Infectious Diseases I

Patient Cases

C.T. is a 48-year-old man sustaining a 40% total body surface area burn to his left side with likely inhala-

tional injury requiring mechanical ventilation. C.T. has been in the ICU for 7 days. Overnight, C.T. had a

temperature of 102.1°F (39°C), a WBC of 18 x 103 cells/mm3, and an increase in macroscopically purulent

sputum production; C.T. is hemodynamically stable with no signs of new-onset organ dysfunction. C.T.’s

chest radiograph is difficult to assess, given his inhalational injury. The respiratory therapist was asked by

the fellow to do a catheter-directed BAL for suspected VAP. The culture was sent to the microbiology labo-

ratory. Which would be best to do at this point?

(COPD), type 2 diabetes, and coronary artery disease. She is readmitted to the ICU with respiratory fail-

ure requiring intubation secondary to severe COPD. C.P. had a 10-day hospitalization 12 days ago, during

which time she received intravenous azithromycin for a COPD exacerbation. On day 4 of this readmission,

a worsening infiltrate is in the left lower lung base with increased sputum production from admission, maxi-

mum temperature is 101.9°F (38.8°C), and there is worsening oxygenation, despite previous improvement

in initial COPD exacerbation. The patient is thought to have clinical VAP, and a semiquantitative tracheal

aspirate is sent to identify causative pathogen(s). The local ICU prevalence of MRSA is 30%, and the most

active β-lactam antibiotic against P. aeruginosa on the antibiogram has 80% activity. Which empiric anti-

biotic regimen is best for this patient?

K.L., a 37-year-old man who presents after a motorcycle collision, has sustained several orthopedic and

chest injuries. K.L. has been mechanically ventilated for 8 days, during which time he was given a diagno-

sis of VAP caused by Klebsiella pneumoniae. K.L. received appropriate empiric antibiotic therapy and has

improved oxygenation, decreased WBC temperature curve. Which would be the best duration of definitive

antibiotic therapy for K.L.’s VAP?

chapter.