Fighting the Bugs

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This is our first of 2 cases exploring the care of patients with sepsis in the Emergency Department.  Similar to our "Out on a Limb" case series, the case presented is followed by a series of questions, with a discussion in the comment section facilitated by the post authors.  In approximately 1 month (November 11th), the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during Grand Rounds.  Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points.  Looking forward to a great discussion!

You're a couple hours into your shift at a 25 bed community ED and it's been a modestly busy day.  You just finished up performing a dental block on a patient with pulpitis and maybe the start of a periapical abscess and admitting a patient with unstable angina who had some lateral ST-depressions but a normal troponin.  

2 patients just checked in while you were off doing the dental block and a squad just rolled in with your next patient, a transfer from a nursing home.  Linda, 79 years old, was sent in for altered mental status, which was initially noticed last night.  She hasn’t said anything on the ride over, and glancing over at the cot, she appears frail and confused.  They think it’s a UTI.  

“Easy,” you think, “check a urine, order antibiotics, admit.”  

Then you get her vitals – 122, 82/60, 97%, 95.8°...  

She gets rolled to the trauma bay.  Glancing at her chart, you see she’s had multiple UTIs:  lots of pan-sensitive E. coli, a couple of proteus infections (sensitive to most things), some yeast, and one previous nasty Pseudomonas infection about 7 years ago which was resistant to nearly everything except meropenem.  

You get a urine quickly and her urinalysis returns with positive leucocyte esterase, but nitrite negative, with a pH of 5.5, and 20 protein.  Her blood work is all pending.

Please respond to a single question and note in the discussion section which question you are responding by beginning your post with Q1, Q2, etc.

Q1:  What antibiotic(s) would you choose at this point?  Does a remote history of one serious UTI change what you would use?

 

Q2:  Now, imagine the same patient, but with a perfectly clean urinalysis, clear chest x-ray, and a benign belly.  Lactate 6.5 and creatinine 2.3 (baseline 1.6), but nothing else particularly remarkable.  Oh, and she’s HIV+, but last CD4 count 6 months ago was 405.  What would your choice of antibiotics then be?  Would your coverage change if she were not so well treated for her HIV?

 

Q3:  Now instead of HIV, the patient on tacrolimus and prednisone for a previous heart transplant.  When calling her up to the ICU residents, you ask them what they think about adding on antifungals or antivirals.  The response is, “nah, don’t worry about it.”  What is your threshold for adding additional coverage?  Would your opinion on the matter change if it were her transplant physician that told you not to worry about adding antifungals or antivirals?

 

Q4:  What if this patient with an uncertain source of sepsis had had a kidney transplant and visible thrush?  How do you weigh the consequences of potentially causing renal injury by adding IV fluconazole (or acyclovir)?