Severe infection is a major risk factor for mortality in patients with liver failure. Multidrug-resistant Klebsiella pneumoniae may lead to fatal infection, especially in patients with severe hepatitis. Case Presentation: We describe a 70-year-old Chinese patient with acute-on-chronic liver failure (ACLF) and multidrug-resistant KPC-producing K. peumoniae V113 isolate infection. The serum total bilirubin (TBIL) level was 308.7 µmol/L at the time of admission, and the international normalized

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... io (INR) was 2.56. The serum level of TBIL ascended to 526 µmol/L on the 14th day after admission, and then gradually declined. The INR was maintained above 1.5 for 2 months. Creatinine level significantly increased (from 92.5 to 241 µmol/L) in the first month after admission, while estimated glomerular filtration rate declined to 16.9 mL/min 1.73m 2 . Diammonium glycyrrhizinate, plasma, as well as albumin were given intravenously. At the time of admission, she had sepsis with symptoms, including fever and shivering, and K. pneumoniae was identified by blood culture test. Biapenem combined with moxifloxacin was shown to be effective, while that could not eliminate the bacteria. Fever and shivering re-occurred, and repeated drug susceptibility tests confirmed the same multidrug-resistant K. pneumoniae isolate without extended-spectrum β-lactamases. Combination treatment of meropenem and ertapenem resulted in a positive clinical outcome without deterioration of liver function. Furthermore, single-molecule real-time (SMRT) sequencing identified 3 genes (blaPKC, blaTXM, and catA2) on the plasmid and 3 genes (blaSHV2, catB3, and arnA) on the chromosome. Moreover, 10 multidrug resistance efflux pump genes and 2 fosmidomycin efflux pump genes were found on the chromosome. Conclusions: Meropenem combined with ertapenem might be used for treating patients with ACLF and multi-drug resistant K. pneumoniae V113 isolate infection.