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An immunocompromised patient was admitted after developing fever and rigors.

Discussion

This high-risk, immunocompromised patient was initially treated with ceftriaxone. The rapid T2Bacteria result for pseudomonas allowed for the escalation of therapy to meropenem and amikacin. Additionally, the positive T2Bacteria result prompted the removal of the central line as the suspected source of the infection. The culture from the catheter tip confirmed P. aeruginosa, five days after the initial P. aeruginosa result from T2Bacteria. Rapid species identification allowed for rapid escalation of therapy. Without the availability of T2Bacteria, the patient may have remained on inappropriate therapy for days until further clinical deterioration may have led to an empiric switch/broadening of therapy.

This case highlights how T2Bacteria can guide early treatment by rapidly identifying the causative pathogen in sepsis cases that are missed by blood cultures. T2Bacteria may be particularly useful in hematology/oncology patients with new-onset of bloodstream infection and/or sepsis due to the heavy antibiotic pre-exposure and the critical importance of getting therapy right on Day 1.

Presentation

An immunocompromised patient was admitted after developing fever and rigors approximately three months after stem cell transplant for treatment of AML. He was given ceftriaxone empirically upon admission. He had been diagnosed with AML the previous year and successfully underwent a stem cell transplant with a normal post-transplant course.

Patient Selection Criteria

Sepsis in an immunocompromised patient with a central line

Evaluation and Treatment Decision

Diagnosis

Sepsis

Empiric therapy

Initially ceftriaxone in addition to the continuation of prophylactic trimethoprim/sulfamethoxazole and posaconazole.

T2Bacteria Result

Positive Pseudomonas aeruginosa

Blood Culture Result

No growth; CVC tip culture: P. aeruginosa

Decision Making Based on T2Bacteria Results

The rapid T2Bacteria result supported the rapid escalation of therapy from ceftriaxone to meropenem and amikacin. The patient also received antibiotic lock therapy with amikacin preceding removal of the central line. The patient completed therapy and was discharged home with no complications.

27-year-old male admitted after developing fever and increased white blood cell count during hemodialysis.

Discussion

This high-risk, immunocompromised patient was initially treated with broad-spectrum antimicrobials. When he developed septic shock, micafungin was initiated immediately as candidemia accounts for 3-10% of all septic shock and each hour delay in instituting an active antimicrobial reduces survival in both septic shock and candidemia. Ideally, T2Candida would have been collected prior to giving micafungin. However, testing after antifungal dosing retains value because T2Candida positivity is significantly less likely to be impacted by treatment than are blood culture results.

This case highlights how T2Candida can identify candidemia cases that are missed by blood cultures and guide early treatment. T2Candida may be particularly useful in targeting antifungal treatment in patients with septic shock and other risk factors for candidemia.

Presentation

A 27-year-old male was admitted after developing fever and increased white blood cell count during hemodialysis. He was given vancomycin at hemodialysis and meropenem upon admission. He had a distant history of a double-lung transplant due to cystic fibrosis and a history of tacrolimus induced renal failure as well as line-associated bloodstream infections due to Enterococcus faecalis, coagulase-negative Staphylococcus, Candida glabrata, and S. aureus over the preceding two years. He had been discharged from the hospital 5 days earlier after receiving treatment for Enterobacter cloacae through a peripherally inserted central catheter (PICC).

Shortly after admission, he developed hypotension and respiratory failure requiring vasopressor therapy and mechanical ventilation. Micafungin was initiated within 2 hours, the PICC was discontinued and blood cultures and T2Candida were collected concurrently at 4 hours after the micafungin dose. The T2Candida was positive 4.5 hours later for C. albicans/C. tropicalis.

Patient Selection Criteria

Septic shock in an immunocompromised hemodialysis patient

Evaluation and Treatment Decision

Diagnosis

Septic Shock

Empiric therapy

Initially, broad-spectrum antibiotics with the addition of micafungin when the septic shock occurred

T2Candida Result

Positive for C. albicans/C. tropicalis

Blood Culture Result

No growth (from hemodialysis and admission); PICC tip: No growth

Ophthalmologic Exam (Day 5)

Consistent with Candida chorioretinitis

Decision Making Based on T2Candida Results

The rapid T2Candida result supported the continuation of antifungal therapy as well as PICC removal while blood cultures remained negative. The finding of chorioretinitis confirmed a diagnosis of deep-seated infection due to hematogenously disseminated candidiasis and justified both the switch from micafungin to fluconazole after 2 weeks and the total duration of therapy of 6 weeks.

 

1. Clancy, Cornelius J., and M. Hong Nguyen. “Diagnosing candidemia with the T2Candida panel: an instructive case of septic shock in which blood cultures were negative.” Diagnostic microbiology and infectious disease 93.1 (2019): 54-57.

An 86 year old patient presented with fevers and lethargy for one week.

Discussion

This case highlights not only the benefit of rapid species identification with the T2Bacteria Panel but also the Panel’s ability to prevent therapy that is not necessary as well as to detect the causative organisms that blood cultures may not due to infection localized within an abscess.

Presentation

An 86 year old patient presented with fevers and lethargy for one week. The patient had a history of an ischemic stroke complicated by residual right-sided weakness, type II diabetes, atrial fibrillation, recurrent urinary tract infections (history of Proteus mirabilis, E. coli, ESBL Klebsiella pneumoniae) as well as a known perianal fistula with ischioanal abscess. On arrival, the patient was in septic shock with fever to 103°F, hypotension requiring pressors, and lactate 3.8. The patient was started on vancomycin, meropenem, doxycycline, and a one-time dose of amikacin for empiric coverage based on prior cultures. Four blood cultures were collected in the ED as well as a T2Bacteria Panel.

CT abdomen/pelvis with contrast was performed which showed the increased size of left ischioanal fluid collection compared to CT previously. Urinalysis was sent with >100 WBCs and negative for bacteria.  Urine culture showed no growth, however, urine was obtained after initiation of antibiotics.

Patient Selection Criteria

A septic patient presenting in the Emergency Department

Evaluation and Treatment

Empiric Therapy

The patient was started on vancomycin, meropenem, doxycycline, and a one-time dose of amikacin

T2Bacteria Panel Result

Positive for Klebsiella pneumoniae, negative for the remaining four pathogens.

Hospital Course and Decision Making Based on the T2Bacteria Panel Result

The patient was transferred from the ED to the medical ICU where broad-spectrum antibiotics were continued and ID was consulted.  The T2Bacteria resulted and was positive for Klebsiella pneumoniae. At this point, the patient was not administered an additional dose of amikacin and the doxycycline was discontinued. Blood culture eventually grew Gram-positive cocci pairs & chains but no Gram-negative rods.  Overall, the patient was improving on broad-spectrum antibiotics, and given that the T2Bacteria Panel was negative for E. faecium despite having pairs and chains in his blood, the ID consults team felt more comfortable with holding off on empiric VRE coverage based on the T2Bacteria result. Blood cultures ultimately speciated to Streptococcus anginosus a day and a half later, but no Klebsiella. The patient’s perianal fluid collection was subsequently drained by colorectal surgery the next day, as this was likely the source of infection which grew many Proteus mirabilis, moderate Klebsiella pneumoniae, and moderate Streptococcus anginosus.

T2Bacteria picked up the Klebsiella from the patient’s abscess but it was never detected in blood culture. Antibiotics were subsequently de-escalated from vancomycin and meropenem to ceftriaxone given that the organisms were highly susceptible (non-ESBL) to complete a fourteen-day course.

An 82-year-old patient presented in the emergency department with a fever.

Discussion

This case highlights not only the benefit of rapid species identification with the T2Bacteria Panel but also the Panel’s ability to detect the causative organisms when blood culture does not.

Presentation

An 82-year-old patient presented in the emergency department with a fever. About three days prior, the patient had an abrupt episode of rigors and was febrile at 103°F at home. The patient was brought to another hospital where workup was negative for infection, including blood culture by her report. Subsequently, the patient was discharged home, although it is unclear if the patient was discharged with or without antimicrobials.  Still having similar chills and rigors the patient presented to an academic medical center and was admitted. The patient was febrile on admission with slight abdominal pain.  A CT scan revealed a severely distended gallbladder but normal common bile duct, with no significant gallbladder wall thickening.  Blood cultures and a T2Bacteria were drawn in the ED and the patient was started on ceftriaxone and flagyl with the abdomen as the suspected source of infection. The patient re-spiked a fever and was broadened to cefepime and given a one-time dose of vancomycin.

Patient Selection Criteria

A septic patient presenting in the Emergency Department

Evaluation and Treatment

Diagnosis

Suspected acute cholecystitis

Empiric Therapy

The patient was started on ceftriaxone and flagyl and broadened to cefepime and vancomycin.

T2Bacteria Panel Result

Positive for E. coli and S. aureus, negative for the remaining three pathogens.

Blood Culture Result

E. coli (4/4 bottles)

Decision making based on the T2Bacteria Result

A rapid T2Bacteria positive for E. coli and S. aureus prompted the team to de-escalate from cefepime to ceftriaxone and add vancomycin.  The high negative predictive value (99.7%) of the T2Bacteria Panel provided important diagnostic information that allowed for more informed treatment decisions, specifically the de-escalation of anti-pseudomonal therapy as well as the addition of vancomycin for the coverage of the S. aureus that was not identified via the blood culture. ID was consulted and they recommended two weeks of ceftriaxone and vancomycin for both organisms identified.  The patient defervesced and improved after 24 hours of therapy and was discharged home with IV antimicrobials for two weeks.

67-year-old female admitted for reduced-intensity conditioning followed by Stem Cell transplant for acute myelogenous leukemia.

Discussion

Patients undergoing cytotoxic chemotherapy and hematopoietic stem-cell transplantation (HSCT) are at high risk for infection, particularly during the period of neutropenia, and are often prescribed antibiotic prophylaxis with fluroquinolones. The majority of patients who develop a fever during neutropenia have no identifiable site of infection and no positive culture results. IDSA guidelines recommend that every patient with fever and neutropenia receive empiric antibiotic therapy with an antipseudomonal beta-lactam urgently after the presentation, because the infection may progress rapidly.1

De-escalation of antimicrobials is challenging in these scenarios, where cultures remain negative, and patients are often exposed to extended durations of broad-spectrum antimicrobials as information is not available to target therapy. This puts the patient at risk for collateral damage associated with antimicrobial therapy such as antimicrobial resistance and toxicity. T2Bacteria negative results in 3-5 hours can help clinicians to improve their empiric therapy for bloodstream infections by providing key information to help narrow a patient’s empiric therapy.

At the time of febrile episode in this case, the patient was on levofloxacin 500 mg daily for bacterial prophylaxis. She had blood cultures obtained and T2Bacteria ordered and was then initiated on broad spectrum therapy with cefepime 2g IV q8h. Due to the patient’s history of recent HSCT, profound immunosuppression, and neutropenia, she was at risk for organisms such as P. aeruginosa in addition to other common causes of febrile neutropenia such as Enterobacteriaceae and Gram-positive commensal bacteria.

The patient received 3 doses of cefepime (~24 hours of therapy) then therapy was de-escalated to ceftriaxone based on negative T2Bacteria Panel results to avoid unnecessary continuation of the broad spectrum, antipseudomonal beta-lactam. Ceftriaxone was continued for 4 more days until the patient defervesced, was hemodynamically stable, afebrile, and displayed no other sign or symptom of infection. Once treatment of the febrile neutropenic episode was complete, the levofloxacin prophylaxis was reinitiated.

Presentation

67-year-old female admitted for reduced-intensity conditioning followed by Stem Cell transplant for acute myelogenous leukemia. She also received methotrexate and tacrolimus for graft-versus-host disease prophylaxis. The patient’s clinical course was complicated by grade 3 nausea, vomiting and mucositis, hyperglycemia, and new-onset left bundle branch block. Six days after transplant the patient developed febrile neutropenia with profound neutropenia, in which stat blood cultures (x2), T2Bacteria, procalcitonin, and lactic acid were drawn, a chest X-ray was taken and cefepime was immediately initiated.

Patient Selection Criteria

Febrile neutropenia in a patient with recent HSCT and profound neutropenia.

Evaluation and Treatment Decision

Diagnosis

Neutropenic fever.

Empiric Therapy

The patient was on levofloxacin 500 mg daily for bacterial prophylaxis at the time of febrile episode. The patient was initiated on cefepime 2g IV q8h at the time of fever spike.

Cefepime was chosen for coverage of common causative pathogens identified in febrile neutropenia.

Procalcitonin, lactic acid, and chest X-ray were benign with no positive findings.

T2Bacteria Panel Result

Negative for all panel pathogens (P. aeruginosa, E. faecium, S. aureus, E. coli and K. pneumoniae.)

Blood Culture Result

No growth

Decision making based on T2Bacteria Result

A rapid T2Bacteria negative result allowed for ruling out of the most common ESKAPE pathogens. The high negative predictive value (99.7%) of the T2Bacteria Panel provided important diagnostic information that allowed for more informed treatment decisions, including early de-escalation of the empiric antibiotic regimen, sparing the patient from unnecessary broad-spectrum antibiotics and the potential risks associated with their prolonged therapy.

1. Freifeld AG, et al.  Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 Update by the Infectious Diseases Society of America. Clin Infect Dis 2011; 52:427-31.

The patient presented with acute onset of pain in his left lower extremity.

Discussion

Rapid molecular diagnostics such as T2MR technology may help with the prognosis of invasive candidiasis. The T2Candida Panel was utilized upon follow-up to assess the clearance of candidemia along with clinical symptoms.

Presentation

A 45-year-old man with an extensive history of bicuspid aortic valve disease, aortic valve replacement, and multiple cases of bacterial endocarditis was treated with prolonged courses of antibiotics and was placed on chronic suppression with amoxicillin 500 mg orally three times per day. He presented with acute onset of pain in his left lower extremity and was diagnosed with a thrombus in his left popliteal artery.

Evaluation and Treatment Decision

Surgical Interventions

Left embolectomy with pathology revealing a thrombus with calcification and multiple fungal forms with pseudohyphae, which grew Candida parapsilosis, along with blood cultures and T2Candida Panel positive for Candida parapsilosis. Transesophageal echocardiogram (TEE) revealed trace aortic regurgitation and mild mitral regurgitation.

Initial Antifungal Regimen

Micafungin 150 mg IV daily PLUS fluconazole 600 mg (6 mg/kg) IV daily was started for suspected prosthetic valve endocarditis.

Additional Culture Data and Modified Antifungal Regimen

Blood cultures remained positive for C. parapsilosis after 14 days of antifungal treatment. Treatment was changed to liposomal amphotericin B 5 mg/kg IV daily, flucytosine 2500 mg orally every six hours and fluconazole 400 mg orally daily. All subsequent blood cultures were negative. Due to an episode of acute renal failure, his regimen was finally changed to micafungin 150 mg IV daily and flucytosine 2500 mg PO every 8 hours.

Follow-up Tomography/Angiography

Scan revealed activity on the aortic leaflets and right lateral wall of the ascending aorta three weeks after starting antifungal treatment.

Second T2Candida Panel Result and Modified Antifungal Regimen

T2Candida Panel completed two months after starting antifungal treatment remained positive for C. parapsilosis while blood cultures remained negative. The regimen was narrowed down to flucytosine 2500 mg orally every eight hours and fluconazole 400 mg orally daily. Repeat T2Candida Panel became negative five months after starting antifungal treatment.

Discharge and Follow-Up Plan

The patient was stable for one year but decided to discontinue his flucytosine, fluconazole, and amoxicillin. He developed low-grade fevers and repeat blood cultures that were negative for bacteria but grew C. parapsilosisas did a follow-up T2Candida Panel. The patient was restarted on liposomal amphotericin B, flucytosine, and fluconazole. Blood cultures became negative, and the T2Candida Panel was negative after two weeks of antifungal treatment. TEE was unchanged and did not reveal any vegetations. Liposomal amphotericin B was discontinued after six weeks, and the patient remains stable on flucytosine and fluconazole.

Decision making based on T2Candida Result

The T2Candida Panel was used to assess for the presence of disease and the continuation of antifungal therapy, despite negative blood cultures.

 

Citation: Ahuja T, Fong K, Louie E. Combination antifungal therapy for treatment of Candida parapsilosis prosthetic valve endocarditis and utility of T2Candida Panel®: A case series. IDCases. 2019;15:e00525.  

A 23-year-old female with a history of acute myeloid leukemia and recent haploidentical stem cell transplant, cytokine release syndrome and severe mucositis following receipt of post-transplant cyclophosphamide therapy.

Discussion:

Upon admission, the patient was initially given cefepime for the treatment of febrile neutropenia. Due to the patient’s history of AML and neutropenia, she was at risk for organisms such as P. aeruginosa in addition to other common causes of febrile neutropenia such as Enterobacteriaceae.

At the time of admission, she had blood cultures obtained and T2Bacteria ordered. At this hospital, patient selection for T2Bacteria testing included onco-hematologic and HSCT patients with suspected bloodstream infections.

Bloodstream infections are a major cause of life-threatening complications in patients with cancer, due to the potential delays in chemotherapy, longer hospital stay, suboptimal treatment, higher mortality rate, and increased healthcare costs. The poor performance of blood cultures has a major impact on the clinical management of febrile neutropenic patients, especially in cases of unexplained persistent fever. T2Bacteria direct from blood diagnostic technology provided clinically relevant information for the diagnosis of infection in this case of blood culture-negative febrile neutropenia. Cefepime was continued for a total of 7 days, which was 2 days longer than would have been prescribed based on the negative blood cultures after the patient defervesced and ANC increased to >500.

Presentation

A 23-year-old female with a history of acute myeloid leukemia and recent haploidentical stem cell transplant, cytokine release syndrome, and severe mucositis following receipt of post-transplant cyclophosphamide therapy. The patient developed fever and blood cultures, T2Bacteria, and empiric antibiotics were ordered.

Patient Selection Criteria

Febrile neutropenia in a patient with AML

Evaluation and Treatment Decision

Diagnosis

Neutropenic fever

Empiric Therapy

Cefepime

Cefepime was chosen for coverage of common causative pathogens identified in febrile neutropenia.

T2Bacteria Result

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

Blood Culture Result

No growth

Decision making based on T2Bacteria Result

A rapid T2Bacteria result allowed for early diagnosis of P. aeruginosa bacteremia and confirmation of effective empiric antibiotic therapy. Identification of P. aeruginosa by T2 also provided important diagnostic information that allowed for more informed treatment decisions, including the continuation of IV antibiotics for longer treatment duration.

 

The patient had a history of multiple myeloma, prostate cancer, & CHF.

Discussion

This case highlights not only T2Bacteria’s benefit of rapid identification but also the ability to detect the causative organism in the presence of antibiotics as this patient had received the dose of vancomycin before the T2Bacteria was drawn.

Utilization of the T2Bacteria test allows for directed therapy on the same day as the identification of suspected infection. In this case, it took almost 48 hours from admission to identify S. aureus in the blood (Day 3 of admission). Ordering T2Bacteria at 24 hours after admission allowed appropriate therapy to be started on Day 2. Had T2Bacteria had been ordered simultaneously with blood culture, appropriate therapy could have been started on Day 1.

Initial Presentation

A high-risk patient was admitted with pulmonary edema and suspected pneumonia. The patient had a history of multiple myeloma, prostate cancer, and CHF. Blood cultures were obtained, and the patient was started on intravenous antibiotics for coverage of pneumonia.

Evaluation and Treatment Decision

Empiric Therapy

The patient was started on levofloxacin and piperacillin/tazobactam for empiric coverage of pneumonia.

Blood Culture Result

Twenty-four hours after admission, the nursing unit was called with a critical result from microbiology: gram-positive cocci in clusters.

Updated Therapy

The physician was notified, and a single dose of vancomycin was ordered.

T2Bacteria Result

The physician was uncertain if the organism might be a contaminating organism such as Staphylococcus epidermidis or a more concerning pathogen such as Staphylococcus aureus. The nurse suggested ordering T2Bacteria, and four hours later, the T2Bacteria resulted as S. aureus prompting the appropriate continued therapy with vancomycin. S. aureus was confirmed by the blood culture result the following morning.

Decision Making Based on T2Bacteria Result

The T2Bacteria Panel was used to detect the presence of S. aureus, allowing appropriate therapy to be initiated one day earlier than using blood culture alone.

81 year old female admitted with a one-day history of fever, rigors, weakness, and confusion. Blood and urine cultures were ordered as well as IV antibiotics.

Discussion/Decision Making Based on T2Bacteria Result

At this point in time, the hospital has not adopted T2Bacteria, however, another hospital in their system has. Given the high likelihood that the repeat BCx would be negative, they were asked to draw a blood sample on the day the patient was ready for discharge and send it to the institution that currently utilized the T2Bacteria Panel.

A courier was called and the test was run 4.5 hours after the blood was drawn, and resulted in 3.5 hours with no organisms detected.  The information was relayed to the ordering resident and physician, and the patient was subsequently discharged roughly a day earlier with oral antibiotics.  The clinician noted that even though this was not standard use of this test, it saved a patient a day in the hospital and also potentially spared the patient additional risk of hospital-acquired infections, further confusion, deconditioning, and risk of falls.

Presentation

81 year old female admitted with a one-day history of fever, rigors, weakness, and confusion. Blood and urine cultures were ordered as well as IV antibiotics.

Hospital Course

The patient was started on broad-spectrum IV antibiotics and baseline BCx and UCx grew E. coli.  The patient rapidly defervesced after the initial antibiotics and was de-escalated to IV ceftriaxone and clinically improved. The patient was ready for discharge two days later, though need to wait for repeat BCx drawn that day to show no growth for 48 hours, thus, prolonging their stay an additional two days. It was noted the patient had an identical episode nine years ago, with a very sensitive E. coli in BCx and UCx and was discharged on oral ciprofloxacin.

The T2Candida Panel was used to assess for the presence of disease and continuation of antifungal therapy, despite negative blood cultures.

Discussion

Rapid molecular diagnostics such as T2MR technology may help with the prognosis of invasive candidiasis. For our case, the T2Candida Panel was utilized upon follow-up to assess clearance of candidemia along with clinical symptoms.

Presentation

A 69-year-old man with a history of testicular cancer, chronic kidney disease, anemia, gangrenous gallbladder, status post cholecystectomy, hypertension, hyperlipidemia, type 2 diabetes mellitus, paroxysmal atrial fibrillation, heart failure with reduced ejection fraction and implantable cardioverter-defibrillator (ICD), and aortic valve disease s/p mechanical aortic valve replacement who presented with fatigue, fever, diarrhea, emesis, febrile to 102.3 degrees Fahrenheit with a blood pressure of 93/43 mm Hg, heart rate of 64 bpm, and respiratory rate of 18 breaths/min.

Evaluation and Treatment Decision

Initial Diagnosis

Initially diagnosed with Candida parapsilosis bloodstream infection and treated with liposomal amphotericin B at 5 mg/kg/day. After developing acute kidney injury, therapy was changed to micafungin 150 mg intravenous (IV) daily.

Blood Cultures and Echography

Repeat blood cultures continued to grow Candida parapsilosis 10 days after admission. A trans-esophageal echocardiogram (TEE) revealed fibrin stranding on the mechanical aortic valve. Due to his multiple comorbidities, he was not deemed safe for surgical intervention.

Updated Therapy

Micafungin 150 mg IV daily and fluconazole 400 mg orally daily

Discharge Plan

A peripherally inserted central catheter (PICC) was placed, and the patient was discharged from the hospital to complete micafungin IV for 12 weeks plus fluconazole oral combination therapy.

T2Candida Panel – Initial Result

Six weeks after negative blood cultures, a T2Candida Panel was ordered, which still detected the presence of Candida parapsilosis. However, all repeat fungal blood cultures remained negative, and the patient had improved overall.

T2Candida Panel – Second Result

18 weeks after blood cultures became negative, a repeat T2Candida Panel was negative for any Candida species while on chronic suppression with fluconazole.

One year later, the patient currently remains alive and doing well on oral fluconazole suppressive therapy at 200 mg daily.

Decision making based on T2Candida Result

The T2Candida Panel was used to assess for the presence of disease and the continuation of antifungal therapy, despite negative blood cultures.

 

1. Ahuja, Tania, Karen Fong, and Eddie Louie. “Combination antifungal therapy for treatment of Candida parapsilosis prosthetic valve endocarditis and utility of T2Candida Panel®: A case series.” IDCases 15 (2019): e00525.

83-year-old male presented to the emergency department with urinary retention.

Had the T2Bacteria test been performed and the result been reported immediately after collection, the patient could have been initiated on effective empiric therapy over 24 hours sooner, and P. aeruginosa bacteremia identified over two days earlier.

Discussion

Upon admission, the patient was initially given ceftriaxone for the treatment of suspected urinary tract infection.  At the time of admission, he had blood and urine cultures obtained, and T2Bacteria ordered. At this institution patient selection for T2Bacteria testing was based on elevated lactate and/or procalcitonin in patients presenting to the emergency department with suspected bloodstream infections.

Empiric therapy was chosen to cover E.coli, the most common cause of urinary tract infection. This patient did not present with usual risk factors for P. aeruginosa; thus effective therapy against P. aeruginosa was not initiated until urine cultures demonstrated the growth of P. aeruginosa over 24 hours after admission (T2Bacteria results were not reported as this case was part of an observational study). Blood culture growth with P. aeruginosa was delayed >48 hours after admission.

Presentation

83-year-old male presented to the emergency department with urinary retention. Sepsis was suspected, and the patient was admitted with orders for blood and urine cultures, T2Bacteria, and antibiotics.

Patient Selection Criteria

Lactic acid 3.29

Evaluation and Treatment Decision

Diagnosis

Urinary tract infection

Empiric Therapy

Ceftriaxone

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

T2Bacteria Panel Result

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

Blood Culture Result

P. aeruginosa (>48 hours after admission)

Urine Culture Result

P. aeruginosa (24 hours after admission)

Decision making based on T2Bacteria Panel Result:

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

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

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 the 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

A 59-year-old male with a history of rectal cancer and COPD. The patient presented to the emergency department with shortness of breath, cough, fever, and chills. Sepsis was suspected, and the 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 the initiation of earlier effective therapy over 30 hours sooner.

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According to the CDC, of the 154 million prescriptions for antibiotics written in doctors’ offices and emergency departments each year, 30% are unnecessary.12

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