Antimicrobial Therapy… December 30, 2011

Posted by Andy Jagoda, MD in: Drugs & Emergency Procedures, Infectious Disease , trackback

At 7:00 on a Monday morning, the day begins with a full line-up of “to be seen.” A 35-year-old female with no past medical history presents to the ED complaining of cough and shortness of breath for 2 days that is progressively worsening. On physical examination, she is febrile with an oxygen saturation of 94% on room air and decreased breath sounds at the right base. You order a chest x-ray that shows right lower lobe consolidation.

The second patient on your tracking board is a 70-year-old female with fever, nausea, and back pain for 3 days. She is accompanied by her daughter, who states her mother hasn’t been herself today and that she had a similar presentation when she had a UTI 2 years ago. She is febrile to 38.3°C (101°F), oriented x2, with left costovertebral angle tenderness. Her urine dipstick is positive for leukocyte esterase and nitrites.

In the next bed, you are evaluating a 23-year-old male who has had a painful, swollen right forearm for 2 days. He reports a subjective fever earlier in the evening, but no other systemic symptoms. He denies any past medical history and has no IV drug abuse and no history of diabetes. He is afebrile with normal vital signs. A 6-cm area of erythema, induration, and tenderness is noted on his proximal forearm with a 2-cm central fluctuant, raised area. He has full range of motion at the elbow.

Just as you sit down for a cup of coffee, the triage nurse notifies you that she just received an 85-year-old male from a nursing home that was sent in for evaluation for fever. He has a history of insulin-dependent diabetes mellitus, hypertension, and dementia. On physical examination, he is febrile, with otherwise normal vital signs. His abdomen is slightly distended, soft, but diffusely tender to palpation.

Four infectious disease cases in a row — it feels like an epidemic. In the age of emerging pathogens — and when the right antibiotic choice may be the difference between a good or bad outcome — which antibiotic(s) do you use?

(Enter to win the latest issue of Emergency Medicine Practice, including CME, by submitting your answer to the question above. To do so, simply enter your response in the comments box. The deadline to enter is January 6th.)

Comments »

1. iv - January 2, 2012


2. Pooja Jain - January 2, 2012

First patient: Co-amoxiclav IV
second patient: co-amoxiclav/ bactrim IV + gentamicin
Third patient: IV flucloxacillin
Fourth patient: CoAmoxiclav + Metronidazole

3. David - January 2, 2012

1st pt: Augmenting
2d pt: Septra DS
3d pt: Septra DS
4th pt: nothing till infectious process is identified

4. dr nasser alsunbuli - January 2, 2012

I.v tazocin in dosde of 4.5 gm. tds for all patients untill culture result is ready.

5. Amal Agarwal - January 2, 2012

1st pt: IV Rocephin and Zithromax
2nd pt: IV Rocephin or Levaquin depending on allergies and Renal function
3rd pt: PO Septra DS
4th pt:IV Zosyn or Leva + Flagyl

6. Christopher Uriarte - January 2, 2012

1st Ceftriaxone + Azitromycin
2nd Carbapenems IV
3rd Oxacylin IV
4th Carbapenems IV

7. Roy C. Brown, MD - January 2, 2012

1 community acquired pneumonia Vibramycin 200mg bid
2. Pyelonephritis Administer ceftriaxone (1g intravenous/intramuscular [IV/IM]) or gentamicin (single 24h dose or divided every 8 hours) on day 1, followed by an oral fluoroquinolone from day 2 to days 10-14

3 .Skin abscess, open and drain the abscess, Antibiotics are generally not necessary; however, they may be prescribed if the abscess is associated with a surrounding skin infection. clindamycin (Cleocin); 150 mg q6hr
4. Abdominal infection Complete blood test, blood culture along with imaging procedures such as X-rays, ultrasound or CT scan are usually performed in order to identify the underlying cause of an infected abdomen. If tests reveal fluid buildup in the peritoneal cavity, the fluid would be tested in order to identify the pathogen responsible for causing an infection. If the presence of bacteria has been detected, antibiotic therapy should be initiated immediately. Antibiotics are given prior to the surgery, and should be continued after surgery as well. Broad spectrum antibiotics will be started after work-up for abdominal infection. amoxicillin 500mg q12hr

8. Katie - January 2, 2012

1.) Avelox 400 mg 1 po qday x 10 days
2.) ceftriaxone 1 gram IV q24hours
3.) no antibiotics are warranted at this time. I &d. If symptoms worsen or if cultures are positive for MRSA add Bactrim, Clindamycin or Doxycycline
4.) Start sepsis work up including urinalysis, stool for hemoccult blood work, ct abdomen/pelvis, treat underlying infection based on source – in Invanz IV which will cover complicated UTI/Pyleonephritis, intra-abdominal infections, Community Acquired Pneumonia and can be used for prophylaxis of surgical sites – dosing depending on Cr and GFR

9. liza - January 2, 2012

patient 1- Community acquired pneumonia- augmentin and azithromycin
patient 2- urosepsis. intravenous ceftriaxone
patient 3- cellulitis/abscess- cloxacillin +- gentamycin if not responding with cloxa/flucloxacillin alone
patient 4- intraabdominal sepsis? – iv cefobid and flagyl

10. Nikolas - January 3, 2012

Patient 1: Ampicillin + macrolide (or monotherapy with levofloxacin or moxifoxacin if allergic to penicillin)
Patient 2: Cefuroxime or Augmentin +/- aminoglycoside (or fluoroquinolone if allergic to penicillin)
Patient 3: Drainage + flucloxacillin (or clindamycin if allergic to penicillin)
Patient 4: Piperacillin with tazobactam (or clindamycin + aminoglycoside if allergic to penicillin)

11. Nurul - January 3, 2012

Case1- iv cefuroxime 1.5g stat and 750mg tds -+ zitromax 500mg od
case2- iv augmentin1.2g bd
case3- cap cloxacillin 500mg qid
case4- iv cefobid -+ metronidazole 500mg tds

12. suresh tampi - January 3, 2012

.1.augmentin iv/po.
2.augmentin iv.
3.incision and drainage.culture,flucloxacillin po pro tem till culture results available.
4.infection screen work up..

13. Lee - January 3, 2012

1. azithromycin po
2. Cipro IV 1 dose, then cipro po x 7d
3. I&D, then septra DS 2 bid x 7d
4. Zosyn IV, inpt

14. Lori Bobula - January 3, 2012

1. Avelox po
2. Cipro IV
3. I & D, then Bactrim DS two tabs BID + Doxy
4. Zosyn + Flagyl

15. saidi - January 4, 2012

ase 1
iv augmentin 1.2mg stat and tds
case 2
iv ciprofloxacin 500mg stat and bd
iv cloxacilline 1g stat and qid
iv flagyl 500mg stat and bd
acute abdomen workup

16. Dr. Nabhani - January 5, 2012

– 1st patient has CAP: Outpatient, Azithro or Clarithro
– 2nd patient has Acute Pyelonephritis: Hospitalization, blood and urine c\s, FQ (IV) or Ceftriaxone
– 3rd patient has Localized Abscess: I&D, Culture, hot packs, +/- (if >5cm) TMP-SMX-DS or Clinda
– 4th patient has Intra-abdominal infection: we have to r/o DKA, needs for emergency surgical intervention, full sepsis workup,
PIP-TZ or AM-SB or MOXI (IV), if life threatining: IMP or MER

17. rita cohen - January 6, 2012

first patient – should we think about community acquired penumonia – i would have given her – azythromycin

second patient – suggests of uti , might be simple and not complicated , it would have been important for me to know her previous cultures – would give her – cefuroxime

third patient – it is not clear that the erythema is infectious , if not just follow up and maybe i would have given an anti-histamine, if infectious – cefazolin

forth patient – intraabdominal infection , i would have done a CT scan of the abdomen – given him a triade of ampicillin + garamycin+ metronidazole

18. Barone - January 7, 2012

1 – ceftriaxone 1g iv x 1+ Rx azithromycin (or other macrolide)

2 – iv gentimicin or fluoroquinolone if inpt, fluoroquinolone x 14 days if outpt

3 – TMP/SMX DS, 2 tabs BID to cover CA-MRSA, +\- I&D

4 – cefepime 2g iv

19. Dr Fernando Cardona - January 9, 2012

I m glad to answer you medical chalenge:
here is my choice:
1. first patient: amoxacilin/ ac.clavulanico + oseltamivir
2. second patient cephalotin 2 gr iv tid
3. third patient dicloxacilin + drainage
4. fourth patient Sincerely I haven`t a clearly diagnosis for this patient so i wouldn`t start antibiotic without a clear diagnosis, because that could mask the clinical case., I ask for a abdominal Tomography with dye

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22. Els - January 29, 2012

1)azitromycin 500mg ud 1st day,250mg ud for other 4 days
2)ciprofloxacin 250mg bid for 10-14 days
3)doxacillin 2 *100mg for 3-4 days
4)augmentin + flagyl after a CT scanner

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