Surgical Critical Care and Emergency Surgery. Группа авторов
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 patient who was being treated as an outpatient, administration of anti‐viral therapy is only recommended within 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