What factors increase the risk of developing an infection with P. aeruginosa?

A 56-year-old man (weight 85 kg; allergies: sulfamethoxazole/trimethoprim) is admitted to the hospital with suspected CAP.

He received ceftriaxone 1 g x 1 dose plus azithromycin 500 mg intravenously x 1 dose; then, orders were for azithromycin 250 mg intravenously daily for 4 days plus ceftriaxone 1 g every 24 hours for 4 days. On day 3, the patient’s hospitalization was complicated by respiratory failure and admission to the intensive care unit.

Azithromycin and ceftriaxone were discontinued, and the patient was transitioned to vancomycin 1250 mg every 12 hours and piperacillin/tazobactam 4.5 g every 8 hours. He responded well to therapy, and antibiotics were discontinued on day 7.

His medication administration record is as follows

Which DOT is most appropriate to assign to this patient?

•Mr H. is a 76-year-old man who was admitted to the cardiac ICU 5 days ago because of exacerbated congestive heart failure. L.B. has no known drug allergies.

•He has several intravenous drips running through a central line that was placed 4 days ago. In the past 24 hours, he became hemodynamically unstable, for which he was initiated on mechanical ventilation; he developed a temperature of 102.3°F (39°C) and is now in septic shock.

•Which empiric antimicrobial therapy would be most appropriate to initiate for Mr H.’s septic shock?

•62-year-old man (weight 88 kg) receiving intermittent PD secondary to longstanding hypertension and diabetes presents to your hospital with acute abdominal pain and change in appearance of his peritoneal exchange.

•Current medications include amlodipine 10 mg orally daily, lisinopril 20 mg orally daily, glargine 40 units every morning with 3 units of lispro with meals, a renal vitamin, and ranitidine 75 mg daily.

•Initial laboratory test results are as follows: WBCs 9.2 cells/mm3 , Hgb 10.7 g/dL, Hct 32.2 g/dL, Plt 220 cells/mm3 , Na 141 mEq/L, K 3.5 mEq/L, Cl 107 mEq/L, HCO3- 20 mEq/L, SCr 2.5 mg/dL, BUN 18 g/dL, and albumin 3.3 g/dL.

•Vital signs include blood pressure 112/65 mm Hg, temperature 96.9°F (36.1°C), heart rate 88 beats/ minute, respiratory rate 20 breaths/minute, and SaO2 96% on room air.

•The PD fluid laboratory values show WBCs 254 cells/mm3 with 65% polymorphonuclear cells. The PD fluid is also sent for culture and sensitivities. The initial Gram stain was positive for gram-negative rods. The PD catheter will remain in for now, and the patient will continue with intermittent PD.

which is the most appropriate initial; therapy

•Mr  A 54-year-old man presents with severe abdominal pain, nausea/vomiting, and subjective fever for the past 3 days. He has a known medical history significant for hypertension, diverticulitis, and obesity.

•Current home medications include losartan 50 mg once daily. He reports no use of antibiotics in the past year.

• Initial laboratory test results are as follows: WBCs 11.5 cells/mm3 , Hgb 12.3 g/dL, Hct 36.8 g/dL, Plt 303 cells/mm3 , Na 142 mEq/L, K 4.4 mEq/L, Cl 108 mEq/L, HCO3- 20 mEq/L, SCr 1.2 mg/dL, BUN 18 g/dL, and albumin 3.9 g/ dL.

•Vital signs include blood pressure 131/65 mm Hg, temperature 98°F (36.7°C), heart rate 88 beats/minute, respiratory rate 20 breaths/minute, and SaO2 97% on room air.

•The patient has a documented allergy to sulfa (hives) and aspirin (Reye syndrome as a child). An abdominal CT done at the time of admission reveals an abscess at the wall of the small bowel with no evidence of perforation.

•The surgical team plans for percutaneous drainage tomorrow. Blood cultures are obtained.

•Which is the best empiric therapy and recommended duration, assuming source control and clinical resolution without evidence of bacteremia?

•24-year-old man (height 178 cm, weight 68 kg) presents to the ED from home after having severe headaches, excessive somnolence, and fevers. On admission, he is febrile with a temperature of 102.2°F (39°C). Physical examination is unremarkable, except for lesions around his genitalia.

•An MRI was done see picture.

• A CSF analysis reveals normal opening pressure, WBC 5 cells/mm3 with 90% lymphocytes, protein 45 mg/dL, and glucose 72 mg/dL.

•Which would be most appropriate to initiate in this patient?

•Mr M. is a 31-year-old man with cystic fibrosis who underwent his second bilateral lung transplant 8 weeks ago. P.M. has no food or drug allergies. He received antithymocyte globulin and methylprednisolone as induction immunosuppression and subsequently received high-dose methylprednisolone 3 weeks ago for empiric treatment of rejection.

• Mr M. presents in the pulmonary transplant clinic with new-onset fever, headache, and worsening shortness of breath, for which he is admitted to the hospital and undergoes bronchoalveolar lavage.

• After the procedure, his oxygen requirements increase, and he is transferred to the ICU for closer monitoring.

•Gram stain from the respiratory cultures was done see picture

• Which is the best initial treatment for this patient?

•. T.F. is a 31-year-old man who presents with a 3-day history of unremitting substernal chest pain that radiates to his shoulders. The pain worsens when he is lying down at rest.

•He denies any dyspnea. His laboratory examination, including cardiac enzyme levels, is within normal limits except for WBC 18.2 x 103 cells/ mm3 and C-reactive protein 12.8 mg/dL. Vital signs are blood pressure 126/82 mm Hg, heart rate 78 beats/ minute, respiratory rate 18 breaths/minute, and temperature 99.8°F (37.7°C).

•An electrocardiogramwas done , and an echocardiogram is positive for a moderate-size pericardial effusion without hemodynamic compromise.

• Two sets of blood cultures have no growth at 24 hours, and viral serology is negative. The patient is  scheduled for a pericardiocentesis later today.

•Which is most appropriate to initiate at this time?

•V.C. is a 63-year-old man with a history of diabetes, hypertension, and end-stage renal disease. He presents to the ED in July with a chief concern of increasing shortness of breath over the past 2 days, coughing, and subjective chills.

•His last dialysis session was 1 week ago. Chest radiography was done

•His vital signs are temperature is 100°F (37.8°C), respiratory rate 22 breaths/minute, heart rate 109 beats/minute, and blood pressure 129/87 mm Hg. He is being admitted to a general medical floor. His hemodialysis graft appears normal. The patient has no history of infections, recent antibiotic use, or inpatient hospitalization.

• Which is the most appropriate therapy to initiate for V.C.?

•Twenty-four hours after V.C.’s admission, a multiplex PCR for viruses and atypical pathogens is negative.

•Repeat chest imaging after emergency dialysis reveals resolved pleural effusions. His chest symptoms have improved, and he is afebrile.

•His WBC is 10.6 x 103 cells/mm3 . Two procalcitonin values were obtained, one on admission and one 12 hours later, with results of 0.32 mcg/L and 0.36 mcg/L, respectively.

•Which is the most appropriate therapeutic plan for V.C.’s potential pneumonia?

•A.M. is a 73-year-old white man who presents to his PCP for evaluation of a large ulcer on his right foot. He has a longstanding history of uncontrolled type 2 diabetes, as well as hypertension, congestive heart failure, and chronic renal insufficiency.

•On physical examination of the foot, you notice that it is edematous, erythematous, warm to the touch, and tender and that it emits a foul odor. The erythema is measured at 2.5 cm.

•A.M.’s vital signs at the office are as follows: temperature 101.3°F (38.5°C), heart rate 95 beats/minute, blood pressure 105/58 mm Hg, and respiratory rate 24 breaths/minute. The CMP and CBC show the following abnormalities: WBC 15 x 103 cells/mm3 , neutrophils 90%, serum creatinine 2.6 mg/dL, and blood urea nitrogen 30 mg/dL. He has no known drug allergies.

• Which is the most appropriate treatment for this patient?