fossa as well as tender nodules on his fingertips. Auscultation of his chest reveals a blowing diastolic murmur. A transthoracic echocardiogram is negative for any signs of endocarditis. The next steps in the management of this patient including blood cultures, fluid resuscitation, and I & D of abscess should include:Transesophageal echocardiography, initiation of vancomycinTransesophageal echocardiography, initiation of vancomycin and piperacillin‐tazobactamTransesophageal echocardiographyMetronidazole and piperacillin‐tazobactamVancomycin and metronidazoleThis patient has 3 minor Modified Duke Criteria – (1) intravenous drug use, (2) fever > 100.4°F, and (3) Osler’s nodes – that indicate possible endocarditis. Intravenous drug use is a risk factor for acquisition of infective endocarditis. The patient should receive a transesophageal echo (TEE) to evaluate his cardiac valves even though the transthoracic echocardiogram was negative as TEE is more sensitive for cardiac vegetations. Staphylococcus aureus is the most common organism that causes infective endocarditis, followed by Viridans group Streptococci, coagulase‐negative Staphylococci, Enterococcus species, and Streptococcus bovis. Antibiotics should be started immediately after drawing blood cultures and should be broad to include MRSA coverage. Answer B is the correct choice as it provides broad‐spectrum coverage as well as the TEE that is needed after a negative TTE in this patient whose presentation is suspicious for infective endocarditis. Answer A adequately covers for MRSA, but without a known causative organism, more broad‐spectrum antibiotics should be initiated. Answer C is incorrect as it is critical that in cases of suspected endocarditis and sepsis that antibiotics be administered immediately after presentation. Answer D does not adequately cover against MRSA and is therefore incorrect. Answer E does not adequately cover gram‐negative bacteria and is therefore inadequate as initial therapy for this patient. It is a strong recommendation to consult Infectious Disease to determine the optimal empirical antibiotic treatment. The fluctuance and induration at the patient’s antecubital fossa indicate an abscess and must be drained as part of the treatment.References for images:Modified duke criteriaPathological criteriaPositive histology or culture from pathological material obtained at autopsy or cardiac surgeryMajor criteriaTwo positive blood cultures with typical organismPersistent bacteremiaPositive serology for CoxiellaPositive echocardiogramVegetation ORAbscess ORNew regurgitation ORDehiscence of prosthetic valvesMinor criteriaPredisposing heart disease or IVDAFever > 38%Immunological phenomenaVascular phenomenaMicrobiological evidence not fitting major criteriaAnswer: BGalindo R . Osler’s nodes on hand. https://commons.wikimedia.org/wiki/File:Osler_Nodules_Hand.jpg. Published 2010. Accessed July 26, 2021.Galindo R . Osler spots on foot. https://commons.wikimedia.org/wiki/File:Osler_Spots_foot.jpg. Published 2010. Accessed July 26, 2021Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015; 132(15):1435–1486. doi:10.1161/CIR.0000000000000296Vogkou CT, Vlachogiannis NI, Palaiodimos L, et al. The causative agents in infective endocarditis: a systematic review comprising 33,214 cases. Eur J Clin Microbiol Infect Dis. 2016; 35(8):1227–1245. doi:10.1007/s10096‐016‐2660‐6Wang A, Gaca JG, Chu VH . Management considerations in infective endocarditis: a review. JAMA ‐ J Am Med Assoc. 2018; 320(1):72–83. doi:10.1001/jama.2018.75961.Miller SE, Maragakis LL . Central line‐associated bloodstream infection prevention. Curr Opin Infect Dis. 2012; 25(4):412–422. doi:10.1097/QCO.0b013e328355e4daLatif A, Halim MS, Pronovost PJ . Eliminating infections in the ICU: CLABSI. Curr Infect Dis Rep. 2015; 17(7). doi:10.1007/s11908‐015‐0491‐8Noto MJ, Domenico HJ, Byrne DW, et al. Chlorhexidine bathing and health care‐associated infections: a randomized clinical trial. JAMA ‐ J Am Med Assoc. 2015; 313(4):369–378. doi:10.1001/jama.2014.184002 A 65‐year‐old man was admitted with acute pancreatitis and has been stable with intermittent tachycardia on the floor since his admission 2 days ago. Admission CT scan of the abdomen and pelvis showed edema and fat stranding around his pancreas. On the third day, he was noted to be more tachycardic, febrile with an increase of his leukocytosis. An interval CT scan demonstrates hypoattenuation of the pancreas, a large peri‐pancreatic retroperitoneal fluid collection with air and surrounding fat stranding. The next best course of treatment is:Start antibiotics with piperacillin‐tazobactam.Start antibiotics and percutaneously drain the collection.Start antibiotics and surgery for emergent necrosectomy.Start antifungals and percutaneously drain the collection.Continue current treatment with IV fluid resuscitation.This patient has infected necrotizing pancreatitis based on the physiologic and laboratory changes and new findings on CT scan. Broad‐spectrum antibiotics should be started since the fluid collection appears to be infected on clinical exam and on CT scan. In general, there is no indication to start antibiotics in necrotizing pancreatitis unless there is a culture‐proven infection or a strong suspicion for infection (gas in collection, sepsis, and clinical deterioration). Prophylactic antibiotics should not be used for sterile necrosis. For infected pancreatic necrosis, a multicenter trial showed that a minimally invasive step‐up approach (percutaneous drainage followed by minimal invasive retroperitoneal necrosectomy if needed) reduced major complications and death when compared to open necrosectomy. Answer A is incorrect because patient has indications for the need of drainage of the fluid collection. Answer C is not optimal as necrosectomy is now suggested to be reserved for failure of a step approach method. Answer D is incorrect because antifungals are not yet indicated. Answer E is incorrect because there is evidence of infection.Answer: BDa Costa DW, Boerma D, Van Santvoort HC, et al. Staged multidisciplinary step‐up management for necrotizing pancreatitis. Br J Surg. 2014; 101(1). doi:10.1002/bjs.9346Baron TH, DiMaio CJ, Wang AY, et al. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology. 2020; 158(1):67–75.e1. doi:10.1053/j.gastro.2019.07.064van Santvoort HC, Besselink MG, Bakker OJ, et al. A step‐up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010; 362(16):1491–1502. doi:10.1056/nejmoa0908821
3 A 68‐year‐old woman was injured in MVC and had exploratory laparotomy, small bowel resection, and splenectomy. She is now three weeks post‐operative, and she has developed copious green fluid extruding from a newly opened wound on the superior aspect of her incision. Her abdomen is soft but exquisitely tender to palpation around the wound. A CT scan of the abdomen with oral contrast shows extravasation of the contrast through the abdominal wall. All of the following are important and necessary in the initial management of an enterocutaneous fistula except:Treatment and control of sepsisFluid resuscitationElectrolyte repletionEffluent control and wound careOral toleration of dietThis patient has an enterocutaneous fistula, a very morbid complication after open surgery. Mortality is associated with sepsis, malnutrition, and fluid and electrolyte disturbances. It is important to control and treat sepsis as well as resuscitate the patient first. Effluent control and wound care are necessary to control output and prevent worsening and infection of any soft tissue wound. Nutrition is important for successful management of an EC fistula and can be a combination of enteral and parenteral, depending on nutritional needs and characteristics of the fistula. Oral toleration is not important initially and definitely not necessary. Characteristics of the fistula should be used to determine the appropriate nutrition source.Answer: EEvenson AR, Fischer JE . Current management of enterocutaneous fistula. J Gastrointest Surg. 2006; 10(3):455–464. doi:10.1016/j.gassur.2005.08.001Rosenthal MD, Brown CJ, Loftus TJ, et al. Nutritional management and strategies for the enterocutaneous fistula. Curr Surg Reports. 2020; 8(6):1–10. doi:10.1007/s40137‐020‐00255‐5Gribovskaja‐Rupp
