Multisystem Critical Illness in Cystic Fibrosis and Pregnancy: Recurrent Enterococcal Urosepsis From Indwelling Bilateral Nephrostomy Tubes

We report a 22-year-old Gravida 1, Parity 0 (G1P0) woman with cystic fibrosis (CF) maintained on elexacaftor/tezacaftor/ivacaftor (ETI; Trikafta) who sustained four hospitalizations for recurrent extendedspectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae urosepsis in the four months preceding this admission, ultimately requiring bilateral percutaneous nephrostomy tube placement.Five days after completing a 14-day course of intravenous meropenem delivered via peripherally inserted central catheter (PICC), she presented at 27 weeks and six days of gestation with fever and left-sided flank pain.On hospital day two, she developed hemodynamic compromise consistent with severe sepsis.Blood and urine cultures confirmed Enterococcus faecalis bacteremia.The emergence of Enterococcus faecalis raised concern for antibiotic-driven enterococcal selection pressure from repeated carbapenem exposure.The hospitalization was complicated by acute anemia requiring transfusion of two units of packed red blood cells (PRBC), with the lowest recorded value of hemoglobin being 6.7 g/dL (normal 11.6-15.0g/dL).Procalcitonin, a marker of bacterial infection severity, was elevated at 3.64 ng/mL (normal ≤0.15 ng/mL).Serum lactate was measured serially throughout the intensive care unit (ICU) stay and remained within normal limits, with a peak value of 1.5 mmol/L (normal 0.5-2.2mmol/L).By the Sepsis-3 consensus definition, a serum lactate above 2.0 mmol/L in conjunction with vasopressor requirement is needed to meet the formal diagnosis of septic shock; this patient did not meet those criteria at any measured time point.Fetal echocardiography revealed atrial bigeminy with frequent premature atrial contractions (PACs), which resolved with maternal hemodynamic stabilization.Despite the severity of antepartum illness, the patient delivered a healthy male infant via spontaneous vaginal delivery at term, with Apgar scores of 8 and 9 at one and five minutes and a birth weight of approximately 8 lbs.She breastfed exclusively postpartum while continuing ETI.The establishment of a structured four-week nephrostomy tube exchange schedule under a perioperative antibiotic umbrella represents a structural source-control strategy with broad applicability to similar highrisk patients.