The patient presents with suspected sepsis.
Discussion
Upon admission, the patient was initially given a 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.
Presentation
53-year-old immunocompromised, morbidly obese female with a recent history of surgery to drain an intra-abdominal abscess. The patient presented at the emergency department 8 days post-op with fever, chills, and abdominal pain. Sepsis was suspected, and the 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 the 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
