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Case Report

Trial of Garlic as an Adjunct Therapy for MultidrugResistant Pseudomonas aeruginosa

Pneumonia in a Critically Ill Infant

Nilufer Yalindag-Ozturk, MD,1 Melda Ozdamar, MD,2 and Pelin Cengiz, MD3

Abstract

We present a case of a critically ill infant with severe multidrug-resistant Pseudomonas aeruginosa pneumonia andbacteremia who was treated with garlic and antibiotics after in vitro demonstration of a change in the resistancepattern via the disc diffusion method on garlic-treated Mueller Hinton agar. To our knowledge, this is the firstreport of therapeutic garlic use in a critically ill infant in the literature.

Introduction

Multidrug-resistant nosocomial infections are seri-ous problems faced in intensive care units. The invad-

ing bacteria express various tissue-damaging virulencefactors in accordance with their numbers in a process calledquorum sensing (QS).1 Garlic extract is shown to have activeQS-inhibiting properties in vitro, specifically for controllingvirulence genes in Pseudomonas aeruginosa.2 It is also a known

antimicrobial agent. We present an infant with severe multi-drug resistant Pseudomonas aeruginosa infection who wastreated with garlic as an adjunct therapy.

Case Report

The patient was a 1-month-old boy with d-transposition ofthe great arteries who had an arterial-switch operation. He hada complicated postoperative course due to low cardiac outputsyndrome, arrhythmias, and Klebsiella pneumoniae pneumoniafollowed by Stenotrophomonas maltophilia sepsis and pneumo-nia. While the patient was being treated with intravenous (IV)trimethoprim-sulfamethoxazole, his bronchoalveolar lavagefluid showed growth of multidrug-resistant Pseudomonasaeruginosa (MDR PA). The pathogen was also identified in thesubsequent blood cultures. The synergy tests did not suggestany effective antibiotic regimen. Combinations of ceftazidime,cefepime, amikacin, piperacillin-tazobactam, and trimetho-prim-sulfamethoxazole were used for almost 3 weeks with nosuccess. The patient had developed bilateral diffuse infiltratesand air leaks that necessitated multiple chest tubeinsertions. Heremained intubated and supported with escalating ventilatory

settings. His endotracheal tube aspirate samples repeatedlygrew MDR PA. Literature search identified the potential roleof garlic in boosting antimicrobial effects of antibiotics.3

The extract of garlic was prepared, and 1 mL was added toMueller Hinton agar as described by Rasmussen et al.2 Whenthe extract was dry, the antibiogram was performed via thedisc diffusion method using the Clinical and LaboratoryStandards Institute criteria. Compared to the standard anti-biogram, there was a 10-mm increase in the amikacin zone,

and an 11-mm increase in the piperacillin zone on the garlicagar. This finding was interpreted as an in vitro additive andsynergistic effect (Fig. 1). After explaining our findings andthe experimental nature of the planned garlic treatment to thefamily, informed consent was obtained. Empirically, 1 g offresh garlic puree was mixed with formula and given twice aday via a nasogastric feeding tube for 3 weeks. The patientreceived IV amikacin and piperacillin-tazobactam therapy for18 and 11 days, respectively. After 7 days of administration ofgarlic and the above antibiotic regimen, the endotracheal tubeaspirate and blood cultures were negative for Pseudomonasaeruginosa. His clinical status gradually improved, and he wasdischarged home 3 months postoperatively. He was doingwell at follow-up visits and at 1 year of age.

Discussion

Ventilator-associated pneumonia (VAP) is the second mostcommon hospital-acquired infection among pediatric andneonatal intensive care unit patients, and it contributes to pooroutcome and the high cost of care.4 Prior antibiotic exposuretogether with prolonged mechanical ventilation poses an en-

1Pediatric Critical Care Medicine, Department of Pediatrics, Baskent University Medical Research and Treatment Center, Istanbul, Turkey.2Department of Microbiology, Anadolu Medical Center, Gebze, Kocaeli, Turkey.3Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine, Madison, WI.

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hanced risk for the development of VAP with resistant or-ganisms, as seen in our case. Such infections often involve the

biofilm of growth, which adds to the bacteriums tolerance tothe antimicrobial treatment. QS renders the biofilm bacteriahighly tolerant to otherwise lethal doses of antibiotics, andprotects against the bactericidal activity of polymorphonuclearleukocytes. Garlic extract is shown to have active QS-inhibitingproperties in vitro.2 In a murine model, garlic blocks QS andpromotes rapid clearing of pulmonary P. aeruginosa infections.5

Garlic has been used since ancient times, with manyclaimed benefits, including antimicrobial, antiviral, and an-tifungal properties. The most common side-effects are gas-trointestinal problems and garlic breath.6 Two (2) casereports suggest a possible increase in the risk of bleedingwith garlic use.7,8

When conventional therapies fail, enteral garlic adminis-

tration could be considered if there is a change of the anti-biotic resistance pattern in vitro with garlic, with riskbenefitassessment. Although there was a resolution of the multi-drug-resistant infection and improvement in the clinicalstatus of the patient, more studies are needed to prove theefficacy of this therapy.

Acknowledgments

The authors would like to thank Alp T. Ozturk, whosuggested garlic as an adjunct therapy.

Disclosure Statement

No competing financial interests exist.

References

1. Fuqua WC, Winans SC, Greenberg EP. Quorum sensing inbacteria: The LuxR- LuxI family of cell density-responsivetranscriptional regulators. J Bacteriol 1994;176:269275.

2. Rasmussen TB, Bjarnsholt T, Skindersoe ME, et al. Screen-ing for quorum-sensing inhibitors (QSI) by use of a novel

genetic system, the QSI selector. J Bacteriol 2005;187:17991814.

3. Tsao S, Yin M. In vitro activity of garlic oil and four diallylsulphides against antibiotic-resistant Pseudomonas aeruginosaand Klebsiella pneumoniae. J Antimicrob Chemother 2001;47:665670.

4. Foglia E, Meier MD, Elward A. Ventilator-associated pneu-monia in neonatal and pediatric intensive care unit patients.Clin Microbiol Rev 2007;20:409425.

5. Bjarnsholt T, Jensen PO, Rasmussen TB, et al. Garlic blocksquorum sensing and promotes rapid clearing of pulmonaryPseudomonas aeruginosa infections. Microbiology 2005;151:38733880.

6. Stevinson C, Pittler MH, Ernst E. Garlic for treating hyper-cholesterolemia: A meta-analysis of randomized clinical tri-als. Ann Intern Med 2000;133:420429.

7. Burnham BE. Garlic as a possible risk for postoperativebleeding. Plast Reconstr Surg 1995;95:213.

8. Rose KD, Croissant PD, Parliament CF, Levin MB. Sponta-neous spinal epidural hematoma with associated plateletdysfunction from excessive garlic ingestion: A case report.Neurosurgery 1990;26:880882.

Address correspondence to:Nilufer Yalindag-Ozturk, MD

Pediatric Critical Care MedicineDepartment of Pediatrics

Baskent Universitesi Istanbul HastanesiOymaci sok. No:7

Altunizade, Uskudar, IstanbulTurkey

E-mail: nyalindag@yahoo.com

FIG. 1. Antibiograms viadisc diffusion method withgarlic added agar (left) andplain Mueller Hinton agar(right). Antibiotic discs are as

follows: PRL (piperacillin), AK(amikacin), FEP (cefepime),CAZ (ceftazidime), TZP(piperacillintazobactam),MEM (meropenem), CN(gentamicin), CIP (cipro-floxacine), and ATM(aztreonam).

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