CASE 5 Admission 66 yearold man Admitted for

CASE 5

Admission • 66 year-old man • Admitted for 2 nd cycle chemotherapy • Chronic myelomonocytic leukaemia • Diagnosed 6/12 previously • Skin and lymph node involvement • 1 st cycle complicated by right lower lobe pneumonia • Empiric treated with meropenem and gentamicin x 8/7

Admission - history • PMHx • COPD • Osteoarthritis • MI - 20 years ago • Allergic to penicillin – throat swelling • Medications • Valaciclovir • Pantoprazole • Nicotine patch • Aqueous cream

Admission - examination • Dry flaky skin rash • PICC – right arm (in situ x 2/12) • Otherwise no abnormal findings • Creatinine 112 (normal range 62 -106) • WCC 6. 5 (normal range 3. 5 -11)

Days 2 -6 • Bone marrow aspirate • Chemotherapy • Fludarabine • Cytarabine • g. CSF • Well throughout • Weekend leave

Day 9 • Returned from weekend leave • Neutropenic • WCC 0. 6 • Neuts 0. 6 • Hb 8. 3 • Plts 177 • Afebrile, no complaints

Days 10 -11 • Day 10 • Afebrile • Diarrhoea x 1 – sample sent for C. difficile PCR • Day 11 • Afebrile • Diarrhoea x 2 • C. difficile PCR positive • Contact precautions • Oral metronidazole

Days 12 -13 • 3 -4 episodes diarrhoea per day • Afebrile • Continued on metronidazole

Day 14 (Saturday) • WCC 0. 1 • 10. 25 • Patient complained of rigors • Temp • BP • HR • RR • O 2 sats 39. 4°C 143/83 95 19 95% (on room air) EWS 4

Irish national early warning score

Irish national EWS – escalation protocol

What’s wrong with the patient?

Day 14 • 10. 30 • Blood cultures drawn (PICC and peripheral) • Medical review requested • 10. 50 • Seen by haematology registrar on call

What are the potential sources of fever?

Day 14 • 10. 50 • Seen by haematology registrar on call • No abdominal pain • Diarrhoea settling • No sore throat • No cough, no SOB • No urinary symptoms • No change in rash • PICC working

Day 14 • Examination • Throat – no erythema, no exudate • PICC site – no erythema, clean • Chest – clear to auscultation • Abdomen – soft, non-tender • Plan • Blood cultures, MSU • CXR • Antibiotics

What do you need to consider when choosing antibiotic therapy?

Antibiotics prescribed • Meropenem 1 g iv 8 -hourly – first dose given at 11. 30 • Gentamicin 300 mg iv – first dose given at 11. 28 • (weight 62 kg, creatinine 101)

What do you think of the antibiotic choice?

What about the timing of the antibiotics?

Day 14 10. 25 12. 55 13. 10 13. 45 14. 50 Day 15 15. 50 16. 50 17. 50 06. 00 09. 30 11. 30

Day 15 • Blood cultures (day 14) • Line – both bottles – Gram negative bacilli • Peripheral – sterile to date • 11. 45 • Haematology registrar phoned by microbiology registrar • Patient afebrile since 17. 50 on day 14 • Advised continue meropenem and gentamicin, repeat blood cultures • Gentamicin 300 mg given (no gentamicin level done, creatinine 103)

CXR – day 15

Day 16 • Blood cultures (day 14) • Line – Klebsiella pneumoniae (MALDI-TOF) • Direct susceptibilty test –susceptible to coamoxiclav, ciprofloxacin, gentamicin, cefuroxime • Peripheral - sterile to date • Blood cultures (day 15) • Line and peripheral – sterile to date • Trough gentamicin level 2. 4 – dose held • Patient remains afebrile, diarrhoea resolved

Day 17 • Blood cultures (day 14) • Line – Klebsiella pneumoniae – resistant to amoxicillin only • Peripheral - sterile to date • Blood cultures (day 15) • Line – sterile to date • Peripheral - sterile to date • MSU (day 14) – WCC < 1, no growth • Patient remains afebrile

What do you advise now?

Day 17 • Seen by consultant microbiologist • Afebrile • No diarrhoea • WCC 0. 1 • EWS 0 • Advice • Consider removal of PICC • Change meropenem to aztreonam • Give one more dose of gentamicin (level = 0. 5)

Progress • PICC not removed • Changed to aztreonam on day 17 • Gentamicin stopped on day 18 (4 days in total) • Metronidazole stopped on day 24 (14 days in total) • Aztreonam stopped on day 28 (15 days mero/azt) • Remained afebrile • Discharged home on day 29 - WCC 1. 8, neut 1. 3 • Line remains in situ, blood cultures sterile