NYU Medicine Grand Rounds Clinical Vignette

1. NYU Medicine Grand Rounds Clinical Vignette Ivan Saraiva MD, PGY-2 December 9, 2009 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint A 74-year-old woman is brought to the emergency room with increasing confusion for three days. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

3. History of Present Illness • The patient was in her usual state of health until four months prior to presentation when she had the first of a series of recurrent urinary tract infections. • Each was successfully treated as an outpatient. • Three days prior to presentation, the patient began experiencing dysuria similar to her prior episodes of urinary tract infection. • She was evaluated by her primary care physician and a urinalysis and urine culture were obtained. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

4. History of Present Illness • The urinalysis demonstrated: • Turbid appearing urine (clear) • Blood: Moderate – 2+ (negative) • Protein: > 300 mg/dL – 3+ (negative) • Nitrite: negative (negative) • Leuk Esterase: Large – 3+ (negative) • WBC: 30-50 (0-5/HPF) • RBC: 5-10 (0-4/HPF) • Bacteria: Many UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

5. History of Present Illness • Given the abnormal urinalysis, the patient was empirically started on a 7-day course of ciprofloxacin for treatment of her recurrent infection. • The patient’s family reports that over the next three days, the patient began to experience fevers and became increasingly disoriented. • She was therefore brought to the emergency room. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

6. Additional History • Past Medical History • Diabetes mellitus • Hypertension • Chronic kidney disease • Hypothyroidism • Recurrent urinary tract infections • Past Surgical History • None • Family History • Non-contributory • Social History • Retired • Ex-smoker • Social alcohol use • Denies illicit drug use UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

7. Outpatient Medications Insulin glargine 12units sc QHS Nifedipine XL 60mg po daily Labetalol 200mg po bid Levothyroxine 50mcg po daily Vitamin B complex 1 tab po daily Famotidine 20mg po daily Simethicone 80mg po daily Allergies: No known drug allergies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

8. Physical Examination General: Elderly woman in no acute distress Vital Signs: T 100.1 F, BP 145/85, HR 76, RR 18, O2 saturation 99% on room air Neurologic examination: Mental status: alert, oriented to person Abdominal exam: Mild suprapubic tenderness, no CVA tenderness The remainder of the physical exam was normal. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

9. Laboratory Findings • CBC: • Leukocytes 8,200 with normal differential • Hemoglobin 10.9 g/dL, Hematocrit 32% • The remainder of the CBC was normal • Basic metabolic panel: • BUN 52 mg/dL • Creatinine 2.4 mg/dL • Glucose 114 mg/dL • The remainder of the BMP was normal UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

10. Laboratory Findings The urine culture from 4 days prior was reviewed: Final ID: Escherichia coli Amikacin-MIC: S (8) Ampicillin-MIC: R (>2) Cefazolin-MIC: R (>24) Ciprofloxacin-MIC: R (>4) Gentamicin-MIC: S (<1) Nitrofur-MIC: R (128) Tetracyclin-MIC: S(2) Ampi/Sulbac-MIC: R (>32) SMX/TMP-MIC: R (>320) Aztreonam-MIC: S (<1) Cefepime-MIC: S (<1) Cefoxtaxime-MIC: S (2) Ceftazidime-MIC: S (<1) Ceftriaxone-MIC: S(4) Levofloxacin-MIC: R (>8) Piperacillin-MIC: R (>128) Imipenem-MIC: S (<1) Meropenem-MIC: S (<0.25) Pip/Tazo-MIC: I (32) Cefuroxime-MIC: R (>64) UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

11. Additional Studies • ECG: Sinus rhythm with first degree AV delay • Chest X-Ray: within normal limits • Head CT: no acute abnormalities UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

12. Working Diagnosis Delirium secondary to E. coli urinary tract infection, resistant to empirically started antibiotics (ciprofloxacin) UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

13. Hospital Course • Based on the urine culture and antibiogram results, the patient was started on ceftriaxone. • She failed to show significant improvement over the next several days and became hypotensive. • While reviewing the patient’s record further, it was noted that the antibiotic sensitivities had been changed due to automatic extended-spectrum beta-lactamase (ESBL) testing. • The ESBL test was abnormal (+). UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

14. Hospital Course • The new antibiogram reflected the abnormal ESBL test, and the sensitivities to aztreonam and the cephalosporins were changed to reflect this resistance. • The ESBL test had been completed on hospital day 1. • Neither the inpatient team nor the ordering outpatient physician were notified of the new results, either by phone call or computer alert. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

15. Hospital Course • The patient’s antibiotic treatment was changed to reflect the change in sensitivity pattern, and imipenem-cilastatin was started. • Over the next several days the patient demonstrated significant clinical improvement and was eventually discharged home. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

16. Final Diagnosis ESBL-positive E. coli urinary tract infection UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

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