Case Studies on Life-threatening Infections in The ICU

Michael S. Niederman, MD, FCCP

Chairman, Department of Medicine
Winthrop- University Hospital
Mineola, NY
Professor of Medicine
Vice-Chariman, Department of Medicine
SUNY at Stony Brook

Nuala J. Meyer, MD, MS
Assistant Professor of Medicine
Pulmonary, Allergy, and Critical Care Medicine Division
University of Pennsylvania
Perelman School of Medicine
Philadelphia, PA


NOTE: A SPECIAL THANKS TO GEORGE KARAM, M.D., FOR PREPARATION AND
REFINEMENT OF MANY OF THESE CASES.


OBJECTIVES

1. Review common skin, heart and respiratory infections in the ICU
2. Discuss management principles for severe infection
3. Discuss treatment approaches to specific infections


1. A 36-year-old injection drug user presents with fever and chills. Exam reveals a blowing diastolic

murmur in the 2nd right intercostal space. Vancomycin and gentamicin are started. Cultures of
blood grow methicillin-sensitive Staphylococcus aureus, and the antibiotic regimen is changed to
nafcillin. On the 4th hospital day, the patient remains febrile. Telemetry monitoring reveals an
increase in his PR interval from 0.16 sec to 0.34 sec. Blood cultures drawn after 3 days of
antibiotics grow S. aureus. Which would be most appropriate?
(1) Cardiac surgery
(2) Beginning heparin
(3) Addition of rifampin to nafcillin
(4) Addition of gentamicin to nafcillin


2. A 24-year-old woman who recently completed treatment for acute leukemia presents to her
primary physician with fever and sore throat. On exam, she has an exudative pharyngitis, and
she is prescribed erythromycin. Five days later she is admitted to the ICU with fever and
respiratory distress. On exam she is acutely ill with marked tenderness over the right
sternocleidomastoid muscle and swelling over the right side of her face. She has a nontender
right subclavian Hickman catheter site without drainage, and no edema of the right arm. Chest x-
ray shows multiple bilateral cavitary lesions. The most likely diagnosis is
(1) Corynebacterium jeikeium line infection.
(2) Fusobacterium necrophorum bacteremia with jugular vein thrombosis.
(3) Staphylococcus aureus tricuspid valve endocarditis.
(4) Candida albicans line sepsis.


3. A 43-year-old man on chronic steroid therapy for asthma is admitted to the ICU with a perforated
duodenal ulcer. After surgery, broad-spectrum antibiotics and total parenteral nutrition are
started. Steroids are continued. Five days postoperatively, the patient becomes febrile in the
102
0
F range. Urine cultures on two different days grows Candida albicans, but one sample also
shows C. glabrata. . All other cultures are negative. Exam reveals no definitive site of infection.
The bladder is not catheterized, and serum glucose is normal. What would be the most
appropriate course of action?
(1) Repeat urine culture to assess whether the candiduria persists
(2) Cultures of sputum and abdominal drains for Candida
(3) Bladder irrigation with amphotericin B
(4) Oral fluconazole in a dose of 200 mg daily
(5) Caspofungin


4. A middle-aged man with alcoholic cirrhosis presents in acute distress two days after cutting his
thenar eminence with an oyster shell. He is febrile and hypotensive, and there are multiple
hemorrhagic bullous lesions with associated gangrene over the distal arms. Admission lab data
show leukopenia and evidence of DIC. The most likely pathogen to cause such an infection is
(1) Vibrio vulnificus
(2) Clostridium perfringens.
(3) Streptococcus pneumoniae.
(4) Neisseria meningitidis.


5. You are asked to see a 41-year-old woman who is found to have a temperature of 39.2
o
C and a
blood pressure of 82/46 six hours after a cholecystectomy. Exam is notable for her acute distress
and for bullous lesions near the surgical wound. Aspiration of one of these lesions reveals
numerous white blood cells with gram-positive cocci in chains. The antibiotic that would be most
helpful in reducing toxin production in this illness is
(1) ciprofloxacin.
(2) clindamycin
(3) aztreonam.
(4) azithromycin.

6. A 51-year-old man with a history of alcoholism is admitted with fever and abdominal pain. On
examination he is in acute distress, with a quiet abdomen and marked tenderness in the
epigastrium and left upper quadrant. Labs are remarkable for leukocytosis, metabolic acidosis,
hypocalcemia, and elevations of pancreatic amylase and lipase. A contrast CT scan of the
abdomen demonstrates evidence of pancreatic necrosis, without abscess or pseudocyst
formation. Which of the following should be included in his initial management?
(1) Oral nonabsorbable antibiotics
(2) Diagnostic CT-guided percutaneous aspiration of the pancreatic bed
(3) Intravenous imipenem
(4) Surgical debridement of necrotic pancreas


7. A 65 year old steroid- dependent COPD patient is admitted with an exacerbation of his dyspnea , along
with cough and purulent sputum. His chest radiograph is clear and he is treated with increased doses of
corticosteroids, bronchodilators and a broad- spectrum antibiotic. On the 6th hospital day, he becomes
febrile and develops a new right lower lobe infiltrate. He is treated with dual anti- Pseudomonal antibiotics
and bacterial culture of the sputum confirms the presence of P. aeruginosa. After 5 days of antibiotic
therapy the patient is not improving. He remains febrile to 102
o
F, his radiographic lung infiltrate has
worsened, a new wedge- shaped lingular infiltrate is present, and he develops respiratory failure requiring
intubation. On examination, he has several pustular lesions on the abdomen and finger tips, he is
obtunded, and has crackles over the right lower lung zone. Sputum Gram's stain shows gram- negative
rods and mycelial elements. At this time you perform a fiberoptic bronchoscopy , but while awaiting the
results you start therapy with:

1) A different combination of anti- Pseudomonal antibiotics
2) Fluconazole and the same anti- Pseudomonal antibiotics
3) Voriconazole and the same anti- Pseudomonal antibiotics
4) Micafungin and a different combination of anti- Pseudomonal antibiotics

8. A 75 year old patient with COPD , on chronic corticosteroids , was admitted in respiratory failure,
and has remained mechanically ventilated, and required tracheostomy. He currently is afebrile
and has clear sputum, and his chest radiograph shows no new infiltrates. Initially his sputum
cultures showed H. influenzae and S. aureus. His most recent sputum culture shows P.
aeruginosa in pure culture. At this time you order:

1) Gentamicin
2) Ciprofloxacin
3) Gentamicin and piperacillin
4) No antibiotics

9. A 27-year-old woman works at a day care center where there is an outbreak of meningitis in three
children who are two years old. Several days later, this lady begins having problems with fever,
neck pain, and difficulty breathing. The most appropriate management of this patient is
(1) inhaled b-2 agonists.
(2) oral erythromycin.
(3) intravenous cefotaxime.
(4) high-dose intravenous corticosteroids.


10. A 47 year old female with no significant past medical history presents with a 2 day history of
fever, chills, pleuritic right sided chest pain and cough with purulent and blood tinged sputum. She
is dyspneic and febrile to 103 degrees F. On exam she is lethargic and confused, with bronchial
breath sounds at the right base. Chest radiograph shows right lower lobe consolidation. Blood
cultures are drawn. A spinal tap shows a glucose of 30 mg/dL, protein of 5.0 g/L, and a white
blood cell count of 7500 per cubic mm. Gram stain shows gram positive dipplococci. The initial
therapy should include:

(1) ceftriaxone and vancomycin
(2) ceftriaxone and dexamethasone started 6 hours after the first dose of antibiotics
(3) ceftriaxone, vancomycin and dexamethasone started 20 minutes before the first dose of
antibiotics and continued every 6 hours for 4 days
(4) ampicillin and dexamethasone started 6 hours after the first dose of antibiotic therapy


11. 46 y/o Hispanic woman, p/w 2 week hx of leg edema, rash and leg pain. The rash was petechial
over the lower abdomen and flanks but was erythematous over both legs. She became febrile on
day of admission.5 weeks PTA kidney bx showed P-ANCA associated hypocomplementic
crescentic necrotizing GN. Treated with bolus cyclophosphamide 0.5gm/m
2
and prednisone
1mg/kg/day.She was treated for cellulitis and improved, but later became febrile again and blood
cultures showed Providencia rettgeri. She was treated with cefepime ,but on day 8, she
developed bilateral infiltrates. Sputum sample showed an abnormal finding. What is the likely
diagnosis?

1. Disseminated candidiasis
2. Gram negative pneumonia
3. Strongyloidiasis
4. Pulmonary hemorrhage
5.Tuberuculosis

12. A 45 year old man had influenza-like symptoms for 5 days with myalgias, fatigue and cough. He
had no chronic illnesses and on admission to the hospital had a right lower lobe pneumonia,
treated with ceftriaxone and azithromycin. Over the next 24 hours he worsened and developed
bilateral infiltrates, requiring mechanical ventilation for respiratory failure . Sputum Grams stain
showed gram-positive cocci and vancomycin was added to his therapy. Blood and sputum
cultures the next day showed gram-positive cocci.
What should you do?
1.Stop vancomycin and add clindamycin
2. Continue current therapy
3. Stop vancomycin and add linezolid
4. Start oseltamivir
5. Start ribavirin