| A |
cool doctor |
1 |
6% |
| B |
|
0 |
0% |
| C |
inkspot, drdadi, lq2006, drkhanktk, digant, guangyu, CocaCola, multani001, nyimalay, khiladi, miha152 |
11 |
61% |
| D |
milestogo, drshvetasm, Justice, fd |
4 |
22% |
| E |
solitarius |
1 |
6% |
| Author | 5 Posts |
Justice
Forum Fanatic
Topics: 100
Posts: 1,881
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Please vote with your answer
A 78-year-old man is admitted to the intensive care unit because of severe congestive heart failure that requires monitoring with a central venous catheter. After 2 days, he develops diaphoresis, tachycardia, and a temperature of 39.5 °C (103.1 °F). A small amount of purulent material is noted at the catheter site. The catheter is removed, blood culture specimens are drawn, and empiric vancomycin is begun. The patient improves, but the catheter tip and both sets of blood cultures grow Staphylococcus aureus that is reported to be sensitive to oxacillin.
Vancomycin is changed to nafcillin, 2 g intravenously every 4 hours. No signs of endocarditis are noted on physical examination, and repeat blood cultures show no growth.
On hospital day 7, the patient appears ready for discharge, based on cardiac and hemodynamic parameters. Which of the following is the most appropriate management at this time?
A. No additional diagnostic studies are needed; stop the intravenous nafcillin
B. No additional diagnostic studies are needed; continue the intravenous nafcillin for a total of 8 weeks
C. No additional diagnostic studies are needed; substitute oral dicloxacillin for the intravenous nafcillin for a total of 10 days of antibiotics
D. Obtain a transesophageal echocardiogram; if this does not show signs of endocarditis, continue the intravenous nafcillin for a total of 14 days
E. Obtain a transesophageal echocardiogram; if this does not show signs of endocarditis, continue the intravenous nafcillin for a total of 6 weeks
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| aspire
Forum Senior
Topics: 24
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My vote is C.
???
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| guangyu
Forum Elite
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| inkspot
Forum Guru
Topics: 26
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| Justice
Forum Fanatic
Topics: 100
Posts: 1,881
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This Qn was tough...
The correct answer is D
The patient has an intravascular catheter-related bloodstream infection. Although the focus of infection was removed, the optimal duration of treatment in this setting is uncertain. Perhaps 25% of such patients have endocarditis, which can be detected most reliably by transesophageal echocardiography. Two studies suggest that the most cost-effective approach for patients with native valves is to obtain a transesophageal echocardiogram and then treat for 4 weeks if endocarditis is diagnosed but for only 2 weeks if endocarditis is not diagnosed. However, some clinicians may want to treat conservatively for 4 (or even 6) weeks without performing an echocardiogram. Others may choose to be guided by their clinical assessment (with or without a less invasive, but less sensitive, transthoracic echocardiogram) and consider stopping the intravenous antibiotics after 2 weeks, although published reports suggest that clinical judgment may not be reliable in this setting. Of the choices given, the only option that falls within these parameters is obtaining a transesophageal echocardiogram and treating with intravenous nafcillin for 14 days if this study does not show endocarditis.
Seven days of intravenous antibiotics would generally not be considered sufficient forS. aureus bacteremia, although some investigators have used such a short course in selected patients who have a normal transesophageal echocardiogram. However, 8 weeks would be an unnecessarily long antibiotic course, given the current information. Changing to an oral antibiotic is not considered a reliable option for treating S. aureus bacteremia, although some investigators have used a combination of oral rifampin and a fluoroquinolone. Finally, if a transesophageal echocardiogram is done and does not show endocarditis, there is no reason to provide treatment for 6 weeks.
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