Transcript Journal Club - NYU Langone Medical Center

NYU Medicine Grand Rounds
Clinical Vignette
Ivan Saraiva MD, PGY-2
December 9, 2009
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
A 74-year-old woman is brought to the
emergency room with increasing confusion
for three days.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient was in her usual state of health until four months
prior to presentation when she had the first of a series of recurrent
urinary tract infections.
• Each was successfully treated as an outpatient.
• Three days prior to presentation, the patient began experiencing
dysuria similar to her prior episodes of urinary tract infection.
• She was evaluated by her primary care physician and a
urinalysis and urine culture were obtained.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The urinalysis demonstrated:
• WBC: 30-50 (0-5/HPF)
• Turbid appearing urine (clear)
• RBC: 5-10 (0-4/HPF)
• Blood: Moderate – 2+ (negative)
• Bacteria: Many
• Protein: > 300 mg/dL – 3+ (negative)
• Nitrite: negative (negative)
• Leuk Esterase: Large – 3+ (negative)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Given the abnormal urinalysis, the patient was
empirically started on a 7-day course of ciprofloxacin
for treatment of her recurrent infection.
• The patient’s family reports that over the next three
days, the patient began to experience fevers and
became increasingly disoriented.
• She was therefore brought to the emergency room.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
Past Medical History
• Diabetes mellitus
• Hypertension
• Chronic kidney disease
• Hypothyroidism
• Recurrent urinary tract infections
Past Surgical History
• None
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Family History
• Non-contributory
Social History
• Retired
• Ex-smoker
• Social alcohol use
• Denies illicit drug use
Outpatient Medications
Insulin glargine 12units sc QHS
Nifedipine XL 60mg po daily
Labetalol 200mg po bid
Levothyroxine 50mcg po daily
Vitamin B complex 1 tab po daily
Famotidine 20mg po daily
Simethicone 80mg po daily
Allergies: No known drug allergies
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
General: Elderly woman in no acute distress
Vital Signs: T 100.1 F, BP 145/85, HR 76, RR 18, O2
saturation 99% on room air
Neurologic examination:
Mental status: alert, oriented to person
Abdominal exam:
Mild suprapubic tenderness, no CVA tenderness
The remainder of the physical exam was normal.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• CBC:
• Leukocytes 8,200 with normal differential
• Hemoglobin 10.9 g/dL, Hematocrit 32%
• The remainder of the CBC was normal
• Basic metabolic panel:
• BUN 52 mg/dL
• Creatinine 2.4 mg/dL
• Glucose 114 mg/dL
• The remainder of the BMP was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
The urine culture from 4 days prior was reviewed:
Final ID: Escherichia coli
Amikacin-MIC: S (8)
Ampicillin-MIC: R (>2)
Cefazolin-MIC: R (>24)
Ciprofloxacin-MIC: R (>4)
Gentamicin-MIC: S (<1)
Nitrofur-MIC: R (128)
Tetracyclin-MIC: S(2)
Ampi/Sulbac-MIC: R (>32)
SMX/TMP-MIC: R (>320)
Aztreonam-MIC: S (<1)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Cefepime-MIC: S (<1)
Cefoxtaxime-MIC: S (2)
Ceftazidime-MIC: S (<1)
Ceftriaxone-MIC: S(4)
Levofloxacin-MIC: R (>8)
Piperacillin-MIC: R (>128)
Imipenem-MIC: S (<1)
Meropenem-MIC: S (<0.25)
Pip/Tazo-MIC: I (32)
Cefuroxime-MIC: R (>64)
Additional Studies
• ECG: Sinus rhythm with first degree AV delay
• Chest X-Ray: within normal limits
• Head CT: no acute abnormalities
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
Delirium secondary to E. coli urinary tract
infection, resistant to empirically started
antibiotics (ciprofloxacin)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Based on the urine culture and antibiogram results,
the patient was started on ceftriaxone.
• She failed to show significant improvement over the
next several days and became hypotensive.
• While reviewing the patient’s record further, it was
noted that the antibiotic sensitivities had been changed
due to automatic extended-spectrum beta-lactamase
(ESBL) testing.
• The ESBL test was abnormal (+).
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The new antibiogram reflected the abnormal ESBL test,
and the sensitivities to aztreonam and the cephalosporins
were changed to reflect this resistance.
• The ESBL test had been completed on hospital day 1.
• Neither the inpatient team nor the ordering outpatient
physician were notified of the new results, either by phone
call or computer alert.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The patient’s antibiotic treatment was changed to
reflect the change in sensitivity pattern, and
imipenem-cilastatin was started.
• Over the next several days the patient demonstrated
significant clinical improvement and was eventually
discharged home.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
ESBL-positive E. coli urinary tract infection
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS