proven strategies and updates. Clin Colon Rectal Surg. 2016; 29(2):130–137. doi:10.1055/s‐0036‐15807324 A 32‐year‐old man with HIV is brought to the hospital post‐ictal after a seizure while at home. He is now complaining of a stiff neck, nausea, and a constant headache. His temperature is 102.3°F, heart rate is 98, and blood pressure is 100/58. His ophthalmic exam reveals bilateral papilledema. What are the next steps for management after blood cultures, antibiotics, and fluids?Lumbar puncture and place an ICP monitorDexamethasone and lumbar punctureDexamethasone and obtain a CT scan of headCT scan of head and place an ICP monitorDCT scan of head and mannitolThis immunocompromised patient has signs and symptoms concerning bacterial meningitis. After blood cultures and broad‐spectrum antibiotics are started, dexamethasone should be given to adult patients. A trial that evaluated outcomes in adult patients with bacterial meningitis found that negative outcomes, including death, were significantly lower in the group that received dexamethasone versus placebo; the group with streptococcus meningitis saw the most benefit. Hence, current recommendations state starting dexamethasone for any patients with possible streptococcal meningitis and continuing it only if culture results confirm the diagnosis. CT scan of the head should be obtained before a lumbar puncture since this patient has physical exam findings of elevated intracranial pressure (ICP), is immunocompromised, and had a new onset seizure within 1 week of presentation (choice A, B). There is a small (~1%) chance of herniation in adults with elevated ICP. A lumbar puncture is eventually necessary to identify the exact organism causing meningitis but is not done immediately (choice D). Mannitol may eventually be used to lower ICP prior to performing lumbar puncture. Initial empiric antimicrobial treatment for patients with suspected bacterial meningitis includes vancomycin in combination with either ceftriaxone or cefotaxime.Answer: CPredisposing factorCommon bacterial pathogensAntimicrobial therapyAge<1 monthStreptococcus agalactiae, Escherichia coli, Listeria monocytogenes, Klebsiella speciesAmpicillin plus cefotaxime or ampicillin plus an aminoglycoside1–23 monthsStreptococcus pneumoniae, Neisseria meningitidis, S. agalactiae, Haemophilus influenzae, E. coliVancomycin plus a third‐generation cephalosporina,b2–50 yearsN. meningitidis, 5. pneumoniaeVancomycin plus a third‐generation cephalosporina,b>50 yearsS. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gram‐negative bacilliVancomycin plus ampicillin plus a third‐generation cephalosporina,bHead traumaBasilar skull fractureS. pneumoniae, H. influenzae, group A β‐hemolytic streptococciVancomycin plus a third‐generation cephalosporinaPenetrating traumaStaphylococcus aureus, coagulase‐negative staphylococci (especially Staphylococcus epidermidis), aerobic gram‐negative bacilli (including Pseudomonas aeruginosa)Vancomycin plus cefepime, vancomycin plus ceftazidime, or vancomycin plus meropenemPostneurosurgeryAerobic gram‐negative bacilli (including P. aeruginosa), S. aureus, coagulase‐negative staphylococci (especially S. epidermidis)Vancomycin plus cefepime, vancomycin plus ceftazidime, or vancomycin plus meropenemCSF shuntCoagulase‐negative staphylococci (especially S. epidermidis), S. aureus, aerobic gram‐negative bacilli (including P. aeruginosa), Propionibacterium acnesVancomycin plus cefepime,c vancomycin plus ceftazidime,c or vancomycin plus meropenemca Ceftriaxone or cefotaxime.b Some experts would add rifampin if dexamethasone is also given.c In infants and children, vancomycin alone is reasonable unless Gram stains reveal the presence of gram‐negative bacilli.van de Beek D, de Gans J, Spanjaard L, et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med. 2004; 351(18):1849–1859. doi:10.1056/nejmoa040845Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004; 39(9):1267–1284. doi:10.1086/425368chart citation:Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004; 39(9):1267–1284. doi:10.1086/425368
5 A 77‐year‐old woman is transferred to the ICU with increased work of breathing and desaturations. She was admitted to the hospital after sustaining multiple rib fractures from a ground‐level fall and was being treated for a hospital‐acquired lobar pneumonia. A new CT chest reveals a loculated pleural collection. Which of the following is not an appropriate antibiotic regimen?Gentamycin and metronidazoleVancomycin, cefepime, and metronidazoleVancomycin and piperacillin‐tazobactamVancomycin and meropenemLinezolid and piperacillin‐tazobactamThis patient has a hospital‐acquired pneumonia complicated by an empyema. Antibiotic coverage for a pleural empyema in this setting should include coverage for gram‐positive, gram‐negative, and anaerobic organisms. In high‐risk patients, coverage should also include MRSA and Pseudomonas. Aminoglycosides could possibly have poor pleural penetration and are inactivated in the setting of infection, so they are avoided as a class in treating empyema (choice A). In patients with hospital‐acquired empyema, it is important to cover for anaerobes, MRSA, and Pseudomonas. Choice B is an appropriate antibiotic regimen as broad‐spectrum coverage is present with vancomycin covering for MRSA, cefepime covering Pseudomonas, and metronidazole for anaerobic coverage. Choice C is appropriate as the piperacillin‐tazobactam covers both Pseudomonas and anaerobes in addition to the MRSA coverage with vancomycin. Choice D is appropriate as the meropenem adequately covers Pseudomonas and anaerobes while the vancomycin covers MRSA. Choice E is an appropriate regimen with linezolid adequately providing MRSA coverage and piperacillin‐tazobactam providing coverage against anaerobes and Pseudomonas. Further treatment with antibiotics can be tailored to the patient based on culture and sensitivity data, and it is recommended that antibiotic treatment continue for at least two weeks following defervescence and source control of the empyema.Answer: AShen KR, Bribriesco A, Crabtree T, et al. The American Association for Thoracic Surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg. 2017; 153(6):e129–e146. doi:10.1016/j.jtcvs.2017.01.030Rosenstengel A . Pleural infection‐current diagnosis and management. J Thorac Dis. 2012; 4(2):186–193. doi:10.3978/j.issn.2072‐1439.2012.01.12Thys JP, Vanderhoeft P, Herchuelz A, et al. Penetration of aminoglycosides in uninfected pleural exudates and in pleural empyemas. Chest. 1988; 93(3):530–532. doi:10.1378/chest.93.3.530
6 A 56‐year‐old woman with asthma, who works in a long‐term healthcare facility, presents with fevers, chills, generalized myalgias, and a severe cough for the past four days. Over the last 24 hours, she has become significantly more short of breath. Her rapid influenza is positive, and her respiratory status continues to deteriorate. Chest x‐ray demonstrates a left lower lobe consolidation. She is admitted to the ICU. What should her treatment regimen include?Oseltamivir, vancomycin, piperacillin‐tazobactam, corticosteroidsOseltamivir, ampicillin‐sulbactam, and corti‐ costeroidsVancomycin and piperacillin‐tazobactamOseltamivir, vancomycin, and piperacillin‐ tazobactamOseltamivir and daptomycinThis patient may have coinfection with influenza and community‐acquired pneumonia. In patients who test positive for influenza and are admitted to the hospital, anti‐influenza treatment should be started, regardless of the duration of the illness before diagnosis. If this were a different
