two days of symptom onset. Given the patient’s employment in a long‐term‐care facility, she is at risk for MRSA, so initial coverage should be broad and cover MRSA as well as gram negatives. Daptomycin should not be used as it is inactivated by surfactant (choice E). Corticosteroids are not routinely prescribed for adults with severe CAP (choice A, B). Overall, the data for treatment with corticosteroids is conflicting with some showing a benefit and others showing no significant difference in outcomes. A meta‐analysis of pneumonia due to influenza based on small studies, however, showed an increase in mortality in patients who receive corticosteroids. Corticosteroids are recommended to be used in patients with refractory septic shock. IDSA guidelines removed the term “healthcare‐associated pneumonia (HCAP)” in 2016 and recommend that pneumonia be categorized as hospital acquired, community acquired, or ventilator associated. This patient has community‐acquired pneumonia as she did not develop the pneumonia after being admitted to the hospital. She does, however, have risk factors for MRSA and Pseudomonas infection due to her job at a long‐term healthcare facility. Because of this, she needs to be covered appropriately for MRSA and Pseudomonas infections.Answer: DMetlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community‐acquired pneumonia. Am J Respir Crit Care Med. 2019; 200(7):E45–E67. doi:10.1164/rccm.201908‐1581STUyeki TM, Bernstein HH, Bradley JS, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza. Clin Infect Dis. 2019; 68(6):895–902. doi:10.1093/cid/ciy874Davis BM, Aiello AE, Dawid S, et al. Influenza and community‐acquired pneumonia interactions: the impact of order and time of infection on population patterns. Am J Epidemiol. 2012; 175(5):363–367. doi:10.1093/aje/kwr402Silverman JA, Mortin LI, VanPraagh ADG, et al. Inhibition of daptomycin by pulmonary surfactant: in vitro modeling and clinical impact. J Infect Dis. 2005; 191(12):2149–2152. doi:10.1086/4303527 A 58‐year‐old man presents to the hospital with left lower quadrant pain for 3 days, subjective fevers at home, and anorexia. He reports that he has been having frequent liquid stools. His vital signs are normal except for his temperature of 100.4°F. He is tender to palpation in his left lower quadrant of his abdomen. He has a leukocytosis of 18 × 103 cells/mm 3 with 80% neutrophils. A CT of his abdomen shows a 6 cm rim‐enhancing fluid collection and dots of free air in his pelvis. His most recent colonoscopy was 9 months ago and showed diverticulosis with no polyps or masses. The next best step in the management of this patient should be:Repeat colonoscopySurgical drainage of the fluid collectionPercutaneous drainage of the fluid collectionPICC line placement for fluid resuscitationSigmoidectomy and primary anastomosisThis patient has Hinchey II diverticulitis with a pelvic abscess. Proper management is percutaneous drainage if amenable and initiation of a fluoroquinolone or cephalosporin and metronidazole. Initiation of broad‐spectrum antibiotics, such as meropenem, should be reserved for patients with severe intra‐abdominal infection or for healthcare‐acquired intra‐abdominal infection. A PICC line is not necessary in this patient as the duration of antibiotics following source control with percutaneous drainage should be four days and there is no need for parenteral nutrition at this point in time. A repeat colonoscopy would not be appropriate at this time and would likely further injure the diseased bowel. He will need a colonoscopy to rule out malignancy 6 to 8 weeks after resolution of his disease. Surgical drainage is an option for obtaining source control but is significantly more invasive than a percutaneous drain. Similarly, choice E is incorrect and sigmoidectomy in this patient should be reserved for disease refractory to treatment. Antibiotic choices for this patient should cover gram‐negative aerobic and facultative bacilli as well as gram‐positive streptococci. This is a community‐acquired intra‐abdominal infection, and there is no need to initiate anti‐pseudomonal treatment in this patient. Ticarcillin‐clavulanate, cefoxitin, ertapenem, or moxifloxacin are adequate single‐agent choices. Treatment can also be dual agent with metronidazole in combination with cefazolin, cefuroxime, ceftriaxone, cefotaxime, levofloxacin, or ciprofloxacin. This patient’s initial antibiotic regimen should be given intravenously; however, if he progresses to tolerating adequate nutrition by mouth, it is reasonable to convert the therapy to an oral antibiotic for the duration of the treatment.Modified Hinchey classificationStageDefinition0Mild diverticulitisIaPericolonic phlegmon/inflammationIbPericolic abscessIIPelvic/retroperitoneal/distant abscessIIIPurulent peritonitisIVFecal peritonitisAnswer: CSolomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra‐abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50(2):133–164. doi:10.1086/649554Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short‐course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015; 372(21):1996–2005. doi:10.1056/nejmoa1411162
8 A 36‐year‐old man was in MVC, and his injuries include large areas of desquamation with dirt and vegetation over the wounds and multiple open fractures. He is taken to the operating room for a positive FAST in the setting of hypotension. He undergoes an exploratory laparotomy and splenectomy as well as external fixation of his open femur fractures with wound washout. On post‐operative day 5, he becomes febrile and areas of his wound are noted to be black and necrotic. A biopsy is sent for histologic examination and returns mold with irregular non‐septate broad hyphae. What is the best treatment course for this patient?PosaconazoleAmphotericin BLipid formulation of amphotericin B and perform serial wound debridementsPosaconazole and perform serial wound debridementsMicafungin and perform serial wound debridementsThis patient has an invasive fungal infection with Mucor, which has irregular non‐septate broad hyphae. While rare, severely injured trauma patients can suffer from an invasive fungal infection. Mortality from this infection can be very high, so prompt debridement and antifungal therapy are important for success. Lipid formulation of amphotericin B (LAmB) is the antifungal of choice. LAmB has been shown to be more effective than other antifungals at treating Mucor, and the liposomal formulation has increased survivorship in patients with Mucor infections significantly (39%–67%). Other antifungals such as iatroconazole, voriconazole, and fluconazole do not have much effect against Mucor. Posaconazole has to be given in high and potentially toxic doses to treat Mucor and is not recommended as a first line option. It is, however, available to be used for refractory disease or for salvage therapy.Choice A is incorrect as Posaconazole is not the first line treatment for Mucor, and it can be used if needed in refractory disease.Choice B is incorrect as traditional formulations of amphotericin B have been shown to be significantly less effective against Mucor infections but it also lacks surgical debridement of the wound that plays a critical role in the treatment of the disease.Choice D is incorrect as Posaconazole is not a first line treatment for this disease.Choice E is incorrect as there is no data to suggest that micafungin is effective against Mucor.Answer: CSpellberg B, Ibrahim AS . Recent advances in the treatment of mucormycosis. Curr Infect Dis Rep. 2010; 12(6):423–9. doi: 10.1007/s11908‐010‐0129‐9. PMID: 21308550; PMCID: PMC2947016.Kronen R, Liang SY, Bochicchio G, et al. Invasive fungal infections secondary to traumatic injury. Int J Infect Dis. 2017; 62:102–111. doi:10.1016/j.ijid.2017.07.002Ganesan A, Shaikh F, Bradley W, et al. Classification of trauma‐associated invasive fungal infections to support wound treatment decisions. Emerg Infect Dis. 2019; 25(9):1639–1647. doi:10.3201/eid2509.190168Wilson W, Ali‐Osman F, Sucher J, et al. Invasive fungal wound infection in an otherwise healthy trauma patient (Mucor Trauma). Trauma Case Reports. 2019; 24:100251. doi:10.1016/j.tcr.2019.100251
9 A 24‐year‐old man sustained multiple gunshot wounds to the abdomen. He was taken to the OR, given a dose of cefoxitin, and underwent an exploratory laparotomy. He was found to have multiple small bowel
