Infectious Diseases 2

TL is an 86 yo male (128kg, 70”) who presents to the ED with complaints of worsening pneumonia. He has had a productive cough and shortness of breath for five days. He went to his primary care office three days ago where he was given a Z-pack, but reports worsening symptoms since that time. He has a past medical history significant for stage 3 CKD, hypertension, CHF, diabetes, and high cholesterol for which he takes losartan, metoprolol, metformin, glipizide, simvastatin, and aspirin. His initial labs and vital signs are as follows: temp 101.2°F, BP 110/46, RR 24, HR 92, O₂ saturation 91% on room air (now 99% on 2L NC), SCr 1.8 (baseline 1.3), WBC 12.8, lactate 4.4, BG 124, all other labs WNL.

S1) TL triggers a sepsis alert, which means he requires a fluid bolus per facility protocol. Which of the following is the most appropriate volume of IV fluid to administer to TL?

TL is an 86 yo male (128kg, 70”) who presents to the ED with complaints of worsening pneumonia. He has had a productive cough and shortness of breath for five days. He went to his primary care office three days ago where he was given a Z-pack, but reports worsening symptoms since that time. He has a past medical history significant for stage 3 CKD, hypertension, CHF, diabetes, and high cholesterol for which he takes losartan, metoprolol, metformin, glipizide, simvastatin, and aspirin. His initial labs and vital signs are as follows: temp 101.2°F, BP 110/46, RR 24, HR 92, O₂ saturation 91% on room air (now 99% on 2L NC), SCr 1.8 (baseline 1.3), WBC 12.8, lactate 4.4, BG 124, all other labs WNL.

S2) Which of the following is the most appropriate recommendation to make regarding fluid selection for TL’s bolus?

TL is an 86 yo male (128kg, 70”) who presents to the ED with complaints of worsening pneumonia. He has had a productive cough and shortness of breath for five days. He went to his primary care office three days ago where he was given a Z-pack, but reports worsening symptoms since that time. He has a past medical history significant for stage 3 CKD, hypertension, CHF, diabetes, and high cholesterol for which he takes losartan, metoprolol, metformin, glipizide, simvastatin, and aspirin. His initial labs and vital signs are as follows: temp 101.2°F, BP 110/46, RR 24, HR 92, O₂ saturation 91% on room air (now 99% on 2L NC), SCr 1.8 (baseline 1.3), WBC 12.8, lactate 4.4, BG 124, all other labs WNL.

S3) TL receives his recommended fluid bolus, but his blood pressure has now dropped to 98/42 and passive leg raise suggests that he is not fluid responsive. Which vasopressor would be most appropriate to initiate?

TL is an 86 yo male (128kg, 70”) who presents to the ED with complaints of worsening pneumonia. He has had a productive cough and shortness of breath for five days. He went to his primary care office three days ago where he was given a Z-pack, but reports worsening symptoms since that time. He has a past medical history significant for stage 3 CKD, hypertension, CHF, diabetes, and high cholesterol for which he takes losartan, metoprolol, metformin, glipizide, simvastatin, and aspirin. His initial labs and vital signs are as follows: temp 101.2°F, BP 110/46, RR 24, HR 92, O₂ saturation 91% on room air (now 99% on 2L NC), SCr 1.8 (baseline 1.3), WBC 12.8, lactate 4.4, BG 124, all other labs WNL.

S4) After admission to the ICU, TL is still hemodynamically unstable and is now on both norepinephrine and vasopressin. Which of the following is the most appropriate recommendation to add to his therapy?

TS is a 54yo female who presents to the ED with concern for a UTI. She has a history of recurrent UTIs and reports a 3-day history of urinary frequency, urgency, and burning, as well as foul smelling, cloudy urine. Her past medical history is significant for chronic UTIs, congenital long QT syndrome, and a Bactrim allergy (rash). Previous cultures show numerous isolates of Escherichia coli that are ESBL positive and typically show resistance to nitrofurantoin as well. Her urinalysis shows 5+ bacteria, positive leukocyte esterase, >10 WBCs, and positive nitrites. She is afebrile and her vital signs and labs are all stable. 

U1) Which of the following is the most appropriate course of therapy to recommend as empiric therapy for TS?

SG is an 82yo female sent from her rehab facility to be assessed for a UTI. While the nursing assistant was helping SG to the restroom, she noticed that her urine had a foul odor. SG denies any urinary complaints, but her urinalysis does show 2+ bacteria. She has a past medical history of hypertension, diabetes, and recent broken hip, which is her reason for admission at her rehab facility. Her vital signs and labs are all normal.

U2) Which of the following is the best treatment plan for SG?

JA is a 78yo female who presents to the ED with due to “not feeling well.” She mentions that she thinks she has a UTI since she has painful urination and urinary frequency, however she is also experiencing vomiting that is preventing her from keeping anything down, despite the use of ondansetron that she had at home from the stomach bug she had several months ago. During triage her temperature is 100.6°F, HR 86, RR 19, and O₂ saturation 99% on room air. Her labs show a WBC of 11.4 but is otherwise unremarkable. She states that she feels too weak to go home. She has no significant past medical history but does have an extensive list of allergies including penicillin, sulfa, ciprofloxacin, and clindamycin.

U3) Based on her overall clinical picture, the ED provider wants to admit JA for initial UTI management. Which of the following is the most appropriate agent for empiric therapy?

TH is a 62yo male who presents to the ED with a 3-day history of weakness, fever, and neck stiffness. He has a past medical history of hypertension for which he takes lisinopril and reports no allergies. In triage his temperature is 101.3°F, HR 102, RR 21, BP 114/72, O₂ saturation 98% on room air. CBC and BMP are significant for a WBC of 11.8 and lactate of 3.7. The physician suspects meningitis and prepares for a lumbar puncture.

M1) Which of the following is the most appropriate recommendation for empiric therapy in TH?

M2) The PA student approaches you and mentions that she has read about using dexamethasone in addition to antibiotics for meningitis. Which of the following is the most appropriate response?

LD is a 26yo female with a past medical history significant for spina bifida and a VP shunt. She is brought in by her mother who is concerned that LD may have a shunt infection as she has been febrile at home and “not acting right.” Her temperature is 100.8°F (received 650mg acetaminophen 90 minutes prior to measurement), HR 92, RR 18, O₂ saturation 97% on room air. BMP and CBC are significant for WBC of 14.2 and lactate of 2.2.

M3) Which of the following is the primary difference in empiric coverage needed due to LD’s VP shunt as opposed to an otherwise healthy 28yo patient?