case presentation mine

8/8/2019 Case Presentation Mine

1/30

Case Study

Medicine Rotation

Camp Pendelton


2/30

Description

38 years old male

Left shoulder arthroscopy and labral repair on Sep 29th .Presenting with 3 days of severe, sharp mid-back pain

and low grade fever He was initially sent home, but he returned several hours

later complaining of SOB.

Patient collapsed in parking lot because of SOB and lackof energy

Chief complaint: back pain and SOB on 10/06

Sharp pain for the past 4 days, worse with respirations

Pain in trunk (7/10)


3/30

Vitals (readmission):

BP: 147/86

HR: 116 RR: 44

O2 SAT: 91% ON RA

PAIN: 7/10

Temp: max 101


4/30

Past medical history:

PNA 1995

GERD

Allergies

None


5/30

Social history

Chewing tobacco x 23 years

Quit 7 years ago

Alcohol use:

1-3 x a month


6/30

Physical Examination

After stabilized:

HR: 94

RR: 23 Wt: 83.8

Ht: 180.3

BMI: 25.8

Crcl: 133


7/30

Current Meds:

Azithromycin 250 mg po daily (concern for pulmonaryembolism after surgery)

Colace 100 mg po BID

Celebrex 200 mg po BID

Oxycodone/APAP 5/325 mg PO Q 4hr prn

Levaquin 750 mg Q24 hr

Morphine 1-2 mg iv Q2hr prn

Zofran 4 mg Q8hr prn iv


8/30

Senna 100 mg BID po

Proventil 2.5 mg INH Tid Prn

Lovenox 40 mg Daily 1 L NS bolus


9/30

Evaluation:

CT scan:

RLL consolidation W/ small pleural effusion

EKG:

Unremarkable

Labs:

Na: 133

Cl: 97

WBC: 15.4 with left shift

Creatinine: 0.8


10/30

Assessment:

Fever

Purulent sputum

Leukocytosis

Decline in oxygenation


11/30

Diagnostics Assessment

Pneumonia

RLL consolidation W/ small pleural effusion

Shallow breathing, minimal air movement, anddecreased breath sounds in the RLL

Leukocytosis

=> With the presenting symptoms we can conclude

that it can be atypical pneumonia or hospitalacquired pneumonia.


12/30

Treatment options

Since there is no growth on blood culture we

conclude that patient does not have sepsis

There is no respiratory culture = no sensitivitytest

Is our patient at risk of MDR?


13/30

Risk factors for MDR organisms

Antibiotic therapy within the past 90 days

Hospitalization of 5 days or more

High resistance in hospital unit

High risk for health care-associated pneumonia


14/30

Treatment options

If MRSA is a frequent nosocomial pathogen in the institution

Linezolid or Vancomycin is a necessary first choice for anti-

staphylococcal coverage (but should be discontinued if MRSA is not

isolated)

Linezolid :600 mg twice daily intravenously (or orally if or when

the patient is able to receive oral medications)

Vancomycin: 15 to 20 mg/kg (based on actual body weight)

intravenously every 8 to 12 hours for patients with normal renal

function, with a target serum trough concentration of 15 to 20mg/L

Daptomycin: cannot be used to treat pneumonia, because it does

not achieve sufficiently high concentrations in the respiratory tract ,

and can cause eosinophilic pneumonia


15/30

Combination antimicrobial therapy:

Especially Pseudomonas

There is no conclusive evidence to support thispractice. The best rationale for the use of combinationtherapy is to provide a greater spectrum of activity

when there is risk for MD

R pathogens No evidence in pt that are colonized with

Pseudomonas or MRSA, and found that combinationversus monotherapy was associated with improvedadequacy of initial antibiotics and microbiological

eradication of infecting organisms in patients who hadinfection due to Pseudomonas, Acinetobacter, andMDR gram-negative bacilli


16/30

No known MDR risk factors:

Ceftriaxone: 2 g intravenously daily

Ampicillin-sulbactam (3 g intravenously every

six hours) Piperacillin-tazobactam (4.5 g intravenously

every six hours


17/30

Levofloxacin (750 mg intravenously daily)

Moxifloxacin (400 mg intravenously daily).

Both agents may be administered orally at thesame doses when the patient is able to take oral

medications.

Ertapenem (1 g intravenously daily)


18/30

Recommendation

Levaquin 750 IV Q 24hr (switch to po after 2

doses and will resume after discharge for total

of 14 days)

Pt wants to continue therapy at home

Pt is compliant

Pt is improving


19/30

48 hr follow up on pt:

Pain 0/10

RLL PNA stable and improving

Afebrile

WBC trending down (last count 9.7)

Pt can ambulate

Pt would like to complete the PNA treatment on

an outpatient basis.


20/30

Follow up

F/u on RLL PNA in 2 weeks

CXR in 6 weeks


21/30


22/30


23/30


24/30


25/30


26/30


27/30


28/30

Another Observational Study

Linezolid more efficacious than vancomycin to

eradicate infecting organism in critically ill

patients with Gram-positive infections

Servicio de Medicina Intensiva (ICU). Hospital Universitari de GironaDoctor Josep

Trueta. Girona. Spain 2Servicio de Microbiologa. Hospital Universitari de Girona

Doctor Josep Trueta. Girona. Spain


29/30

Methods:

Study design:

A prospective and observational study involving critically ill patientsadmitted in ICU with therapy to proven Gram-positive bacterialinfection was conducted from January 2005 to January 2008. Oursis a surgical, medical and trauma ICU with 16 beds in a 435-bed

university hospital. Study protocol was approved by the hospitalsinstitutional review board and ethics committee for clinicalresearch. Inclusion criteria were patients with proven Gram-positiveinfection treated with vancomycin (VAN) or linezolid (LNZ) accordingto the atten- ding ICU physician. Demographic data (age, sex),severity of ill- ness score (Simplified Acute Physiology Score, SAPS

II)7, diag- nosis for admission (surgical, medical or trauma),comorbidities and risk factors for infection were reported andregistered.


30/30

Conclusion: Treatment with linezolid in

critically ill patients with Gram-positive

infections was equivalent to vancomycin in

terms of efficacy and safety, but linezolid was

associated to a higher rate of microbiologic

eradication of the infecting organism at the

seventh day of treatment.

case presentation mine

Documents