Justice
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A 67-year-old woman is admitted to the intensive care unit following urgent surgery because of bowel perforation and peritonitis. Despite having a colostomy and careful peritoneal lavage, she remains hypotensive and intubated postoperatively. She improves somewhat after ceftazidime and metronidazole are started by intravenous infusion, but on hospital day 9 she develops a new fever and recurrent hypotension. All intravenous catheters are replaced, blood cultures are obtained, and vancomycin is added to her regimen.
On hospital day 11, a blood culture and a catheter tip culture are both growing an Enterococcus faecalis strain that is resistant to vancomycin but susceptible to ampicillin. Repeat blood cultures are obtained, and intravenous ampicillin is substituted for vancomycin.
Three days after ampicillin is started, her fever persists, and she has developed an extensive rash. The blood cultures obtained on days 9 and 11 are all growing the same strain of E. faecalis.
Which of the following should be done next?
A. No change in antibiotics is needed, as the infected intravenous catheter was removed
B. Begin piperacillin/tazobactam; stop all other antibiotics
C. Begin quinupristin/dalfopristin; stop ampicillin
D. Begin linezolid; stop ampicillin
E. Stop ampicillin; resume this drug after the patient completes a desensitization protocol
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Don't live in a town where there are no doctors
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| nyimalay
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D
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| aspire
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D
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| peter90036
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d
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| GOGETA
I'm Dr. GOGETA
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Dude I hope this questions are not from NBME
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| peter90036
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doesnt look like it, doesnt look like uw either...
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| ganesha123
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nope not nbme or UW
guess the answer is D
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| Justice
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GOGETA wrote:Dude I hope this questions are not from NBME
Relax, these Qns are not from either NBME or UW
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| cool doctor
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D
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| GOGETA
I'm Dr. GOGETA
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Justice wrote:
Relax, these Qns are not from either NBME or UW
OK then I still love you , and keep posting questions
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As a general rule, the better it felt when you said it, the more trouble it's going to get you into.
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| Justice
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The correct answer is D
This is a complicated case study. When ampicillin is not a choice (because of resistance or intolerance), linezolid is probably the best available antibiotic for vancomycin-resistant strains of Enterococcus faecalis. Resistance of E. faecalis to linezolid is very rare, although it is prudent to evaluate this possibility.
Not treating the pathogen is appropriate for a patient with transient bacteremia but is inadvisable for a critically ill patient who continues to have positive blood cultures. Piperacillin/tazobactam is a reasonable choice in terms of the treatment spectrum, but the likelihood of adverse reactions in a patient with a recent penicillin allergic reaction is very high. Quinupristin/dalfopristin is a reasonable alternative for resistant Enterococcus faecium, but less than 10% of strains of E. faecalis are susceptible to this agent. Although ampicillin can be given safely to patients with IgE-mediated allergies after completion of an appropriate desensitization protocol, other types of allergic reactions do not abate following desensitization.
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