Infectious Diseases II

ardship in the ICU?

antimicrobial

stewardship

team

membership should be reserved for clinical

pharmacists with infectious diseases training.

antimicrobial resistance.

pharmacist may constitute an antimicrobial

stewardship effort.

tuted in critically ill patients because restriction

of antimicrobial choices may worsen outcomes.

A 33-year-old woman with a history of hydrocepha-

lus since early childhood requiring placement of an

internal cerebrospinal fluid (CSF) shunt, presents

with a temperature of 102.8°F (39.3°C), altered

mental status, and a white blood cell count of 19 x

103 cells/mm3. After a computed tomography scan

reveals no hydrocephalus or midline shift, a lum-

bar puncture is performed. Initial cell count shows

elevated CSF white blood cells with a high propor-

tion of neutrophils and low glucose. Neurosurgery

is consulted for a presumed CSF shunt infection.

Which empiric systemic antibiotic regimen is most

appropriate?

A 75-year-old man is admitted to the medical ICU

from the emergency department with septic shock.

He is fluid resuscitated and administered broad-

spectrum antibiotics with piperacillin/tazobactam

and vancomycin. On day 2 of therapy, the patient

remains hemodynamically unstable, requiring nor-

epinephrine. The patient’s blood culture is positive,

according to the institution’s microbiology labora-

tory, which recently implemented rapid diagnostic

tests using nanoparticle microarray technology, and

the microarray results show the presence of

Escherichia coli with the CTX-M resistance gene.

Which intervention regarding the patient’s antimi-

crobial therapy is most appropriate?

An 81-year-old man is admitted to the medical

ICU with presumed line-associated sepsis. Blood

cultures are obtained that grow pan-sensitive

Enterobacter cloacae. The patient is being treated

with intravenous ceftriaxone, and the offending

CVC is removed. The patient initially responds, but

on day 10 of therapy, he becomes febrile, and blood

cultures are re-sent. At that time, the patient was

maintained on ceftriaxone because he was hemo-

dynamically stable. Gram stain for the new blood

cultures is positive for lactose-positive gram-nega-

tive bacilli. Which is the most appropriate action for

this patient’s antimicrobial management?

An 86-year-old woman with a history of end-

stage renal disease is admitted to the hospital

with respiratory distress requiring intubation,

fluid resuscitation, and hemodynamic monitoring.

Bronchoalveolar lavage cultures show methicillin-

resistant Staphylococcus aureus (MRSA). The

patient is being treated with intravenous vancomy-

cin. On day 4 of therapy, the patient develops fever,

leukocytosis, and erythema around the insertion site

of her tunneled dialysis catheter. Blood cultures are

sent, and the dialysis catheter is removed. Gram

stain from blood cultures is significant for gram-

positive cocci in pairs and chains. The medical

team discontinues vancomycin and approaches you

to inquire about treatment options for this patient.

Which agent is most appropriate for this patient?

A 35-year-old man is admitted to the medical ICU

with respiratory distress. He has a 3-week history of

cough and pleuritic chest pain that has worsened with

time. Chest radiography is performed, which shows

bilateral infiltrates with ground-glass opacities. The

patient is HIV positive and not currently receiving