Suspected Acute Cholecystitis

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. 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.  Patient defervesced and improved after 24 hours of therapy and was discharged home with IV antimicrobials for two weeks.

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