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LET’S PRACTICE

R.G., a 63-year-old man in the intensive care unit, underwent emergency

resection of his large bowel. He has been intubated throughout his

postoperative course. On day ! of his hospital stay, R.G. suddenlybecomes confused" his blood pressure #$%& drops to '!(3! mmHg, with a

heart rate of )3! beats(minute. His e*tremities are cold to the touch, and

he presents with circumoral pallor. His temperature increases to +!

#a*illary& and his respiratory rate is + breaths(minute. opious amounts

of yellow-green secretions are suctioned from his endotracheal tube.

%hysical e*amination reveals sinus tachycardia with no rubs or murmurs.

Rhonchi with decreased breath sounds are observed on auscultation. he

abdomen is distended and R.G. complains of new abdominal pain. /o

bowel sounds can be heard and the stool is guaiac positive. 0rine output

from the 1oley catheter has been )! m2(hour for the past hours.

rythema is noted around the central venous catheter.

4 chest radiograph reveals bilateral lower lobe in5ltrates, and urinalysis

reveals 7! white blood cells(high-power 5eld #8$(H%1&, few casts, and

a speci5c gravity of ).!)7. $lood, tracheal aspirate, and urine cultures are

pending. Other laboratory values include sodium #/a&, )3) m9(2 #normal,

)37 to )+'&" potassium #:&, +.) m9(2 #normal, 3.7 to 7&" chloride #l&, ))!

m9(2 #normal, ;7

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7. 8hat are the most liJely pathogens associated with R.G.Es

infection#s&F6. 4 Gram stain of R.G.Es tracheal aspirate shows gram-negative bacilli.

8hat tests may assist with the identi5cation of the pathogen#s&F'. Aerratia marcescens grows from a culture of R.G.Es tracheal aspirate,

and the decision to treat this organism is based on whether the

isolate is a true pathogen. How can the diKerence between true

bacterial infection and coloniation or contamination be

determinedF=. Bn light of the positive culture for Aerratia, his increased respiratory

secretions, and a worsening chest radiograph, R.G.Es lungs are

considered a source of infection. %ending susceptibility results, R.G.

is started on combination imipenem and gentamicin. 4re there

e9ually eKective, less to*ic options for this patientF

;. 8hat factors should be included in calculating the cost of R.G.Esantimicrobial therapyF

)!. he Aerratia was determined to be susceptible to

ciproLo*acin. Oral ciproLo*acin was considered for the treatment of 

R.G.Es presumed Aerratia pneumonia, but the BM route was

prescribed. 8hy is the oral administration of ciproLo*acin

reasonable #or unreasonable& in R.G.F)). 8hat dose of BM ciproLo*acin should be given to R.G.F 8hat

factors must be taJen into account in determining a proper

antimicrobial doseF). R.G.Es respiratory status remains unchanged" thus, the

ciproLo*acin is discontinued and cefota*ime and gentamicin are

started empirically. he use of a constant BM infusion of cefota*ime is

being considered in R.G. Bn addition, the use of single daily dosing of 

gentamicin is being discussed. 8hat is the rationale for these

approaches, and would either be advantageous for R.G.F)3. eftria*one #Rocephin&, rather than cefota*ime #laforan&, is

being considered for the treatment of R.G.Es infection. eftria*one is

more highly protein bound than cefota*ime. 8hy is protein binding

important in the selection of therapyF)+. Nespite appropriateI treatment, R.G. is unresponsive to

antimicrobial therapy. 8hat antibiotic-speci5c factors may

contribute to antimicrobial failureIF)7. 8hat pharmacologic or pharmaceutic factors may be

implicated in failure of therapyF)6. 8hat host factors may contribute to the failure of  

antimicrobial therapyF)'. Other than initiation of ade9uate antimicrobial therapy, what

adunct measures can be considered in this patient with septic

shocJF

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