Running head: WEB CASE STUDY
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Web Case Study
Leah Fite
Wright State University
WEB CASE STUDY
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Focused History and Physical
Source
Patient is pharmacologically sedated. Recently discharged pt, so medical records are the most
reliable source. The patient’s healthcare power of attorney (POA), a friend of the patient, is at
the bedside, and may not be very reliable.
Chief Complaint
“Vomiting, diarrhea, fever and weakness that started early this morning.”
History of Present Illness
V.S. is a 47 year old female who presents to the emergency department via ambulance with acute
onset of vomiting, diarrhea, malaise and fever. She denies chest pain, shortness of breath, and
abdominal pain. She is on immunosuppressive therapy (prednisone and mycophenolate mofetil)
for her recent kidney transplant. Her abdomen is soft with a recent surgical incision with evident
bruising, but no drainage or erythema noted. She complains of significant pain at this incision
10/10, unable to describe the quality. Yesterday, she was discharged from the hospital following
cadaveric renal transplant with subsequent antibody mediated rejection (AMR). The AMR was
treated with plasmapheresis, velcade and rituximab on post operative day six, and was well
tolerated. Upon discharge, she was feeling fine, creating urine, and had no signs or symptoms
of infection. She denies any contact with anyone ill since discharge home.
Initially in the ED, pt was alert and oriented, hemodynamically stable, with no evident
distress. However, within two hours of her care, she acutely decompensated, requiring
increasing oxygen and multiple fluid boluses to maintain adequate perfusion. The transplant
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team was notified of her arrival and current condition and she was transferred to the intensive
care unit.
Upon admission to the ICU the patient further decompensated requiring intubation and
mechanical ventilation. High dose vasopressors were initiated and multiple fluid boluses were
given to improve hemodynamic instability. The advanced practice nurse (APN) ordered labs,
blood and urine cultures, chest x-ray, and 12-lead EKG. A bedside echo was performed by the
APN to evaluate cardiac function. A computerized tomography (CT) of the abdomen was
ordered but unable to be complete due to the instability of the patient. Within hours of admission
to the ICU, the wound ecchymosis had doubled in area and subcutaneous emphysema had
developed around the incision.
Past Medical History
End Stage Renal Disease (ESRD) secondary to diabetes mellitus (DM), hemodialysis three
days/week x one year, hypertension, obesity, urinary tract infection with recent treatment of
ciprofloxacin.
Past Surgical History
Cholecystectomy 2010, Cadaveric kidney transplant April 2012
Family History
Mother deceased secondary to myocardial infarction. Unknown history regarding father due to
estrangement. No siblings or children.
Social History
WEB CASE STUDY
47 year old female who lives alone. She is a retired customer service clerk, who quit working
full time after developing renal failure requiring hemodialysis. Denies smoking, drinking, and
illicit drug use. For exercise, she rides a stationary bike daily for 30 minutes, and enjoys taking
her puppy outside for play. The patient has been eating a more “healthy” diet since before
receiving her kidney transplant. She denies being around anyone who is ill. She also denies
being in a relationship or any recent sexual activity.
Allergies
Vancomycin-rash
Medications
Amaryl 3mg PO daily
Lantus 35 units subcutaneous daily
Metoprolol Tartrate 25mg PO twice a day
Norvasc 10mg PO daily
Mycophenolate Mofetil 1000mg PO twice a day
Prednisone 20mg PO daily
Review of Systems
General:
Prior to intubation, pt reports fever, malaise, and nausea. Height 5’6”, current
weight 178 lbs
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WEB CASE STUDY
Neurological: Pharmacologically sedated. Previously reported alert and oriented, with
complaints of generalized weakness and lethargy.
HEENT:
Unable to obtain.
Skin:
Unable to obtain.
CV:
Prior to intubation, denied chest pain or palpitations
Respiratory:
Prior to intubation, denied cough, wheezing, or shortness of breath
Abdomen:
Prior to intubation, complaints of nausea, vomiting, and diarrhea. Also had
complaints of increasing abdominal pain, 10/10 unable to describe the quality,
with nothing making it better or providing relief.
M/S:
Prior to intubation, complaints of generalized weakness, but denied muscle and
joint pain.
Physical Examination
Vital Signs:
Temperature 102 degrees Fahrenheit, HR 120 beats per minute (bpm), BP 94/57
(on pressors), RR 16 breaths/min (on ventilator), Oxygen saturation 99%
General:
Pharmacologically sedated well nourished, well developed caucasion female.
Neurological: Pharmacologicallly sedated with propofol and fentanyl. Opens eyes to name.
Able to weakly follow commands. RASS -2.
HEENT:
Head is midline and normocephalic. Atraumatic. No masses or lesions palpated.
Sclera white, conjunctiva pink, no hemorrhages or exudates noted. Pupils 4mm,
5
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constricting to 3mm, and equal and reactive to light and accommodation.
Bilateral tympanic membranes pearly gray. Nasal mucosa pink and moist with no
exudates. Dentition in good health. Trachea midline and thyroid smooth,
without nodules. No lymphadenopathy. Unable to view throat due to presence of
endotracheal tube.
Skin:
Skin is pale, hot, and dry. Non-tenting skin. Nails without cyanosis. Recent
surgical incision with significant ecchymosis that has grown in size over the past
several hours. Subcutaneous emphysema noted around the incision. Otherwise
no rashes or erythema noted.
CV:
Apical pulse palpated at fifth intercostal space, six centimeters lateral to
midsternal line. Tachycardic on monitor at 120 beats/min. S1 and S2 normal
without S3 or S4, no murmurs, rubs, or gallops noted. No jugular venous
distention noted. 1+ bilateral lower extremity edema noted. Pulses 2+ bilaterally,
radial, brachial, posterior tibial, and dorsalis pedis.
Respiratory:
Intubated and mechanically ventilated. Lung expansion symmetric. Respiratory
effort regular and unlabored on ventilator. Diffuse rhonchi auscultated in all lung
fields. Resonance over majority of lung fields with percussion. Dullness to
percussion noted bilateral lower lung fields.
Abdomen:
Active bowel sounds in four quadrants. Soft, non-distended, but firm 2cm around
incision. + grimace to palpation around healing surgical incision. Guarding
noted with deep palpation. No hepatosplenomegaly or palpable masses.
Subcutaneous emphysema and ecchymosis around incision.
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M/S:
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No erythema, warmth, or crepitus noted on extremeties. Unable to fully assess
muscle strength or range of motion due to current patient condition.
Laboratory Findings
Tissue pathology obtained during surgical exploration and debridement remains the
standard for diagnosis of necrotizing fasciitis (Stevens et al., 2005). To further distinguish
necrotizing fasciitis (NF) from other soft tissue infections, the Laboratory Risk Indicator for
Necrotizing Fasciitis (LRINEC) uses an objective scoring system based on standard lab testing
including total white blood cell count (WBC), hemoglobin, sodium, creatinine, glucose, and Creactive protein (Wong, Khin, Heng, Tan, & Low, 2004) (See Appedix A for LRINEC). Each
lab value is given a point, which is added to a total. A point value of 6-7 indicates an
intermediate risk for NF, while 8 points or more indicate a high risk of NF (Wong et. al, 2004).
Due to the rapid progression of disease, and the immunocompromised status in this patient,
initial treatment should not be delayed. According to the lab values, this patient presents with a
LRINEC of 9.
Table 1. Complete Blood Count, Coagulation, and Renal Panel
Complete
Blood Count
WBC
Results
2.8 cells/mL
RBC
2.23 cells/mL
Hemoglobin
8.8 g/dL
Hematocrit
25.7%
Normal
Values
3.8-10.8
Kcells/mL
3.8-5.10
cells/mL
11.7-15.5
g/dL
35.0-45.0%
MCV
79.0 fL
80.0-100.0 fL
Renal Panel
Results
Sodium
140 mmol/L
Potassium
3.7 mmol/L
Chloride
101 mmol/L
Carbon
Dioxide
BUN
20 mmol/L
140 mg/dL
Normal
Values
135-146
mmol/L
3.5-5.3
mmol/L
98-110
mmol/L
21-23
mmol/L
7-25 mg/dL
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MCH
26.0 pg/cell
MCHC
31.0 g/dL
RDW
11.0%
27.0-33.0
pg/cell
32.0-36.0
g/dL
11.0-15.0%
Creatinine
8.8 mg/dL
Glucose
187 mg/dL
Calcium
10.0 mg/dL
0.50-1.20
mg/dL
65-99 mg/dL
Platelet
82 K/uL
140-400 K/uL Phosphorus
5.0 mg/dL
8.6-10.2
mg/dL
2.5-4.5 mg/dL
MPV
7.9 fL
7.5-11.5 fL
Magnesium
2.1 mg/dL
1.5-2.5 mg/dL
Neutrophils
Relative
Bands
Relative
Lymphocytes
Relative
Monocytes
Relative
nRBC
46%
40.0-80.0%
Albumin
2.9 g/dL
3.6-5.1 g/dL
44%
0.0-9.0%
Total protein
5.8 g/dL
6.2-8.3 g/dL
5%
15.0-45.0%
PT
20.8 seconds
5%
0.0-12.0%
INR
1.9
11.6-14.4
seconds
0.9-1.1
1
0.0/100 WBC
PTT
42.5 seconds
25-35 seconds
Neutrophils
Absolute
Lymphocytes
Absolute
Monocytes
Absolute
Bands
Absolute
1288 /uL
1500-7800/uL
140 /uL
850-3900/uL
140/uL
200-950/uL
1232/uL
0-750/uL
Table 2. Arterial Blood Gas and Other Laboratory Findings
Arterial Blood Gas
(ABG)
Results
Normal
Values
pH
7.26
7.35-7.45
pCO2
pO2
45 mmHg
76 mmHg
HCO3
18 mmol/L
CO2 content
17.5
mmol/L
35-45mmHg
80100mmHg
2226mmol/L
23-27
mmol/L
Other
Laboratory
Findings
Alkaline
Phosphatase
CRP
Lactic Acid
Results
Normal
Values
62 U/L
40-115 U/L
21.2 mg/dL
6.5 mmol/L
AST
23 U/L
<0.8 mg/dL
0.5-2.2
mmol/L
14-65 U/L
ALT
65 U/L
13-69 U/L
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Base Excess
9
-12.5
-2.0-3.0
Carboxyhemoglobin 1.2
Unknown
Methoglobin
Reduced
Hemoglobin
%HBO2
0.4%
1.2%
0.0-1.5%
0.0-5.0%
95.5%
95.0-98.0%
Direct
Bilirubin
Total
Bilirubin
ESR
0.1 mg/dL
0.4 mg/dL
42 mm/hr
0.0-0.2
mg/dL
0.2-1.2
mg/dL
<15mm/hr
Diagnostic Data
12-lead EKG reveals sinus tachycardia with left axis deviation. Ventricular rate is 120
bpm, with no Q waves or ST abnormalities. Chest xray shows no evidence of pulmonary edema,
however small bilateral pleural effusions are noted. CT of chest, abdomen and pelvis was unable
to be completed due to instability of patient. Bedside echo shows increased wall thickness in a
pattern of mild left ventricular hypertrophy (LVH), with no regional wall abnormality. Mitral
valve with mildly calcified annulus and mildly thickened leaflets. Ejection fraction (EF) is 55%.
Urine culture shows no growth. No growth to date from blood cultures.
Differential Diagnoses
The presenting symptoms of fever, pain, and rapid deterioration in the recently
discharged immunocompromised patient with surgical incision lead to differential diagnoses of
gangrenous cellulitis, abscess, necrotizing fasciitis (NF), and infectious myositis (Lipworth,
Saavedra, Weinberg, & Johnson, 2012). Given that the patient had diarrhea, fever, and
bandemia, acute infection of Clostridium difficile should be ruled out. Immunocompromised
patients are at high risk for acquiring infections, which can cause life-threatening complications
in this population. Clinical assessment and early recognition of the severity of infection is
important, especially in this patient, to decrease the incidence of mortality.
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Systemic toxicity as presented by fever, tachycardia, hypotension and renal failure are
clinical signs that accompany soft tissue infection (Stevens et. al, 2005). Initial signs of skin
inflammation, such as pain, edema, and erythema may be present in less serious conditions such
as cellulitis, but pain disproportionate to the degree of inflammation, firm tissue around incision,
and skin ecchymosis are hallmark signs of NF (Anaya & Dellinger, 2007). Violaceous bullae,
cutaneous hemorrhage or ecchymosis, skin sloughing, skin anesthesia, rapid progression, and gas
in the tissue are other clues to deep soft-tissue infection (Stevens et al., 2005).
Necrotizing fasciitis is the likely diagnosis for this patient. She presents with systemic
toxicity, pain consistent with diagnosis, and ecchymosis at the site of recent surgery with
subsequent crepitus at and around the incision. Immunosuppressive drug therapy, recent
surgery, and diabetes also led to susceptibility and vulnerability of this infection (Anaya &
Dellinger, 2007).
Plan
Clinical guidelines for the management and treatment of NF are currently being updated,
but the recommendations are consistent in that to achieve optimal outcomes, aggressive and
timely resuscitation, prompt and appropriate administration of antibiotic therapy, and early
surgical debridement are required to decrease mortality (May et al., 2009). NF may be
monomicrobial or polymicrobial, involving both aerobic and anaerobic bacterial flora (Stevens et
al., 2005). Polymicrobial infections are most common, especially in immunocompromised
individuals (Anaya & Dellinger, 2007), therefore treatment must include therapies efficient
against both aerobes and anaerobes.
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Initiation of appropriate antibiotic therapy should depend on medical history and allergies
of the patient, as well as suspected pathogens and progression of the infection. Broad spectrum
antibiotics are indicated to cover aerobic and anaerobic gram-negative and gram-positive
pathogens, as well as resistant gram-positive bacteria such as MRSA, especially in the
immunocompromised patient experiencing toxicity (Stevens et al., 2005). The antibiotic
regimen to be initiated in this patient will be Piperacillin-tazobactam (3.375g I.V. over 4 hours,
every 12 hours, for 7-14 days), Clindamycin (600mg I.V. every 8 hours, for 10-14 days), and
Linezolid (600mg I.V., every 12 hours, for 10-14 days).
Complete debridement of the infected tissue and early empiric broad spectrum antibiotic
coverage allow for future recovery in the patient with NF (Anaya & Dellinger, 2007). In
addition to these interventions and close monitoring, further treatments are indicated. These
treatments include adequate organ support, aggressive fluid resuscitation, tight glycemic control,
and transfusion of appropriate blood products (Anaya & Dellinger, 2007). When appropriate,
enteral nutritional support should be started to increase wound healing and control catabolic
response (Anaya & Dellinger, 2007).
Drug Therapy
Drug and
Dose
Drug to Drug
Interactions
Piperacillintazobactam
(Zosyn)
Increased
Effect/Toxicity:
Floxacillin,
Methotrexate,
Vecuronium,
Vitamin K
Antagonists
Decreased Effect:
Aminoglycosides,
BCG,
2.25g/50mL
3.375g/50mL
4.5g/100mL
Adverse
Effects/Precaution
s
Adverse Effects:
Insomnia,
headache, fever,
agitation, pain,
anxiety,
hypertension, chest
pain, edema,
diarrhea,
constipation,
nausea, vomiting,
Follow-up
Monitoring
Cost
CBC with
differential, BUN,
Creatinine, Coags,
serum electrolytes,
LFTs. Monitor for
signs of
anaphylaxis with
initial dose.
Zosyn (per
dose)
2.25g/50m
L: $18.31
3.375g/50
mL:
$27.47
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Mycophenolate,
Sodium Picosulfate,
Typhoid Vaccine
Levels of
Piperacillin/tazobac
tam may be
decreased by
Tetracycline
Derivatives
Clindamycin
(Cleocin)
Cleocin in
D5W:
300mg/50mL
600mg/50mL
900mg/50mL
dyspepsia, rash,
pruritis, increased
AST, local reaction
at site of injection,
pharyngitis,
dyspnea, moniliasis
Precautions: Use
with caution in
patients with renal
impairment. Dose
adjustments are
recommended.
Use with caution in
patients with a
history of seizure
disorder; high
levels may increase
risk of seizure.
Avoid concomitant
Adverse Effects:
use with BCG and
Cardiac arrest
Erythromycin
(rare), hypotension
Increased
(rare), StevensEffect/Toxicity:
Johnson Syndrom
Neuromuscular(rare), erythema
Blocking Agents.
multiforme (rare),
Decreased Effect:
pruritis, rash,
BCG, Erythromycin, urticaria,
Sodium Picosulfate, abdominal pain,
Typhoid Vaccine.
diarrhea,
Levels/effects of
esophagitis,
Clindamycin may be nausea, vomiting,
decreased by
pseudomembrane
Kaolin.
colitis,
agranulocytosis,
eosinophilia
(transient),
neutropenia
(transient),
thrombocytopenia,
jaundice, abnormal
LFTs,
thrombophlebitis at
injection site,
Precautions:
Use with caution in
patients with
4.5g/100m
L: $34.81
CBC, renal
function, and
hepatic enzymes.
Observe for
changes in bowel
frequency and
monitor for colitis.
Cleocin in
D5W (per
dose)
300mg/50
mL:
$11.89
600mg/50
mL:
$18.20
900mg/50
mL:
$22.24
WEB CASE STUDY
Linezolid
(Zyvox)
600mg/300mL
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hepatic
impairment.
Dosage
adjustments may
be necessary based
on hepatic enzymes
Increased
Adverse Effects:
Effect/Toxicity:
Insomnia,
Antihypertensives,
dizziness,
Antipsychotics,
headache, nausea,
Apraclonidine,
diarrhea, vomiting,
Atomoxetine, Beta2- increased serum
Agonists,
lipase, increased
Betahistine,
ALT and AST,
Bezafibrate,
increased serum
Brimonidine,
bilirubin, rash,
Bupropion,
increased BUN and
Clozapine,
creatinine
Dexmethylphenidate Precautions: Use
, Dextromethorphan, in caution with
Diethylpropion,
patients with
Domperidone,
cardiovascular
Doxapram,
disease due to the
Doxylamine,
mild MAO
Epinephrine,
inhibitor
Hydrocodone,
properties. Avoid
Hydromorphone,
use with
Hypoglycemic
sympathomimetic
Agents,
and dopaminergic
Isometheptene,
agents. May cause
Levondordefrin,
thrombocytopenia
Lithium,
(use caution in
Meperidine,
patients with
Methadone,
thrombocytopenia).
Methyldopa,
Methylene Blue,
Methylphenidate,
Metoclopramide,
Mertazapine,
Morphine,
Nefazodone,
Norepinephrine,
Oxycodone,
Pizotifen, Reserpine,
SSRIs, Serotonin 5HT1D Receptor
CBC and platelet
count, especially in
patients at risk for
bleeding. Monitor
for
myelosuppression
(anemia,
leukopenia,
pancytopenia, and
thrombocytopenia)
in patients
receiving Linezolid
for >2 weeks.
Zyvox I.V.
(per dose)
600mg/300
mL:
$216.54
Zyvox
tablets (20)
600mg:
$2807.52
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Agonists, Serotonin
Modulators,
SerotoninNorepinephrine
Reuptake Inhibitors,
Sympathomimetics,
Trazodone, Tricyclic
Antidepressants
Levels/Effects of
Linezolid may be
increased by:
Altretamine,
Anilidopiperidine,
Buspirone,
Carbamazepine,
COMT inhibitors,
Cyclobenzaprine,
Levadopa, MAO
Inhibitors,
Maprotiline,
Oxymorphone,
Tapentadol,
Tetrabenazine,
Tramadol,
Tryptophan
Decreased Effect:
Domperidone
Drug information retrieved from Lexicomp 2014
Advanced Practice Nurse (APN) Authority to Prescribe
APNs who hold a current certificate to prescribe (CTP) in the state of Ohio may prescribe
many drugs that fall within their scope of practice, unless there are listed exclusions or additional
parameters specified within the formulary (Ohio Board of Nursing, 2014). In this case,
according to the formulary by the Ohio Board of Nursing (2014), the APN has the authority to
prescribe Clindamycin and Piperacillin-tazobactam without physician collaboration. Prescribing
Linezolid, however, requires the APN with a CTP to have prescribing designation addressed in
the standard care arrangement with the collaborating physician(s) in order to initiate treatment
WEB CASE STUDY
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(Ohio Board of Nursing, 2014). Due to the complexity of the patient’s history and current status,
collaboration with a physician specializing in infectious disease would be most beneficial for
optimal outcomes.
Clinical Studies
Current guidelines recommend several antibiotics for the treatment of polymicrobial
necrotizing fasciitis (Stevens et al., 2005). No current literature supports recommendations of
one regimen over another in severe infections with NF (May et al., 2009). With the increase in
incidence over the past decade of antibiotic resistance gram-positive cocci (MRSA), especially in
the immunocompromised patient, additional antibiotics must be considered (Yue, Dong, Yang,
Chen, Wu, & Liu, 2013).
Vancomycin and Linezolid are commonly used in the treatment of MRSA complicated
skin and soft tissue infections (SSTIs) (Yue et al., 2013). A Cochrane Review of nine
randomized control trials (RCTs) was conducted to evaluate and compare the treatment of SSTIs
with Linezolid and Vancomycin (Yue et al., 2013). 3114 participants of the 4496 were
diagnosed with SSTI; five trials enrolled people with MRSA, while the other four trials enrolled
those with gram-positive bacterial infection; eight of the nine RCTs included adults age greater
than 18 (Yue et al., 2013). In all trials with adult participants, doses of the drugs were similar, in
that Linezolid 600mg I.V. administered every 12 hours, and Vancomycin 1000mg I.V. every 12
hours, with the exception of one RCT where participants were randomized to receive oral or I.V.
Linezolid 600mg every 12 hours, or Vancomycin 15mg/kg every 12 hours (Yue et al., 2013).
Investigators evaluated the clinical cure, microbiological cure, SSTI-related mortality,
and treatment-related mortality, with secondary evaluation of adverse events, duration of hospital
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stay, duration of treatment, and cost (Yue et al., 2013). In participants with suspected or proven
MRSA infection (2659 participants), clinical cure (resolution of signs and symptoms) was
evaluated, while in those with confirmed MRSA at baseline (1289 participants), microbiological
cure (elimination of bacteria on wound culture) was evaluated. Linezolid was proven to have
statistically significant clinical and microbiological cure rate when compared to Vancomycin
(Yue et al., 2013).
Other outcomes which were evaluated showed no significant difference in mortality
between the two groups with SSTI. Linezolid participants showed lower incidence of red man
syndrome, pruritis, and rash, but was also associated with increased incidence of
thrombocytopenia and nausea. Inpatient treatment cost of Linezolid was higher than inpatient
treatment cost of Vancomycin, however, the length of hospital stay was three days shorter,
proving that the total cost of treatment with Linezolid is less than that of Vancomycin (Yue et al.,
2013).
Several limitations with the RCTs used in this Cochrane review were addressed. First,
although the studies included were randomized, none of the studies mentioned the method of
randomization. In the majority of the studies reviewed, the treatment allocation was not
concealed, which may lead to an overestimation of treatment effect. Also, in seven of the nine
RCTs, it was not reported, or is unclear of the dropout rate of the studies, which can cause
problems with false-positives or negatives regarding the data. Lastly, all of the trials reviewed
were funded by the pharmaceutical company which manufactures Linezolid, leading to biased
publication and a potential miscalculation of the effects of Linezolid (Yue et al., 2013).
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Issues
Several considerations are necessary when developing the plan of treatment in this
patient. This patient was recently discharged status post kidney transplant, has a listed allergy to
vancomycin, and was admitted with a serum creatinine of 8.8mg/dL. Thorough evaluation of the
patient, including medical and social history, along with complex physical assessment and
progression of infection will aid the APN to the appropriate treatment.
Although anti-rejection drugs and corticosteroids are indicated for all solid organ
transplants, in the case of severe infection such as this, all anti-rejection and immunosuppression
medications should be stopped to allow for adequate immune response to fight the infection.
Collaboration between the APN and the transplant team would be necessary to determine when
to restart this therapy based on patient status.
Based on the patient weight and admitting serum creatinine, the creatinine clearance of
this patient is 7.8 mL/min (Mdcalc, 2014). According to this calculation, dosage adjustment for
the Piperacillin-tazobactam must be made to ensure no further renal injury occurs. Current
guidelines recommend treating SSTI with 3.375g I.V. every 6-8 hours, however, with this
patients renal impairment, extended infusion dosing of 3.375g I.V. over 4 hours every 12 hours
is safe and effective (Lexicomp, 2014).
This patient also has a listed allergy to Vancomycin, which is the first line treatment for
MRSA-associated NF. Given this allergy, Linezolid or Daptomycin would otherwise be
considered. Since this patient also has acute renal injury to the newly transplanted kidney,
Daptomycin could be administered 4mg/kg I.V. every 48 hours, but should be avoided to
decrease the risk of further renal injury due to its renal clearance (Lexicomp, 2014). Although
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Linezolid has been shown to increase BUN and creatinine levels, it is not cleared renally, and no
dosage adjustment is required in the patient with renal impairment. Linezolid does have
thrombocytopenic side effects and the risk versus benefit should be considered in this patient
who presents with an already decreased platelet count. Linezolid is also a better option due to
the ability to change from I.V. therapy to oral therapy if the patient required further antibiotic
treatment upon discharge.
Drug to drug interactions should always be taken into consideration when prescribing
medications. Since the immunosuppressive therapy in this patient will be stopped, the APN does
not need to consider these drugs with interactions, but may need to when the patient has
recovered from the infection, and it is time to restart those medications. Linezolid is the only
current medication that may cause drug to drug interactions. This patient is requiring high doses
of pressors upon admission to the ICU, and it is likely that she was receiving both
norepinephrine and epinephrine for blood pressure support. Both of these medications may have
increased effects/toxicity when used in combination with Linezolid, so dosage adjustments to
those pressors may need to be made in accordance to patient response.
This patient has rapidly deteriorated since admission, so education regarding treatment
plan and economic concerns are of decreased importance until the patient recovers from the
severe, life-threatening infection. Once recovery has been gained, patient education should
include methods to prevent contraction of another opportunistic infection. If the patient requires
antibiotics upon discharge, teaching regarding side effects and signs of infection should be
considered. Economical considerations can be discussed at that time, with referral to drug
assistance companies if needed.
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Ethical and Legal Considerations
When implementing a treatment plan, ethics must always be taken into consideration.
Non-maleficence is being practiced in this patient by providing prompt treatment with surgical
intervention and appropriate antibiotic therapy. It is the goal of the APN and healthcare team to
do no harm. Beneficence is practiced by using the most up-to-date guidelines to treat this
patient, however, there is a concern of risk versus benefit. This patient is severely
immunocompromised with a complicated, life-threatening illness, so the APN must decide what
would be best for the patient regarding continuing to treat. This patient has a lack of autonomy
in her care since she is incapacitated due to medications and severity of the illness. It is up to her
POA to decide what the patient would want, and may not feel comfortable in ending treatment if
the APN and treatment team continue to provide additional “life-saving” therapies.
With all instances of patient care and treatment, confidentiality and privacy must be
maintained. Prior to initiating a treatment plan, it is essential to know and understand the Ohio
Revised Code and Administrative code for APNs. Legal action for the APN may take place if
adverse events occur as a result of failure to recognize contraindications, poor monitoring, or
inadequate follow-up (Lawriter, 2013).
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References
Anaya, D., & Dellinger, P. (2007). Necrotizing soft-tissue infection: Diagnosis and
management. Clinical Infectious Disease, 44, 705-710. doi: 10.1086/511638
Lawriter (2013). Administrative rules for prescribing drugs and therapeutic devices (Report no.
4723.50). Retrieved from Ohio laws and rules: http://codes.ohio.gov/orc/4723.50
Lexicomp, Inc. (2014). Lexi-Drugs. Retrieved from http://webstore.lexi.com/PDA-Softwarefor- Nurses
Lipworth A.D., Saavedra A.P., Weinberg A.N., Johnson R (2012). Chapter 179. Necrotizing Soft
Tissue Infections: Necrotizing Fasciitis, Gangrenous Cellulitis, and Myonecrosis. In
Goldsmith L.A., Katz S.I., Gilchrest B.A., Paller A.S., Leffell D.J., Wolff K (Eds),
Fitzpatrick's Dermatology in General Medicine, 8e. Retrieved February 06, 2014 from
http://accessmedicine.mhmedical.com.ezproxy.libraries.wright.edu:2048/content.aspx?bo
okid=392&Sectionid=41138906.
May, A., Stafford, R., Bulger, E., Heffernan, D., Guillamondegui, O., Bochicchio, G., &
Eachempati, S. (2009). Treatment of complicated skin and soft tissue infections.
Surgical Infections, 10(5), 467-499. doi: 10.1089/sur.2009.012
Mdcalc. (2014). Creatinine Clearance (Cockcroft-Gault Equation). Retrieved from
http://www.mdcalc.com/creatinine-clearance-cockcroft-gault-equation/
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Ohio Board of Nursing (2014). The formulary developed by the Committee on Prescriptive
Governance. Retrieved from http://www.nursing .ohio.gov/practice/jan-62014_Formulary.pdf
Stevens, D., Bisno, A., Chambers, H., Everett, D., Dellinger, P., Goldstein, E., Gorbach,
S…Wade, J. (2005). Practice guidelines for the diagnosis and management of skin and
soft-tissue infections. Clinical Infectious Diseases, 41, 1373-1406.
Wong, C., Khin, L., Heng, K., Tan, K., & Low, C. (2004). The LRINEC (Laboratory Risk
Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis
from other soft tissue infections. Critical Care Medicine, 32(7), 1534-1541.
Yue J, Dong B., Yang M., Chen X., Wu T., Liu G. (2013). Linezolid versus vancomycin for
skin and soft tissue infections. Cochrane Database of Systematic Reviews, 7, 1-62. doi:
10.1002/14651858.CD008056.pub2
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Appendix A. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score
Variable, Units
Score
C-Reactive Protein, mg/L
<150mg/L
0
>150mg/L
4
White Blood Cell count, per mm^3
<15
0
15-25
1
>25
2
Hemoglobin, g/dL
>13.5
0
11-13.5
1
<11
2
Sodium, mmol/L
>135
0
<135
2
Creatinine, mg/dL
<1.6
0
>1.6
2
Glucose, mg/dL
<180
0
>180
1
Adapted from: “The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool
for distinguishing necrotizing fasciitis from other soft tissue infections” (Wong et al., 2004).
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Discussion Questions
1. Initial tissue pathology came back positive for gram-positive cocci in chains
resembling Group A-bega hemolytic Streptococcus, as well as thick gram-positive
bacilli resembling Clostridium Perfringens, and gram-negative rods resembling
Escherichia coli. How would antibiotic treatment differ? Consider mechanism of
action, drug interactions, side-effects, and monitoring.
2. There are adjunctive therapies that have been proposed for treatment of NF in
combination with surgical debridement and antibiotics. Discuss these therapies,
including benefits, risks, and current recommendations.