Question 11 - CASE STUDY

A 56-year-old female with a history of uncontrolled type 2 diabetes mellitus presents to the ED with a four-day history of fevers, chills, dysuria and frequency. She was seen by her primary care clinician 3 days ago and started on ciprofloxacin. However, the patient feels her symptoms continued to worsen despite taking ciprofloxacin.

Her vitals on presentation are:

• Temperature, 102.1°F
• Heart rate, 120/min
• Blood pressure, 120/81 mm Hg
• Respiration rate, 20/min

She denies any respiratory complaints.

The patient’s work up includes:

• Chest X-ray: clear lung fields
• UA: Many bacteria, WBC >180, RBC 10, 3+ leukocyte esterase, positive nitrite, 1+ glucose
• Urine culture in process
• Blood culture: Gram negative rods
• Labs: WBC 25 with 10% bands; Hgb 10; Platelets 380; Glucose 181; BUN 68; Cr 1.0; normal liver enzymes
• CT abdomen/pelvis: severe perinephric stranding seen on the left kidney, no abscess

Physical exam: Appears tired but answering questions appropriately. Heart and lung exam normal. Abdomen not tender or distended. Left sided CVA tenderness noted on exam.

Prior cultures and chart review showed the patient was admitted 4 months ago with similar presentation and found to have ESBL Escherichia coli (susceptible to piperacillin-tazobactam and ciprofloxacin/levofloxacin). She was treated with piperacillin-tazobactam during that particular hospitalization however she has been treated multiple times in the past with ciprofloxacin for UTIs.

Patient has no drug allergies.

Question 12 - CASE STUDY

A 66-year-old male with history of CAD s/p 3 vessel CABG 2 weeks ago with course complicated by multiple PEA arrests. He is currently in the cardiac ICU, ventilated for 2 weeks.

• Recent chest X-ray is suggestive of bilateral lower lobe pneumonia.
• Respiratory and blood cultures grew MRSA
• The patient is thrombocytopenic (platelets 66)
• He has no known drug allergies.