with regular inammatory parameters
and routine laboratory workup showing resolution in derangement.
3. Discussion
Infectious ailments of pancreatic pseudocysts remain a widely known
Fig. 1. CT scan of the abdomen revealing a huge pancreatic pseudocyst.
Fig. 2. An infected pancreatic pseudocyst communicating with the posterior
stomach wall, consistent with an intact cystogastrostomy.
Fig. 3. Lateral view depicting pseudocyst communication with the posterior
stomach wall.
M.A. Khan et al.

Annals of Medicine and Surgery 77 (2022) 103648
3
complication of acute pancreatitis. Medical and surgical literature is
replete with studies detailing pancreatic pseudocyst infections, many of
which are delineated in Table 1 [7–26]. In 2018, Shi et al. presented the
case of a 26-year-old Chinese woman presenting with severe acute
pancreatitis with subsequent hospitalization [6]. Following hemody-
namic instability, she was determined to have multiple-organ dysfunc-
tion syndrome. Treatment ensued, which led to improvement in her
condition over 18 days. On day 19, the patient’s temperature spiked, and
meropenem and linezolid were administered empirically while awaiting
blood culture results [6]. On day 20, the patient continued experiencing
high fevers. Blood culture results returned positive for a fungal blood
infection, which prompted administration of caspofungin and discon-
tinuation of the antibacterials. Gene detection methods conrmed
Candida glabrata as the causative agent. She was discharged on day 33
of admission and continued to do well.
In another case report, a 45-year-old man was hospitalized for a
constellation of symptoms, characterized by early satiety, worsening
epigastric pain, hypoglycemia, and altered mental status three weeks
after his hospitalization for acute pancreatitis [7]. He began experi-
encing these symptoms while at a rehabilitation facility, as his acute
pancreatitis episode was presumed secondary to alcohol abuse. A day
two abdominal computed tomography (CT) scan revealed a mass
consistent with a pancreatic pseudocyst, and blood cultures revealed
Burkholderia cepacia resistant to amikacin, cefepime, ciprooxacin,
gentamicin and piperacillin-tazobactam and sensitive to ceftazidime,
meropenem, and trimethoprim-sulfamethoxazole (TMP-SMX). By day
10 of ceftazidime treatment, the patient continued to experience spiking
fevers [7]. A CT-guided drainage of the pseudocyst with culture revealed
multidrug-resistant (MDR) B. cepacia, Candida dubliniensis, and
Candida glabrata. Micafungin was added to his regimen. On day 15, a
cyst gastrostomy was performed with stent placement using endoscopic
ultrasound. However, a biliary stricture prevented adequate endoscopic
retrograde pancreatography (ERCP), and an AXIOS stent was placed.
The drained uid continued to grow MDR B. cepacia. Two weeks later,
repeat ERCP with sphincterotomy and stent removal was performed.
Repeated CT after two weeks showed a dwindling pseudocyst. Despite
these measures and the continuation of ceftazidime and micafungin for
10 weeks, the patient experienced recurring symptoms and growth of
the cyst. Finally, four months after his diagnosis, surgical intervention
with explorative laparotomy and open cystogastrostomy revealed a
pus-lled pseudocyst and necrotic pancreas. This intervention proved
denitive, with improvement and infection elimination [7].
Another case report from Germany implicated a 34-year-old woman
suffering from alcoholic hepatitis and an acute-on-chronic pancreatitis
who developed Candida infection of a pseudocyst 12 days post-ERCP
[8]. She successfully recovered after US-guided percutaneous drainage
followed by IV and intracavity amphotericin B and obliterative therapy
using a tetracycline [8]. Another case report detailed the successful
treatment of a 48-year-old man’s pancreatic pseudocyst infected with
Candida albicans using a Roux-en-Y cystojejunostomy and amphotericin
B as an adjuvant [9]. Other cases of pancreatic pseudocyst fungal in-
fections have been discussed in the literature, including one in a post-
partum woman [10,11].
Fungal infection of a pancreatic pseudocyst has proven to be rapidly
fatal. A 40-year-old man with a history of diabetes mellitus, congestive
heart failure, alcoholic cirrhosis, and acute-on-chronic pancreatitis was
determined to be septic despite negative blood cultures [12]. After
appropriate treatment, multiple antibiotic therapy, and total parenteral
nutrition, the patient slowly improved. However, imaging revealed the
development of a phlegmon that transformed into pseudocysts, and
percutaneous aspiration and culture revealed Candida albicans infec-
tion, which led to dissemination [12]. Treatment with amphotericin B
and aggressive supportive care proved insufcient, and the patient
deteriorated and expired due to multiple organ system failure [12].
A retrospective study of patients with walled-off pancreatic necrosis
between 2005 and 2013 fungal infection was documented in 57 of 123
patients (46%) [13]. The most common pathogen implicated was
Candida albicans (55%) followed by Candida glabrata (20%) [13].
Moreover, there was no signicant difference in mortality between those
treated with antifungals after the rst conrmation of fungal infection
versus those not treated or treated inadequately [13]. A total of 10 pa-
tients (18%) with fungal infection died, three with concomitant funge-
mia and seven with isolated walled-off necrosis. In another similar
retrospective study, 54 patients of 136 (40%) were found to have
Candida-infected pancreatic necrosis, of which seven developed candi-
demia [14]. Here, patients with concomitant candidemia boasted a
signicantly higher mortality rate (57.1% vs 20.2%, p =0.042) [14].
While it is rare, fungal infection is a crucial consideration for patients
with pancreatic pseudocysts, especially in the context of a lack of an
Fig. 4. Upper limit of the infected pancreatic pseudocyst.
Fig. 5. Lower limit of the infected pancreatic pseudocyst.
M.A. Khan et al.

Annals of Medicine and Surgery 77 (2022) 103648
4
Table 1
Baseline characteristics, fungal etiology, and management in studies reporting incidences of fungal pseudocyst infection.
Author Year Age &
Gender
Finding Predisposing
factors
Presenting
symptoms
Fungal type Management Outcome Follow up
Rawi et al.
[7]
2020 45 M Pancreatic
pseudocyst
Alcohol abuse Abdominal pain
radiating to the
back, early
satiety and
fevers
Burkholderia
cepacia,
Candida
dubliniensis,
Candida
glabrata
CAZ, MCFG. SD: ex-
lap cystojejunostomy
Recovered No follow up
mentioned
Frommeyer
et al. [8]
1991 34 F Pancreatic
pseudocyst
Alcohol abuse,
ERCP
– Candida AmB, TET, PD Recovered Cant access full
article
Zulkaroglu
et al. [9]
2004 48 M Pancreatic
pseudocyst
BSA Abdominal pain
and fevers.
Candida
albicans
Am B (1mg/kg/day);
SD: ex-lap: Roux-en-Y
cystojejunostomy
with internal
drainage
Recovered 6 month –
asymptomatic, no
abx needed
Chia et al.
[11]
1990 18 F Pancreatic
pseudocyst
Pregnancy Abdominal
pain, nausea,
vomiting, sore
throat,
odynophagia
and night
sweats
Candida
albicans
AmB (1000mg), SD Recovered Cant access full
article
Foust [12] 1996 40 M Pancreatic
pseudocyst
Alcohol abuse,
chronic
pancreatitis
Intermittent
fever
Candida
albicans
PD, AmB Died Nil
Gupta et al.
[15]
2009 4 F Pancreatic
pseudocyst
Sodium valproate Abdominal
pain, feeding
intolerance,
diarrhoea and
fever.
Candida
glabrata
SD Recovered No follow up
mentioned
Premkumar
et al. [17]
2021 51 M Pancreatic
pseudocyst
Alcohol abuse Epigastric pain
radiating to
back, fever and
vomiting.
Candida
glabrata
sensitive to
uconazole.
FLZ (14 days), ED Recovered 2 week post op:
Follow-up contrast-
enhanced CT of the
abdomen reported
complete collapse
of the cyst cavity
Janani et al.
[18]
2017 42 F Pancreatic
pseudocyst
Alcohol abuse,
chronic
pancreatitis
Abdominal pain
and fevers
Candida
albicans
FLZ, MEM; SD: ex-lap
with debridement,
open abdomen with
wound-vac drainage
and several PWT
Recovered Cant access full
article
Olivero et al.
[19]
1973 42 M Pancreatic
pseudocyst
Renal transplant Persistent
abdominal pain
and fevers
Candida
albicans
AmB (775mg), SD:
ex-lap:
cystojejunostomy
Recovered Cant access full
article
Chemsi et al.
[20]
2018 65
unknown
Pancreatic
pseudocyst
End-stage chronic
kidney disease
Acute
pancreatitis
Acinetobacter
baumanii,
Candida
albicans
FLZ, Colistin, ED Recovered No follow up
mentioned
Kumar et al.
[21]
2011 45 F Pancreatic
necrosis
and abscess
None Abdominal pain
and respiratory
distress
Escherichia coli,
Candida
tropicalis
IPM, Am B,
necrosectomy
Recovered Indicates the
patient was
followed up –
unknown time and
method of follow
up
Shekar et al.
[22]
1992 71 M Pancreatic
pseudocyst
Recent
cholecystectomy,
appendicectomy
Fevers Candida
albicans
FLZ, Am B, 5FC, PD Died Nil
Worthington
et al. [23]
1984 73 M Pancreatic
abscess
Aortic aneurysm
repair
– Candida
albicans
SD Died Nil
Howard et al.
[24]
1988 66 M Pancreatic
abscess
Aortic
aneurysmectomy,
BSA
Fevers Candida
albicans
Am B (480mg), SD:
limited laparotomy
and FNA
Recovered Cant access full
article
Fitzgerald
et al. [25]
2014 65 M Pancreatic
abscess
Splenectomy – Candida
albicans
BSA, PD Recovered Cant access full
article
Keiser et al.
[26]
1992 20 F Pancreatic
pseudocyst
Idiopathic chronic
pancreatitis
Abdominal pain
and fevers
Enterobacter
cloacae,
Xanthomonas
maltophilia,
Candida
albicans.
Mezlocillin,
gentamicin, Am B
(869 mg), SD
Recovered Cant access full
article
Keiser et al.
[26]
1992 37 F Pancreatic
abscess
Alcoholic abuse,
chronic
pancreatitis
Abdominal pain
and fevers
Enterobacter
cloacae,
Pseudomonas
aeruginosa,
Candida
albicans
BSA, Am B(1500mg),
SD
Recovered Cant access full
article
M.A. Khan et al.

Annals of Medicine and Surgery 77 (2022) 103648
5
adequate response to antibiotics, deterioration, comorbidities, and
immunocompromised states [15]. In its exacerbated forms, pseudocysts
can culminate in additional sinister complications such as secondary
pleural effusions [15]. Retrospective analysis of patients with pancreatic
pseudocysts in Germany divulged that patients with fungal infection of
pseudocysts had longer hospital stays, required more aggressive treat-
ment strategies, and had lower 1-year survival when compared to those
aficted with bacterial etiologies [16].
In the present paper, uconazole- and amphotericin B-susceptible
Candida glabrata was isolated, and uconazole was thus used in com-
bination with meropenem to thwart the potential for residual infection.
The patient recovered with prompt eradication of infection and his
symptoms subsequently abated. Finally, the patient’s conrmed COVID-
19 infection poses the question surrounding a possible link to his sus-
ceptibility to this rare pseudocyst infection. Not uncommonly, COVID-
19 has been reported to induce a cytokine storm and susceptibility to
secondary infections. In this case, admittedly, we cannot ascertain
whether concurrent COVID-19 infection played any major role in the
development of this Candida glabrata infected pancreatic pseudocyst.
Further studies with similar patient populations are therefore warranted
in order to better inform the debate on what constitutes optimal medical
and surgical management.
4. Future direction
The results of this study are interesting as it showcases the rare case
of the incidence of pancreatic pseudocysts with concurrent infection by
COVID-19. This raises the question whether infection from COVID-19
potentially plays a mediating role in developing complications to a
pre-existing medical condition. Prior data and research in this area are
sparse which warrants further investigation. Future studies should
investigate the relationship between fungal infections of pancreatic
pseudocysts and COVID-19, if one exists. We propose the implementa-
tion of double blinded placebo randomized control trials to fully eluci-
date the link between complications of pancreatitis and COVID-19. Not
only will this inform us of the role COVID-19 plays in the development of
complications or side effects for pancreatic pseudocysts, but also open
the doors to investigating how other rare diseases may be affected by
concurrent infection with COVID-19.
5. Conclusion
Fungal infections of pancreatic pseudocysts remain a rare but well-
studied complication of acute pancreatitis. While pancreatic pseudo-
cysts can spontaneously remit, percutaneous, endoscopic, or even sur-
gical intervention may eventually be warranted. Telltale signs of an
infected pancreatic pseudocyst include a patient with worsening
symptoms and positive blood cultures. Rapid identication of the
responsible microbe is vital for time-sensitive treatment and a more
rapid recovery. Especially in the case of fungal species, predominantly
Candida spp, aggressive treatment with antifungal agents is warranted
to curb the risk of disseminated candidemia. Further studies with similar
patient populations are warranted to further explore the possible link
between Covid-19 and development of fungal pseudocyst infection.
Ethical approval
NA.
Sources of funding
N/A.
Author contributions
MAK, TA, MU, MA, FS, SS, IB: conceived the idea, designed the study,
and drafted the manuscript.
AS, AA, MKK: Curated the literature review table and revised the rst
draft of the paper critically.
TK, VRN, JR, MS, RA, DA: conducted literature search and created
the illustrations.
AHA, MA, DR, MA, IB, FS, SS, MA: revised the manuscript critically
and rened the illustrations.
DRN, OK, HH, MO, AS, NA: revised the nal version of the manu-
script critically and gave the nal approval.
Registration of research studies
Name of the registry: NA
Unique Identifying number or registration ID: NA
Hyperlink to your specic registration (must be publicly accessible
and will be checked): NA
Guarantor
Talal Almas.
RCSI University of Medicine and Health Sciences, 123 St. Stephen’s
Green, Dublin 2, Ireland, Talalalmas.almas@gmail.com.
Consent
Written informed consent was obtained from the patient for publi-
cation of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request.
Provenance and peer-review
Not commissioned, externally peer-reviewed.
Declaration of competing interest
N/A.
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Legend: ED: Endoscopic drainage (cystogastrostomy), FLZ: Fluconazole, PD: Percutaneous drainage, MEM: Meropenem, Ex-lap: Exploratory laparotomy, PWT:
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