Community Acquired Pneumonia

Patient presented to the emergency department with shortness of breath, cough, fever and chills.

Discussion

Upon admission, the patient was initially given ceftriaxone and azithromycin for the treatment of suspected community acquired pneumonia. Due to the patient’s history of COPD, he was at risk for organisms such as MRSA (methicillin resistant Staphylococcus aureus) in addition to the more common causes of community acquired pneumonia such as Streptococcus pneumoniae and atypical organisms.

At the time of admission, he had blood cultures obtained and T2Bacteria ordered. At this hospital, patient selection for T2Bacteria testing was based on elevated lactate and/or procalcitonin in patients presenting to the emergency department with suspected bloodstream infections.

Effective therapy against MRSA was not initiated until blood cultures demonstrated growth of S. aureus over 30 hours after admission (T2Bacteria results were not reported as this case was part of an observational study). Had the T2Bacteria test been performed and result been reported immediately after collection, the patient could have been initiated on effective empiric therapy over 30 hours sooner.

Presentation

59-year-old male with history of rectal cancer and COPD. Patient presented to the emergency department with shortness of breath, cough, fever and chills. Sepsis was suspected and patient was admitted with orders for blood cultures, T2Bacteria and antibiotics.

Patient Selection Criteria

Lactic acid 2.8 mg/dl

Procalcitonin 59 ng/ml

Evaluation and Treatment Decision

Diagnosis: Community acquired pneumonia

Empiric Therapy: Ceftriaxone, Azithromycin

Ceftriaxone and azithromycin were chosen for coverage of common causative respiratory pathogens identified in community acquired pneumonia.

T2Bacteria Result: Positive for S. aureus and negative E. faecium, P. aeruginosa, E. coli and K. pneumoniae.  

Blood Culture Result: Methicillin-resistant Staphylococcus aureus (36 hour delay in species identification from time of blood culture collection)

Decision making based on T2Bacteria Result:

A rapid T2Bacteria result could have allowed for more informed treatment decisions, including initiation of earlier effective therapy over 30 hours sooner.

 

 

Suspected urinary tract infection

91-year-old female presented to the emergency department with several day history of fever, chills, and nausea/vomiting.

Had the T2Bacteria test been performed and result been reported immediately after collection, the patient could have potentially avoided premature discharge and readmission.

Discussion:

Upon presentation to the emergency department, the patient was initially given ceftriaxone for the treatment of suspected urinary tract infection. At the time of admission, she had blood and urine cultures obtained and T2Bacteria ordered. Patient selection for T2Bacteria testing was based on procalcitonin in at the time of presentation.

The patient was discharged prior to blood culture resulting positive for growth (T2Bacteria results were not reported as this case was part of an observational study). Had the T2Bacteria test been performed and result been reported immediately after collection, the patient could have potentially avoided premature discharge and readmission.

Presentation:

91-year-old female presented to the emergency department with several day history of fever, chills, and nausea/vomiting. Patient was admitted with orders for blood cultures, T2Bacteria, urine cultures and antibiotics.

Patient Selection Criteria:

Procalcitonin 1.5 ng/ml in a patient suspected of bloodstream infection.

Evaluation and Treatment Decision:

Diagnosis:  Suspected urinary tract infection

Empiric Therapy: Ceftriaxone x 1 dose

Ceftriaxone was chosen for coverage of common causative gram-negative pathogens identified in UTIs.

T2Bacteria Result: Positive for E. coli and negative for S. aureus, E. faecium, P. aeruginosa and K. pneumoniae.

Blood Culture Result: E. coli on Day 2

Urine Culture Result: E. coli on Day 2

Patient was discharged in the morning of Day 2 prior to availability of culture results. Patient returned to the ED on the next day with ongoing fever/chills and was readmitted.

Decision making based on T2Bacteria Result:

A rapid T2Bacteria result could have allowed for more informed treatment decisions, including continuation of antibiotic therapy and avoidance of readmission less than 24 hours after her initial premature discharge.

Deep-seated invasive candidiasis in a liver recipient without candidaemia.

Patient with insulin-dependent diabetes mellitus, primary sclerosing cholangitis, multiple bacteremic episodes and recent liver transplant was admitted.

In this case, T2Candida® results could have permitted earlier focused therapy and aided with the diagnosis of invasive Candida infection and lead to appropriate antifungal therapy. Unfortunately, the T2Direct Diagnosticsresults were not in clinical use at the time and not obtained until after patient death.

Discussion:

T2Candida retrospectively revealed C. albicans/C. tropicalis, even at the beginning of the process when the patient was asymptomatic. This case highlights the potential advantage of T2Direct Diagnostics aiding in the diagnosis of deep-seated infection in an immunosuppressed patient without confirmed infection, even before the onset of symptoms.

The two key findings were that arteritis and thrombosis of the hepatic graft resulted from an undocumented fungal infection in the explanted liver and that T2Candida was a suitable diagnostic tool for the diagnosis of deep-seated invasive candidiasis in the absence of positive blood culture results.

Presentation:

A 57 year-old woman with insulin-dependent diabetes mellitus, primary sclerosing cholangitis, multiple bacteremic episodes and recent liver transplant was admitted for sudden abdominal pain. After identification of an intrahepatic abscesses the patient underwent a second liver transplant. Subsequently, non-purulent inflammatory tissue was observed in the liver with extensive clotting of the portal vein and hepatic artery, and generalized hepatic ischemia. In the following hours, the patient developed graft failure, severe coagulopathy and died.  

Evaluation and Treatment Decision:

All of the cultures collected before death, including blood (obtained at admission and repeated 3 times during hospitalization), ascitic fluid at admission, and liver and abdominal tissues during the re-transplantation procedure, were sterile.

Final Diagnosis: Liver abscess

Empiric Therapy (May 31, 2017): Vancomycin, meropenem, caspofungin

T2Candida Panel Result: Retrospective T2MR performed on blood samples obtained on May 27th, May 31st, June 9th, June 16th, and June 26th showed C. albicans/C. tropicalis present in all samples.

Histology Result: Histopathology of explanted liver tissue revealed multiple ischemic areas with abundant filamentous fungal structures in their interior and C. albicans was identified using multiplex PCR.

Decision making based on T2Candida Result: T2Candida result from May 27th (and subsequent results) could have permitted earlier focused therapy and aided with the diagnosis of invasive Candida infection. Unfortunately, the T2Direct Diagnostics results were not in use clinically and not obtained until after death.

Suspected Aspiration Pneumonia vs HCAP

Patient presents to the Emergency Department from nursing home with fever, dyspnea, and altered mental status.

Presentation:

PS is a 69 y/o M who presented to the Emergency Department from nursing home with fever, dyspnea, and altered mental status. His initial lactic acid was 4.5. He was seen by the treating physician and sepsis was suspected. PS was admitted with orders for labs, blood cultures, T2Bacteria®, and broad-spectrum antibiotics.

Patient Selection Criteria:

SIRS criteria:

  • Temperature: 103.5˚F
  • Heart Rate: 130 bpm
  • Respiratory Rate: 20
  • WBC (initial): 19,920/mm3

Evaluation and Treatment Decision:

Suspected aspiration pneumonia vs HCAP

Empiric Therapy: Vancomycin, Clindamycin, Ceftazidime

T2Bacteria scheduled to result at 2030 on second shift. Result: K. pneumonia (time to result: ~5 hours), result reviewed by ID pharmacist next am

Blood Culture Result: Negative after 5-days incubation

WBC next am on Ceftazidime: 24,950/mm3 (worsening)

Decision making based on T2Bacteria Result:

  1. Reviewed internal antibiogram. Changed Ceftazidime to Meropenem based on antibiogram percent susceptibility of 88% vs 99%.
  2. Discontinue Clindamycin and vancomycin
  3. WBC next am after switch to Meropenem: 10,960/mm3

Discussion:

At the time of admission, this patient had blood cultures obtained and T2Bacteria ordered. At Piedmont Columbus Regional, patient selection for T2Bacteria testing was based on >2 SIRS criteria PLUS suspected source of infection PLUS hypotension or altered mental status. This patient was positive for 2 of 4 SIRS criteria and had a suspected source of infection and altered mental status, thus meeting criteria for testing.

Determination of the causative organism for this patient’s infection allowed optimization of the antibiotic regimen within 24 hours of presentation. The patient was not improving on empiric therapy and experienced clinical improvement after the switch from ceftazidime to meropenem. Additionally, clindamycin was discontinued on Day 2 and vancomycin was discontinued on Day 3 allowing for 5 days of therapy to be saved for clindamycin and 4 days of therapy to be saved for vancomycin. The patient continued to improve and was discharged back to the nursing home after meropenem therapy was completed.

 

 

 

Suspected Intra-Abdominal Sepsis

Patient presents with suspected sepsis

Presentation:

53-year-old immunocompromised, morbidly obese female with recent history of surgery to drain an intra-abdominal abscess. Patient presented at the emergency department 8 days post-op with fever, chills and abdominal pain. Sepsis was suspected and patient was admitted with orders for blood cultures, T2Bacteria® and broad spectrum antibiotics.

Patient Selection Criteria

SIRS criteria:

  • Temperature: 103.4
  • Heart Rate: 133 BP90/62
  • Respiratory Rate: 34
  • WBC: 6,800/mm3
  • NEWS Score: 9
  • QSOFA Score: 2

Evaluation and Treatment Decision

Diagnosis: Suspected Intra-abdominal sepsis

Empiric Therapy: Linezolid, Aztreonam, Metronidazole

Linezolid was chosen for gram-positive coverage due to challenges with vancomycin dosing in obese patients. Aztreonam was chosen for gram-negative coverage due to patient history of penicillin allergy. Metronidazole was chosen for anaerobic coverage.

T2Bacteria Result: Positive for E. coli and P. aeruginosa and negative for S. aureus, E. faecium, and K. pneumoniae. (SA -, PA + & EC +); T2Bacteria results were not reported as this case was part of an observational study.  

Blood Culture Result: Negative

Decision making based on T2Bacteria Result:

The negative S. aureus result meant that the patient did not have MRSA and therefore linezolid could have been discontinued after the first dose when the T2Bacteria result was available, a 4.5 day reduction in linezolid. The patient’s therapy could have been more targeted gram-negative coverage by switching to meropenem to cover E. coli and P. aeruginosa

Discussion:

Upon admission, the patient was initially given the broad spectrum antibiotics linezolid, aztreonam and metronidazole for the treatment of suspected intra-abdominal sepsis. Due to the patient’s recent healthcare exposure, she was at risk for organisms such as MRSA (methicillin resistant Staphylococcus aureus) and Pseudomonas aeruginosa in addition to the more common causes of intra-abdominal infection such as enterobacteriaceae and anaerobic organisms. 

At the time of admission, she had blood cultures obtained and T2Bacteria ordered. At Lee Health patient selection for T2Bacteria testing was based on the NEWS (National Early Warning Score) scoring system. The NEWS score was developed to standardize the approach to detection of clinical deterioration in acutely ill patients in the United Kingdom, and a score of 7 or higher puts the patient in the high risk category. This patient also was positive for 3 of 4 SIRS criteria and had a qSOFA score of 2 indicating a high risk of mortality.

Due to the negative blood culture (T2Bacteria results were not reported as this case was part of an observational study), the patient remained on empiric therapy for 5 days and then was changed to oral therapy and discharged 2 days later. Had the T2Bacteria result been reported, the patient could have been changed to meropenem to cover the E. coli and P. aeruginosa, allowing discontinuation of aztreonam. Given the S. aureus was negative, linezolid could have been discontinued as well. Discontinuation of these two antibiotics within the first 24 hours of admission would have led to ~$6,000 savings in antibiotic charges, and potentially led to earlier discharge on effective oral therapy.

 

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