Supplemental Reading

Garrett DO et al. The emergence of decreased susceptibility to vancomycin in Staphylococcus epider-midis. Infect Control Hosp Epidemiol1999;20:167-170.

Healy DP et al. Vancomycin-induced histamine release and "red man syndrome": Comparison of 1- and 2hour infusion. Antimicrob Agents Chemother 1990;34:550-554.

Hogasen AK and Abrahamsen TG. Polymyxin B stimulates production of complement components and cytokines in human monocytes. Antimicrob Agents Chemother 1995;39:529-532.

McMaster P et al. The emergence of resistant pneumococcal meningitis: implications for empiric therapy. Arch Dis Child 2002;87:207-210.

Murray BE. Vancomycin-resistant enterococcal infections. N Engl J Med 2000;342:710-721.

Robinson-Dunn B et al. Emergence of vancomycin resistance in Staph aureus. Glycopeptide-Intermediate S. aureus Working Group. N Engl J Med 1999;340:493-501.

Schaison G, Graninger W, and Bouza E. Teicoplanin in the treatment of serious infection. J Chemother 2000;12(Suppl 5):26-33.

Srinivasan A, Dick JD, and Perl TM. Vancomycin resistance in staphylococci. Clin Microbiol Rev 2002;15:430-438.

Yoshikawa TT. Antimicrobial resistance and aging: Beginning of the end of the antibiotic era? J Am Geriatr Soc 2002;50:S226-S229.

^ Case Study Endovascular Infection

A 72-year-old male nursing home resident is brought to the emergency department with change in mental status, fever, and shortness of breath. Last year he underwent partial resection of his colon to treat ischemic bowel disease. He receives total parenteral nutrition (TPN) via a central line. His examination revealed temperature 104°F (40°C), heart rate 110 beats/minute, respiratory rate 32/minute, blood pressure 90/50 mm Hg. He was lethargic but arousable. He denied any cough or headache, abdominal pain, or change in bowel or bladder function except that his urinary output has fallen over the past few shifts. Pertinent points in his examination included a supple neck and a central venous catheter in place without any evidence of infection. Heart sounds were normal, without any murmurs, and he reported diffuse nonspecific vague abdominal discomfort without any localization or rebound tenderness. His laboratory findings were WBC 29,000/mm2, hemoglobin 13 g/dL, platelets 300,000.

Urinalysis showed 2 to 5 WBC with a negativegram stain and nitrite test. He had clear lung fields with a few old calcific deposits. An abdominal series showed no evidence of obstruction or perforation. You get a call from the nursing home that three of four bottles of blood cultures drawn the day before were positive for gram-positive cocci in clusters. A correct statement with regard to his management is

Because of recent surgery, perforation of the bowels should be considered and an emergency laparotomy performed. With a chronic indwelling Foley catheter, he most likely has urosepsis. His central line should be immediately discontinued, and specific therapy with vancomycin should be initiated.

He has aspiration pneumonia. The lung fields were clear because findings on chest radiographs take time to evolve, and film may remain negative at initial presentation. Discontinue his central line and initiate treatment with IV nafcillin.

Answer: This patient has line sepsis. The causation of his infection is not clear initially, and his presentation, without any localizing features, gives rise to the possibility of a line infection. The catheter sites frequently do not reveal any evidence of infection, but high-grade bacteremia (3 of 4 bottles) with grampositive cocci strongly suggests an endovascular infection. With a high prevalence of methicillin resistance in staphylococcal infections in hospital and nursing home settings, vancomycin therapy should be initiated along with discontinuation of the line. Indeed, the organisms later prove to be MRSA, and neither nafcillin nor any other (3-lactam or cephalo-sporin would be effective in management of his infection.

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