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CC: “My chest hurts, I can’t catch my breath, and this cough is getting worse.”

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Recommendation for Directed/targeted Therapy for DB.
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DB, a 60 Yom, was admitted to the hospital 5 days ago to undergo a scheduled surgical procedure following a recent diagnosis of colorectal adenocarcinoma with metastatic lesions to the liver. DB was taken to the OR on day 2 and underwent a surgery. DB received one dose of preoperative IV antibiotic therapy to prevent surgical site infection. Postoperatively, DB was transferred to the progressive ICU for his recovery without complication. On day 5, DB complained of retrosternal crushing chest pain radiating to the left shoulder and left jaw, shortness of breath, and a worsening cough with sputum production. DB was noted to have respiratory distress with O2Sat 87%. He was then transferred to the medical ICU and underwent endotracheal incubation due to worsening respiratory status. Imaging and blood & sputum cultures were obtained after patient transfer.

PMH: CAD, S/P MI 3 years ago without surgical intervention

SH: Lives with his wife, smokes one ppd × 40 years, denies alcohol or illicit drug use

Home meds: none

Hospital medications:

Aspirin 81 mg PO daily

Enoxaparin 70 mg subcutaneously every 12 hours

Pantoprazole 40 mg IV daily

Fentanyl 25 mcg/hour IV continuous infusion

Lorazepam 2 mg/hour IV continuous infusion

Metoprolol 25 mg PO every 12 hours

Nicotine patch 21 mg per day applied daily

Allergies: NKDA

Physical Examination

  • VS: BP 162/103, P 147, RR 42, T 38.5°C; Wt. 70 kg, Ht 5′6″
  • Lungs/Thorax: Scattered bronchi with expiratory wheezing; diffuse bilateral crackles; decreased breath sounds in bilateral bases
Lab Parameter Admission Hospital Day 5
Na (mEq/L) 130 141
K (mEq/L) 4.1 5.1
Cl (mEq/L) 92 110
CO2 (mEq/L) 24 19
BUN (mg/dL) 22 34
SCr (mg/dL) 1 1.1
Glu (mg/dL) 113 148
Ca (mg/dL) 9.4 9.2
WBC (mm–3) 9.5 × 103 17 × 103
Neutros (%) 89 88
Bands (%) 0 5
Lymph’s (%) 5 4
Monos (%) 6 3
Eos (%) 0 0
Hgb (g/dL) 11.9 12.4
Hct (%) 35 37
Plts (mm–3) 448 × 103 584 × 103

Chest X-Ray: New bilateral opacities are noted in the left upper lobe and right middle lobe; likely infectious process. Some increased alveolar infiltrates in the perihilar location and involving the lower lobes.

Chest CT Scan with IV Contrast: There are pleural-based airspace opacities within the left upper lobe and right middle lobe; this is most consistent with an acute infectious process.


  • Sputum Gram Stain: >25 WBC/hpf, <10 epithelial cells/hpf, 1+ (few) Gram-positive cocci, 3+ (many) Gram-negative rods
  • Sputum Culture: Pending
  • Blood Cultures × Two Sets: Pending


DB was initiated on appropriate empiric antimicrobial therapy while awaiting the results of sputum and blood cultures. The blood and sputum cultures revealed Klebsiella pneumoniae. The organism’s susceptibility profile is provided below. Over the next 72 hours, clinical status improved with decreased sputum production, oxygen requirement, temperature, and WBC count, and improvement in chest x-ray findings was also noted, resulting in extubation on hospital day 8. DB was transferred to the regular floor for his continued recovery. DB also started on regular diet and is able to take oral medication.

Antimicrobial Agent MIC (mg/L) Interpretation
Ampicillin ≥32 Resistant
Ampicillin/sulbactam ≥32 Resistant
Piperacillin/tazobactam ≤4 Susceptible
Cefazolin 32 Resistant
Ceftriaxone ≤1 Susceptible
Cefepime ≤1 Susceptible
Meropenem ≤0.25 Susceptible
Gentamicin ≤1 Susceptible
Tobramycin ≤1 Susceptible
Ciprofloxacin ≤0.25 Susceptible
Levofloxacin ≤0.12 Susceptible
Trimethoprim/sulfamethoxazole ≥320 Resistant
  1. Based on the culture and susceptibility results above, provide a recommendation for directed/targeted therapy for DB.
  1. Continue the current regimen.
  2. De-escalate to piperacillin/tazobactam
  3. De-escalate to cefepime
  4. De-escalate to ceftriaxone
  5. De-escalate to levofloxacin and vancomycin.

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