PATIENT CASE

Madison Heath, PharmD

September 12, 2022
 OVE RVIE W OBJE CTIVES

• Patient Presentation • Understand the course of therapy this

patient underwent
• Course of Hospital Stay
• Identify areas of improvement in
• Medication Timeline medication management
• Debrief • Develop knowledge on pressure injury
staging and management
PATIENT PRESENTATION
 PAST MEDICAL HISTORY

• 80yo Male
• Allergies: Bee Venom (anaphylaxis), Ciprofloxacin (photosensitivity), Pioglitazone (abdominal pain)
• Including but not limited to:

Decubitus Ulcer of the Sacral region
Hypertension
Atherosclerotic Heart Disease
Stage 3a CKD
Dementia
Severe protein-calorie malnutrition
Pressure Injury of sacral region, stage 4
Hypercholesterolemia
Type 2 Diabetes Mellitus
Prostate Hyperplasia with urinary obstruction
Emphysema
Iron deficiency anemia
 ADMISSION HISTORY & PHYSICAL

• CC: Hypotension and Sepsis

• HPI: Presented with c/o hypotension and sepsis – sent by wound care center with SBP in 70s. Patient stated
they had been ill for the past 12-15 days.
• ROS: Chills, Fever, Cough, Chest Tightness, SOB, Nausea, Wound, Weakness
• PTA Medications: Aspirin 81mg, Atorvastatin 40mg, Cefdinir course, Clopidogrel 75mg, Ferrous sulfate,
Gabapentin 300mg, Metoprolol succinate 12.5mg, Midodrine 5mg TID, Norco PRN, Zofran PRN, Tramadol
PRN
• Physical Exam:
• afebrile, BP 109/66, WBC 16.6, Hgb 9.3, BUN 22, SCr 0.92
• ill-appearing, heart sounds are distant, pulmonary diminished sounds in left base, pale, lesion present,
sensory deficit (hard of hearing)
• Chest X-Ray: Left lower lobe pneumonia cannot be entirely excluded
 ADMISSION ASSESSMENT/PLAN

• In ED: Acetaminophen 650mg POx1, Midodrine 10mg POx1, Zosyn 4.5g IVx1, 2L IV Fluids
• Sepsis 2/2 LLL PNA
• Criteria met with: HR >90, WBC 16.6, Lactic Acid 3.3, Procalcitonin 0.21
• Zosyn 4.5g IV Q8H initiated
• UTI vs Colonization from indwelling foley catheter
• Covered by Zosyn
• Chronic Osteomyelitis of the sacrum with stage 4 decubitus sacral ulcer
• Had completed outpatient antibiotics a month prior
• Debridement needed
• Severe Protein Calorie Malnutrition: Nutrition Consult Pending
COURSE OF HOSPITAL STAY
 DAY 1

• C/o fevers, chills, malaise. Had N/V in AM. Productive cough.

• AF, WBC 13.4, Hgb 8.4, BUN 21, SCr 0.74
• Sepsis 2/2 LLL PNA/Bacteremia/Ulcer wound
• Blood Cultures (+) Staph spp., on Vancomycin
• Zosyn stopped due to bone culture having intermediate sensitivity to Morganella  ertapenem
• UTI vs Colonization from indwelling foley catheter: Changed in ED
• Chronic Osteomyelitis of the sacrum with stage 4 decubitus sacral ulcer: PT/Wound/Surgery
Consulted
• Severe PCM: Dietary added Glucerna TID to diet
• Hx CAD: DAPT, Statin, Beta-blocker on hold d/t low BP
• T2DM: SSI
• CKD Stage 3a: Baseline SCr of 1.1-1.3, at baseline
• Recurring Admissions: 3rd this year for same ulcer, unlikely to ever heal. Hospice discussion possibly
needed.
 DAY 2

• C/o headache. Productive cough.

• AF, WBC 11.9, Hgb 7.5, BUN 20, SCr 0.66
• Sepsis 2/2 LLL PNA/Bacteremia/Ulcer wound
• Blood Cultures (+) Staph spp., on Vancomycin
• Repeated Blood Cx
• UTI vs Colonization from indwelling foley catheter: Changed in ED
• Chronic Osteomyelitis of the sacrum with stage 4 decubitus sacral ulcer: Debridement performed
• Non-sustained ventricular tachycardia: 5 beats occurred, BP stable, Magnesium sulfate 2g IV to keep ≥ 2
• Recurring Admissions: 3rd this year for same ulcer, unlikely to ever heal. Hospice discussion possibly
needed.
 DAY 3

• Productive cough improving. Having diarrhea

• AF, WBC 12.0, Hgb 6.9  8.7, BUN 19, SCr 0.69
• Sepsis 2/2 LLL PNA/Bacteremia/Ulcer wound
• Blood Cultures (+) Staph spp., on Vancomycin: Dose increased d/t AUC
• Repeated Blood Cx negative
• Acute Enterococcus + Yeast CAUTI: Changed in ED, Fluconazole 200mg
• Diarrhea: C. diff tests ordered
• Chronic Osteomyelitis of the sacrum with stage 4 decubitus sacral ulcer: Debridement D2
• Non-sustained ventricular tachycardia: 5 beats occurred, BP stable, Magnesium sulfate 2g IV to keep ≥ 2
• Iron deficiency anemia: 1unit prbc, Iron sucrose 200mg daily x4 doses, Clopidogrel held
• Recurring Admissions: 3rd this year for same ulcer, unlikely to ever heal. Pt and family will not consider
hospice.
 DAY 4

• Productive cough improving.

• AF, WBC 11.2, Hgb 8.2, BUN 17, SCr 0.57
• Sepsis 2/2 LLL PNA/Staph epidermidis bacteremia/Ulcer wound
• Blood Cultures (+) Staph epidermidis, vancomycin transitioned to linezolid for concomitant VRE CAUTI
• VRE + Yeast CAUTI: Linezolid, Fluconazole 200mg Q72H x 3 doses (d/t open ulcer and comorbidities)
• C. diff Colitis: Vancomycin PO
• Chronic Osteomyelitis of the sacrum with stage 4 decubitus sacral ulcer: Debridement D2
• Iron deficiency anemia: Iron sucrose 200mg daily x4 doses
• Hypotension: Midodrine and IVF
 DAY 5

• C/o chest pain, cough improving, diarrhea better.

• AF, WBC 11.3, Hgb 8.1, BUN 17, SCr 0.69
• Sepsis 2/2 LLL PNA/Staph epidermidis bacteremia/Ulcer wound: Covered below
• VRE + Yeast CAUTI: Linezolid, Fluconazole 200mg Q72H x 3 doses
• C. diff Colitis: Vancomycin PO
• Chronic Osteomyelitis of the sacrum with stage 4 decubitus sacral ulcer: Debridement D2
• Atypical Chest Pains: Cardiology consult
• Iron deficiency anemia: Iron sucrose 200mg daily x4 doses
• Hypotension: Midodrine and IVF
• Recurring Admissions: Consulting hospice for GOC conversation.
 DAY 6

• Still having diarrhea

• AF, WBC 10.4, Hgb 8.5, BUN 15, SCr 0.61
• Sepsis 2/2 LLL PNA/Staph epidermidis bacteremia/Ulcer wound: Covered below
• VRE + Yeast CAUTI: Linezolid, Fluconazole 200mg Q72H x 3 doses
• C. diff Colitis: Vancomycin PO
• Chronic Osteomyelitis of the sacrum with stage 4 decubitus sacral ulcer: Debridement D2
• Atypical Chest Pains: Cardiology consulted, TTE ordered
• Iron deficiency anemia: Iron sucrose 200mg daily x4 doses
• Hypotension: Midodrine and IVF
• Recurring Admissions: Not interested in hospice
 DAY 7

• No complaints, midline placement ordered for outpt antibiotics

• AF, WBC 9.1, Hgb 8.1, BUN 13, SCr 0.56
• Sepsis 2/2 LLL PNA/Staph epidermidis bacteremia/Ulcer wound: Covered below
• VRE + Yeast CAUTI: Linezolid, Fluconazole 200mg Q72H x 3 doses
• C. diff Colitis: Vancomycin PO
• Chronic Osteomyelitis of the sacrum with stage 4 decubitus sacral ulcer: Debridement D2
• Atypical Chest Pains: TEE negative for vegetations
• Hypotension: Midodrine and IVF
 DAY 8

• No complaints, midline placement ordered for outpt antibiotics

• AF, WBC 10.3, Hgb 7.8, BUN 12, SCr 0.57
• Sepsis 2/2 LLL PNA/Staph epidermidis bacteremia/Ulcer wound: Covered below
• VRE + Yeast CAUTI: Linezolid, Fluconazole 200mg Q72H x 3 doses
• C. diff Colitis: Vancomycin PO
• Chronic Osteomyelitis of the sacrum with stage 4 decubitus sacral ulcer: Debridement D2
• Hypotension: Midodrine and IVF
 DISCHARGE PLANS

• IV antibiotics x 4 weeks
• Linezolid 600mg IV BID
• PO vancomycin x 14 days – needed prior authorization, which was not done until a week later after pt
presented to ED
OVERALL TIMELINES
 CULTURE TIMELINE

• 2 PTA Bone Cultures: Morganella morganii

• 1st: Susceptible to Cefepime, Meropenem
• 2nd: Susceptible to Cefazolin, Cefepime, Ceftazidime, Meropenem, Zosyn, Tobramycin
• Day 0: Blood Cultures 2/4 bottles positive for Staph epidermidis
• Susceptible to Cefazolin, Daptomycin, Erythomycin, Gentamicin, Linezolid, Tetracycline, Vancomycin
• Day 1 Urine Culture: Positive Yeast (50-60k CFU/mL), Positive Vancomycin Resistant Enterococcus faecium (50-
60k CFU/mL)
• Susceptible to Nitrofurantoin, Tetracycline, Daptomycin, Linezolid
• Day 2 Repeat Blood Cultures: No Growth
• Day 4 C diff: GDH Positive, PCR Positive, A/B Toxin Negative
 ANTIBIOTIC TIMELINE

Admission Day 0: Zosyn

Day 1: Zosyn + Vancomycin  Ertapenem + Vancomycin
Day 2: Ertapenem + Vancomycin
Day 3: Ertapenem + Vancomycin + Fluconazole
Day 4: Ertapenem + Linezolid + PO Vancomycin
Day 5: Ertapenem + Linezolid + PO Vancomycin
Day 6: Ertapenem + Linezolid + PO Vancomycin
Day 7: Ertapenem + Linezolid + PO Vancomycin + Fluconazole
Day 8: Ertapenem + Linezolid + PO Vancomycin
 ULCER
CLASSIFICATION/MANAGEMENT
 ULCER RISK FACTORS

Intrinsic: Diabetes, Smoking, Malnutrition, Immunosuppression,

Vascular Disease, Spinal Cord Injury, Contractures, Prolonged
Immobility

Extrinsic: Lying on Hard Surfaces, Nursing Home, Poor Skin

Hygiene, Patient Restraints
 ULCER
STAGING

• Stage I: Skin intact

• Stage II: Partial skin loss
• Stage III: Full-thickness skin loss
with subcutaneous tissue exposed
• Stage IV: Muscle, tendon, bone or
organs exposed
• Unstageable: Damage hidden
• Deep tissue injury: Hidden by intact
skin appearing as a bruise
 ULCER MANAGEMENT

• Pressure Relief: Repositioning regularly, Padding area

• Infection Control:
• Examined for redness or signs of pus beneath the skin
• Inadequate source control requires then appropriate drainage or debridement
• Topical Antiseptics: Povidone iodine, Silver sulfadiazine, Hydrogen peroxide, Dakin’s solution (sodium
hypochlorite)
• Thought to kill bacteria in the ulcer for better healing
• IV Antibiotics: Significant cellulitis, systemic signs and symptoms of infection
• Regular Wound Care: Dressings and topical agents
 CLOSTRIDIOIDES DIFFICILE
DIAGNOSIS AND TREATMENT
 Age >65 years old

Antibiotic Use

Long-term care facilities

CDI RISK
FACTORS Cardiac disease

Chronic kidney disease

Irritable bowel disease

 • “Only individuals with symptoms suggestive of active CDI should be
tested (3 or more unformed stools in 24 hours).”
• Testing should include a highly sensitive and a highly specific test
• To distinguish colonization vs active infection

CDI DIAGNOSIS
 CDI PROPHYLAXIS

• “Oral vancomycin prophylaxis may be considered during subsequent systemic antibiotic use in patients with a
history of CDI who are at risk of recurrence to prevent further recurrence.”
• Conditional recommendation, low quality of evidence
• Limited data, most studies involved pts with history of CDI
• Johnson et al: open-label RCT of low-dose vancomycin 125mg PO daily vs placebo
• 100 patients
• Eligible pts: >60 years old, hospitalization in the past 30 days, were hospitalized and getting high-risk
systemic antibiotics
• No patient in OVP developed CDI, 6 in placebo developed CDI (p=0.03)
APPLICATION TO OUR PATIENT
 THINGS TO THINK ABOUT

• Was it necessary to treat everything that we did?

• Urine culture only grew 50-60k
• Bone culture was from previous month, and completed IV antibiotic outpatient therapy
• Did this patient truly have a CDI?
• No documented fevers while inpatient
• WBC count pretty much trending down during hospital course
• Toxin test was negative
 REFERENCES

Boyko TV, Longaker MT,Yang GP. Review of the current management of pressure ulcers. Adv Wound Care. 2018;
7(2): 57-67. doi: 10.1089/wound.2016.0697
Kelly CR, Fischer M, Allegretti JR, et al. ACG clinical guidelines: prevention, diagnosis and treatment of
Clostridioides difficle infections. Am J Gastroenterol. 2021; 116: 1124-1147. doi: 10.14309/ajg.0000000000001278
PATIENT CASE

Madison Heath, PharmD

September 12, 2022