Case Study A Sudden onset of stomach pain © Academy Of Infection Management 2015 (All Rights Reserved) Case Study A Sudden onset of stomach pain

37 year lady with sudden onset of abdominal pain Learning's: Manage the obvious first : Pregnancy Test Importance of perioperative Abs do you and which ones Juniors and weekends reduce quality Duration of dosing Resistance and ESBLs Decision on changing Abs or not 37 year lady with sudden onset of abdominal pain

History and examination 37-year-old female has had abdominal pain for the past 24 hours: abrupt in onset radiating No relevant past medical history Smoker for 22 years Sexually active Physical examination reveals right lower quadrant tenderness

Keypad question Which of these tests would you perform first? pregnancy test 1 laparoscopy 2 transabdominal ultrasound 3 CT scan of abdomen 4

Test results Pregnancy test is negative

CT scan shows perforated appendix

Laparoscopic surgery is performed Area of gangrene/perforation Pus/fibrin

Keypad question Would you administer perioperative antibiotics? yes 1 no 2 7s countdown

Keypad question What antibiotic therapy would you choose? cefoxitin or cefotetan 1 trimethoprim sulphamethoxazole (co-trimoxazole) 2 ciprofloxacin and metronidazole 3 levofloxacin, ampicillin and metronidazole 4 ampicillin/sulbactam or amoxicillin/clavulanic acid 5 ampicillin, gentamicin and metronidazole 6 cefuroxime and metronidazole 7 Centers for Disease Control (CDC): www.cdc.gov Surgical Infection Society (SIS): Mazuki et al. Surg Infect (Larchmt) 2002;3:161–173 Infectious Diseases Society of America (IDSA): www.idsociety.org

Keypad question For how many days would you administer antibiotics? one 1 three 2 five 3 seven 4 nine or more 5 7s countdown

Postoperative period Following surgery, patient receives 3 days’ therapy with cefuroxime and metronidazole On this day (Friday), she is seen by a junior resident feels unwell continuing abdominal pain fever (38.7°C) H2-receptor antagonist and codeine

Keypad question What would you do now in terms of antibiotic therapy? continue unchanged 1 stop 2 change 3 Idea OF capturing the esbl on a plate picture

Postoperative period Antibiotics are continued unchanged Idea OF capturing the esbl on a plate picture

Postoperative period On postoperative Day 6 (Monday), patient is still unwell Idea OF capturing the esbl on a plate picture

Postoperative period On postoperative Day 7 (Tuesday), examination shows: cough, shortness of breath bowel sounds present leukocytosis 17.0 x 109/L (17 000 /mm3) hypotension 105/50 mmHg tachycardia 125 beats/min tachypnoea 30 breaths/min fever 38.8°C Pulse oximeter SpO2 85% on air Abdominal examination is normal

Follow-up Chest X-ray is performed showing right sided pneumonia

Chest X-ray

Follow-up Patient is transferred to intensive care unit (ICU) and is intubated

Keypad question What is the appropriate microbiological investigation? tracheal aspirate culture 1 nondirected bronchoalveolar lavage 2 bronchoscopic specimen 3 el-Ebiary et al. Am Rev Respir Dis 1993;148:1552–1557 Fagon et al. Ann Intern Med 2000;132:621–630 Ruiz et al. Am J Respir Crit Care Med 2000;162:119–125

Further tests Bronchoscopy with bronchoalveolar lavage (BAL) is performed: differential cell count: 78% granulocytes, 10% lymphocytes, 12% macrophages Gram stain shows predominance of a single organism

Keypad question What is the most likely ‘bug’? methicillin-resistant Staphylococcus aureus (MRSA) 1 Pseudomonas aeruginosa 2 Acinetobacter baumannii 3 Klebsiella spp. 4 Haemophilus influenzae 5 Pneumococcus spp. 6 anaerobes 7 a combination of the above 8 Why did you choose this “bug”?

Gram stain of BAL fluid Abundance of Gram-negative bacilli Neutrophils

Keypad question What factor(s) would influence your choice of antibiotics at this time? prior use of H2-receptor blockers 1 hospital exposure 2 presence of nasogastric tube 3 prior antibiotic administration 4 recent abdominal surgery 5 smoking 6 all of the above 7 none of the above 8 Trouillet et al. Am J Respir Crit Care Med 1998;157:531–539

Keypad question What empiric antibiotic(s) would you administer now? ceftazidime 1 piperacillin/tazobactam 2 ciprofloxacin 3 cefepime 4 carbapenem 5 meropenem and vancomycin 6 continue cefuroxime and metronidazole 7 Paterson. Clin Microbiol Infect 2000;6:460–463

Treatment Sedation and analgesia with remifentanil Intravenous fluids to maintain blood pressure and urine output Low tidal volume ventilation, FiO2 0.45, PEEP 10 cm H2O Meropenem 1g three-times daily

Follow-up Two days later, Klebsiella pneumoniae is identified from BAL sample ESBL producer Antibiogram ceftazidime R cefuroxime R ciprofloxacin R gentamicin S meropenem S piperacillin/tazobactam R

TWTFSSMTWTFSSMTWT CEF / MET MERO ICU Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 TWTFSSMTWTFSSMTWT CEF / MET MERO ICU While in the ICU, the patient’s temperature begins to resolve and her pulse rate starts to normalise.

Keypad question For how many days would you administer meropenem? three 1 five 2 seven 3 ten 4 fourteen 5 more than fourteen 6 Rosa & Craven. Infect Med 2003;20:248–259

TWTFSSMTWTFSSMTWT CEF / MET MERO Ward Home ICU Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 TWTFSSMTWTFSSMTWT CEF / MET MERO Ward Home ICU Outcome ●  The patient is transferred to a general ward on ICU Day 5 ●  Three days later, meropenem is stopped after a total of seven days’ therapy ●  The following day, she leaves hospital and goes home

www.AIMinfection.org Outcome ●  The patient is transferred to a general ward on ICU Day 5 ●  Three days later, meropenem is stopped after a total of seven days’ therapy ●  The following day, she leaves hospital and goes home www.AIMinfection.org

Additional Questions What are the key learning points from this case? Which of the AIM core principles could be applied to this case? How could the educational value of this case be improved?