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18 Apr 2019

A patient with a heart pacemaker received antibiotic therapy for streptococcal bacteremia (bacteria in the blood.) One month later, he was treated for recurrence of the bacteremia. When he returned six weeks later, again with bacteremia, the physician recommended replacing the pacemaker. Why did this cure his condition?

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14 Mar 2023
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Related questions

Julie was proud and excited about her new tattoo; it was cool! Jason, her boyfriend, had bought it as a gift for her 18th birthday, and she loved the way it covered her arm. A week later something else covered her arm … and his leg. Julie and Jason had fallen victim to an emerging disease—community-associated, methicillin-resistant Staphylococcus aureus (CA-MRSA) infection. Julie’s arm was covered with red, swollen, painful, pus-containing lesions, and she had a fever. Jason thought he had a spider bite on Wednesday, but by Thursday morning a bright red line extended from his ankle to his groin. He could barely walk, and then his condition worsened. By the weekend, he was hospitalized, and his fever hit 107°F107°F during his 10 days there. MRSA had entered his blood (bacteremia) and infected his bones (osteomyelitis). Jason’s pain was so severe that he wondered only when he might die to be free of the agony. Click for more options Click for more options For years, health care workers have battled healthcare-associated MRSA (HA-MRSA), which commonly afflicts patients in hospitals. Now, researchers are concerned that victims who have never been in a hospital are succumbing; MRSA has escaped hospitals and travels communities worldwide, including among athletes, students in middle schools, and customers of unsafe tattooists. The bacterium can be spread between individuals who share fomites—towels, razors, clothing, or sheets. Physicians drained Julie’s lesions and prescribed oral antimicrobials, including trimethoprim-sulfamethoxazole, doxycycline, and clindamycin. Jason received intravenous vancomycin. Both eventually recovered, but her tattoo is now a reminder of a terrible experience and not a happy birthday. (For more about staphylococcal infections, see Chapter 19.) 1. How were Julie and then Jason likely infected? 2. Why is CA-MRSA considered an “emerging disease,” given that MRSA has been around for years? 3. Why doesn’t the map show more countries in Africa and South America with cases of CA-MRSA?

Case Study #1: A Common Opportunistic Infection

Ben, a seven-year-old second grader, quickly finished his homework after school so he could play outside with his friend form next door. Since Ben had started coughing the day before, his mother insisted he wear his jacket. At bedtime, Ben was exhausted from his busy day. When kissing his forehead goodnight, Ben’s mother noted that he felt a little warm. To help Ben sleep more comfortably since he was likely getting a cold, his mother gave him a dose of pediatric Tyenol, “Poor Ben,” she thought. “Three weeks ago he had the flu and now a cold is starting. He could really use a break.”

In the morning, Ben didn’t come to the breakfast table when called. His mother found Ben still in bed, barely responsive, and extremely feverish. She immediately drove him to the walk-in clinic in their neighborhood. Ben’s oral temperature was 40.8C (105.4F). IV fluids were started and an ambulance transported Ben to the nearest hospital.

In the hospital emergency room, Ben presented with the following viral signs: temperature = 41.9C (107.4F), pulse = 162 bpm, pulse ox = 90%, respirations = 24/minutes and labored, BP = 62/54 mmHg. Ben was completely unresponsive. His physical exam was remarkable for rales or “crackles” heard over both right and left lower lung fields. Bilateral chest radiographs were ordered and revealed infiltrates in the lower lobes of both lungs.

Preliminary lab results yielded a white blood cell count of 16,200 cells/mm^3 and a differential count with 74% neutrophils, including 18% bands. Respiratory acidosis was indicated by an arterial blood pH of 7.2. These results were immediately called from Ben’s local hospital to his new facility and broad-spectrum IV antibiotic therapy was initiated.

9. Approximately 6 hours later, the clinical microbiologist examined the BAP and chocolate agar plates. What morphological features did she likely observe on the plates? Why were these two media types selected for culturing?

10. What results would you predict from the following tests?

Optochin

Catalase

Bacitracin

Bile solubility

Quellung reaction

11. What is the significance of the following laboratory results?

The WBC

High neutrophil count with elevated bands

Respiratory acidosis

Automated identification and sensitivity testing were initiated and the presumptive microbe identification called to the other facility to aid in treatment. Ben’s attending physician was relieved to find that the CSF was sterile, as she had just initiated prophylactic antibiotic treatment of Ben’s caregivers. Unfortunately, she reported that Ben’s condition had continued to decline and he has been pronounced dead earlier that hour. She requested that identification/sensitivity data be forwarded upon completion so Ben’s record could be finalized.

12. Why was Ben’s physician relieved that the CSF was sterile? What possible infection was she considering?

13. Assuming Ben was receiving broad-spectrum IV antibiotic therapy that was effective against his infection, what reasons can you give to explain his rapid deterioration and eventual death when receiving an appropriate empiric therapy?

Within 6 hours, the Virek analyzer confirmed the identity of this microbe and indicated its sensitivity to penicillin, cephalosporins, and fluoroquinolones. While Ben’s attending physician was pleased that her staff had not been exposed to a resistant microbe, she was frustrated to have lost a young patient to one so sensitive to standard antibiotics.

14. Were there any predisposing factors that put Ben at greater risk for this infection?

An older adult male is readmitted to the hospital with an exacerbation of heart failure just 2 weeks after being discharged for the same problem. He lives alone and does not drive. He presented to the emergency department reporting severe shortness of breath at rest. Physical exam shows 4+ peripheral edema of the lower extremities, abnormal breath sounds in both upper and both lower lobes with a labored breathing pattern and an extra heart sound. His weight in the emergency department is 10 pounds more than his weight on discharge 2 weeks ago. Oxygen saturation is 90% on 4 liters by nasal cannula; heart rate 110; blood pressure 140/90; respiratory rate 24. When he was discharged 2 weeks ago, he had been provided the standardized package of discharge information for heart failure patients. This information discussed medications, diet, exercise and when to seek medical help for changes in his symptoms. Address the Following: Select one of these listed variables - communication, discharge planning or health literacy. Describe why your selected variable is a priority for this patient and support your answer with a reference or references. Identify an intervention that the RN can implement that addresses your selected variable and help prevent further readmissions for this patient. Base your initial post on your readings and research of this topic. Your initial post must contain a minimum of 250 words. References, citations, and repeating the question do not count towards the 250 word minimum.

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