• 68 years old male• Pain in leg for 1 day• Alter mental status and fever this morning.• V/S BP 88/40 HR 126/min RR 28/min Temp 39.3

C O2Sat 92 %• Left leg: Diffuse swelling with brawny edema,

pain on light palpation, several bullaes with dark purple fluid.

• ABG pH 7.22 PaCO2 28 Pa02 93• Cr 3.2• WBC 22660 N 70% Band 28% L 2%• CPK 553• Gram stain of fluid aspirated from bulla.

What is the most appropriate therapy for this patient?

A. Ampicillin, Clindamycin and Gentamycin

B. Clindamycin and Penicillin

C. Clindamycin, penicillin, and debridement

D. Penicillin and debridement

E. Vancomycin, penicillin, and debridement

Answer:

Penicillin ,Clindamycin and debridement

Diagnosis:

Septic shock secondary to NF with GAS.

NF

Caused

GAS

Mixed aerobic anaerobic organism

C. Perfringens

Some strains of MRSA

Symptoms and Signs

• Starts with pain and fever

• Swelling then edema and tenderness

• Dark red induration of epidermis with bullae

• In later stage, the skin will be friable and turn brownish grey accompanying with shock

GAS

• Absent of Hx of streptococcal infection is common.

• Myositis occurs in 20-40% of cases which might cause elevation of CPK level.

Mixed aerobic-anaerobic

• Site of breach in the integrity of mucosa of GI or GU tract may be presented in question e.g. malignancy, diverticulum or hemorrhoid

• Other possible comorbidities : DM, Peripheral vascular disease, Surgery or penetrating abdominal trauma

Clostridium

• Hx of severe penetrating trauma with contamination by soil.

• Spontaneous case can happen in patient with neutropenia, GI cancer or recent RT to abdomen.

Treatment

• IVIG is not recommended.

Explanation

• Clinda is more effective than penicillin in terminating toxin production by bacteria (Inh. of protein synthesis VS Inh. of cell wall synthesis.)

• Because clinda resistance in GAS, although rare, has been reported. Penicillin should be administered concomitantly until C/S result is available.

1. Same manifestation but different gram stain. Which antibiotic?

Same question but with history of penicillin allergy, which antibiotic?

Depend on type of reaction

immediate reaction or life threatening manifestation : Vancomycin

minor reaction : 1st gen cephalosporin

2. NF with history of colon cancer and uncontrolled DM with following gram stain?