Justice
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A 45-year-old woman is brought to the emergency department after she becomes unresponsive. Family members state that she developed an earache 3 days ago. Her primary care physician diagnosed otitis media and prescribed ciprofloxacin. However, the patient did not improve and became increasingly lethargic. Medical history is noncontributory, she has no allergies, and her only medication is ciprofloxacin.
On physical examination, the patient is obtunded and has meningismus. Temperature is 40.0 °C (104.0°F), pulse rate is 120/ min, respiration rate is 32/mm, and blood pressure is 80/50 mm Hg. A purpuric rash is present on her lower extremities.
The leukocyte count is 25,000/μL (with 25% band forms), and the platelet count is 20,000/μL. A lumbar puncture is performed. The cerebrospinal fluid is cloudy. The leukocyte count is 2500/μL (with 99% neutrophils), glucose is 20 mg/dL (simultaneous plasma glucose is 72 mg/dL), and protein is 230 mg/dL. A Gram stain of cerebrospinal fluid shows many neutrophils and gram-positive diplococci in pairs.
Which of the following empiric antimicrobial regimens is most appropriate?
A. Penicillin
B. Ceftriaxone
C. Vancomycin
D. Vancomycin plus ceftriaxone
E. Vancomycin plus ampicillin
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| dr.wad
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A
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| ganesha123
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vanco and ceftiraxone
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| sandra
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for strep meningitis, penicillin is the initial treatment, right?
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| doc_clotaire
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This patient has the so called " Waterhouse Friedrichsen " Sd due to N.Meningitis ( purpural rash on lower extremities )
The DOC should be :
B. Ceftriaxone
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| godfather1212m
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go with B
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| cool doctor
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D
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| Markus2009
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A Gram stain of cerebrospinal fluid shows many neutrophils and gram-positive diplococci in pairs
D
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| liliaeliz
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CEFTRIAXONE PLUS VANCO
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| fafa
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 sure D ,,and the route is IM ceftriaxone plus IV vanco
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| Jcala
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I would say D
It is gram positive-diplococci in pairs, no positive culture for N. meningitidis yet, purpuric rash could be from sepsis, so I believe empiric treatment must be Ceftriaxon PLUS Vanco.
What do you think ?
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| solitarius
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I think IV ceftriaxone only would cover both S.Pneumoniae and N.Menigitidis....Vanco would be way too much coverage then necessary...so Answer would be B.
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| WaqasQureshi
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I dont get it. The question is asking for EMPERICAL TREATMENT
while the question is also telling the culture results :S
emperical treatment is D
but if the cultures are available then its penicillin.
Please review the question 
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| WaqasQureshi
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the indications are as below
A. Penicillin (if s. pneumoniae found on culture)
B. Ceftriaxone (if meningococcus is found on culture)
C. Vancomycin (never used alone! until definite about MRSA, status post neurosurgery, penicillin resistant strep pneumoniae with MIC of greater than 1 )
D. Vancomycin plus ceftriaxone (usual combination for emperical treatment. at this age)
E. Vancomycin plus ampicillin (emperical therapy for >65 years of age)
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| solitarius
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I thought Empiric doesn't have to be combination of 2 or more drugs
and in the kaplan lecture notes they mention that you can use ceftriaxone in pneumonia(strep) as well.but thank you for such a nice and brief info.
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| Novak75
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Justice, what is the right answer??, please.
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| cool doctor
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hey Justice
it has been a week, waiting for the right answers.
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| Justice
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The correct answer is D
This patient has meningitis caused byStreptococcus pneumoniae. The infection likely originated in her middle ear, and she was placed on an inappropriate antimicrobial agent (ciprofloxacin) that has no significant activity against pneumococci.S. pneumoniae meningitis can be diagnosed presumptively based on the positive cerebrospinal fluid Gram stain, and antimicrobial therapy should be targeted at the causative organism. Empiric antimicrobial therapy for pneumococcal meningitis is vancomycin plus a third-generation cephalosporin (either cefotaxime or ceftriaxone), pending in vitro susceptibility testing.
If the pneumococci are highly resistant to penicillin or the cephalosporins, administering either penicillin or ceftriaxone alone may not achieve adequate cerebrospinal fluid concentrations to kill these organisms. Although vancomycin has good in vitro activity against resistant pneumococci, it should not be used alone for treating pneumococcal meningitis because of its unreliable penetration into the cerebrospinal fluid. The addition of ampicillin to vancomycin does not provide increased activity against S. pneumoniae.
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| guangyu
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if pt have s pneumoniae, where is rash coming from?
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| Justice
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guangyu wrote:
if pt have s pneumoniae, where is rash coming from?
from platelets 20K/ul... In N. meningitides and WF syndrome, the rash is due to DIC syndrome, and is not limited to extremities...
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