Case 6 – patient in intensive care unit with septic shock

Question 1

General info - no need to memorize

Answer 1

A 60-year-old man is hospitalized in intensive care after a car accident. The patient is ventilated, has a urinary catheter, central venous catheter, a drain of an abdominal wound, and multiple skin lacerations. Patient develops sepsis + pulse of 150 + blood pressure of 80/40. Noradrenaline is required for blood pressure maintenance.

Question 2

DD ? - 5

Answer 2

1. VAP– ventilator associated pneumonia
2. Central venous catheter infection
3. Urinary tract infection
4. Bacteremia originating from the skin
5. Intra abdominal infection

Question 3

Likely pathogens? - 3

Answer 3

1. Staph aureus
2. Gram neg (including pseudomonas)
3. Carbapenem-resistant enterobacteria (CRE)

Question 4

Tx - 3

Answer 4

1. Staph aureus – Tx w/ Vancomycin (since possibly MRSA from hospital), can give together w/ Oxacillin (to cover MSSA)
2. Gram neg (including pseudomonas) – give Carbapenems (since very broad spectrum) or late generation Cephalosporin
3. Carbapenem-resistant enterobacteria (CRE) – inc prevalence, Tx w/ Colistin or Aminoglycosides (not effective other than UTI but if there is resistance to everything there is no choice)
   • In emergency situations like this one, give one from each category to cover all options