NYU Medicine Grand Rounds Clinical Vignette

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NYU Medicine Grand Rounds Clinical Vignette

• Ivan Saraiva MD, PGY-2
• December 9, 2009

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Chief Complaint
A 74-year-old woman is brought to the emergency
room with increasing confusion for three days.
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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.

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History of Present Illness

• The urinalysis demonstrated
• Turbid appearing urine (clear)
• Blood Moderate 2 (negative)
• Protein gt 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

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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 patients 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.

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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

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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
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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.
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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

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Laboratory Findings
The urine culture from 4 days prior was
reviewed Final ID Escherichia
coli Amikacin-MIC S (8) Ampicillin-MIC R
(gt2) Cefazolin-MIC R (gt24) Ciprofloxacin-MIC R
(gt4) Gentamicin-MIC S (lt1) Nitrofur-MIC R
(128) Tetracyclin-MIC S(2) Ampi/Sulbac-MIC R
(gt32) SMX/TMP-MIC R (gt320) Aztreonam-MIC S (lt1)
Cefepime-MIC S (lt1) Cefoxtaxime-MIC S
(2) Ceftazidime-MIC S (lt1) Ceftriaxone-MIC
S(4) Levofloxacin-MIC R (gt8) Piperacillin-MIC R
(gt128) Imipenem-MIC S (lt1) Meropenem-MIC S
(lt0.25) Pip/Tazo-MIC I (32) Cefuroxime-MIC R
(gt64)
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Additional Studies

• ECG Sinus rhythm with first degree AV delay
• Chest X-Ray within normal limits
• Head CT no acute abnormalities

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Working Diagnosis
Delirium secondary to E. coli urinary tract
infection, resistant to empirically started
antibiotics (ciprofloxacin)
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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 patients 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 ().

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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.

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Hospital Course

• The patients 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.

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Final Diagnosis
ESBL-positive E. coli urinary tract infection
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