1. Case Study A Sudden onset of stomach pain
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Case Study A Sudden onset of stomach pain

2. 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

3. 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

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

5. Test results
Pregnancy test is negative

6. CT scan shows perforated appendix

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

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

9. 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): Surgical Infection Society (SIS): Mazuki et al. Surg Infect (Larchmt) 2002;3:161–173
Infectious Diseases Society of America (IDSA):

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

11. 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

12. 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

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

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

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

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

17. Chest X-ray

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

19. 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

20. 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

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

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

23. 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

24. 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

25. 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

26. 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

27. TWTFSSMTWTFSSMTWT CEF / MET MERO ICU
Day
TWTFSSMTWTFSSMTWT
CEF / MET
MERO
ICU
While in the ICU, the patient’s temperature begins to resolve and her pulse rate starts to normalise.

28. 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

29. TWTFSSMTWTFSSMTWT CEF / MET MERO Ward Home ICU
Day
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

30. 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

31. 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?