Urinary Tract Infection Case Study SP is a 21 year old male who is S/P MVA with subsequent paraplegia one

year ago. He has been straight catheterizing himself 4 times a day since that time. He presents to the ER with complaints of malaise, fevers, occasional chills, hematuria and anorexia. PMH: 1. Paraplegia secondary to C4-5 fracture one year ago. 2. L4 and L3 fractures. 3. Basal skull fracture. 4. Rib fractures. 5. S/P inferior vena cava filter for DVT and PE. 6. Depression. 7. Nonhealing leg wounds with osteomyelitis of the right leg. 8. History of VRE and Pseudomonas in his urine two months ago. FH: Noncontributory

SH: Patients lives with his parents. He denies tobacco use. He intermittently binge drinks. MEDS: Neurontin 300 mg 5x/day, Ditropan 10 mg bid, Prevacid 15 mg qd, MVI, Effexor XR qd, Colace, Baclofen 10 mg qd, Warfarin 8 mg qd, and Ampicillin which was discontinued several days ago. ALL: PE: Tape and possibly milk Flushed white male who is quite warm to the touch with a temp of 102.2, BP 120/70, P 96, R 23. HEENT: Anicteric, no conjunctival lesions, no nasal discharge. There is a well-healed former tracheostomy site. Lungs: clear to A/P. COR: mild tachycardia but regular, without murmur. ABD: Slight fullness in the RLQ, bowel sounds present. Back is without skin breakdown. CVA tenderness could not be assessed. EXT: left lower extremity has a 10 cm ulcer over the posterior calf with good granulation tissue surrounding a rim of maceraton. A right heel ulcer is clean and without discharge. Wt. 65 kg.

LABS: WBCs 18,900 with 13% bands, H/H 12.4/36.6, Plts 132,000, PT 22.6, INR 3.9, Na 135, Cl 101, K 4.1, C02 28, BUN 25 mg/dL, SrCr 1.6 mg/dL, glucose 125 mg/dL, Urine R and M bloody, nitrite positive, Leukocyte esterase large, WBCs 15-30, RBCs 15-30.

1. What signs and symptoms are consistent with pyelonephritis?

2. What is the most likely pathogen? 3. What would be your initial empiric antibiotic therapy?

4. At 24 hours the blood culture is positive for gm-negative rods, lactose negative, oxidase positive (2/2 bottles). Would this cause you to modify your initial empiric therapy? If you would change therapy, what would be the new regimen?