A 67-year-old man has been intubated and sedated in the intensive care unit (ICU) for 6 days. He has a central venous catheter and an indwelling urinary catheter in place. He develops a fever to 38.4°C, and blood, urine, and sputum samples are sent for analysis. His urinalysis is notable for <10 white blood cells, negative for leukocyte esterase and nitrites. Urine culture grows >100,000 Candida glabrata after 2 days, susceptible to micafungin, caspofungin, and fluconazole.
What is the MOST appropriate way to manage the yeast growing in urine culture?
Correct Answer: D
Asymptomatic candiduria rarely requires treatment. Patients who should be treated for asymptomatic candiduria include neutropenic patients, very low birthweight infants, and patients with urinary tract (urologic) manipulation. Where possible, when candiduria is detected, it is strongly recommended that indwelling catheters be removed. If catheter removal is not possible, catheter exchange is recommended. Catheter exchange alone can lead to elimination of candiduria in 20% or more of patients with asymptomatic candiduria with no additional therapy.
A 28-year-old pregnant woman is admitted to the ICU, requiring norepinephrine to treat hypotension due to pyelonephritis from highly susceptible, pan sensitive Escherichia coli. Ultrasound imaging of the kidneys and bladder on admission was normal. She is treated with ceftriaxone for 2 days, with improvement in her pain, fever, and hypotension. However, on day 3 she develops a fever to 38.4 while still receiving intravenous antibiotic therapy. She has no new symptoms, and no costovertebral angle tenderness to palpation.
What is the MOST likely cause of her recrudescent fever?
Correct Answer: B
Perinephric and renal abscesses are uncommon conditions. Both tend to be insidious in nature with a subacute onset of vague or nonspecific symptoms. Most patients do not report symptoms typical of a urinary tract infection. The majority of patients with renal (Answer D) or perinephric (Answer C) abscesses have fever, chills, flank pain, and costovertebral angle tenderness. Abscesses generally develop over many days to weeks, and it is unlikely that this patient admitted with a normal renal ultrasound (which is common even in pyelonephritis) would develop an abscess within 48 hours, especially while clinically improving. Similarly, antibiotic resistance to ceftriaxone (Answer A) would require time to emerge and is unlikely to occur while on appropriate antibiotics for a short time period with improving clinical parameters. Thus, among the answers given, drug fever to ceftriaxone (Answer B) or another medication is the most likely cause of her fever.
A 78-year-old woman with diabetes and hypertension presents to the emergency department with confusion and hypotension. A urinalysis is notable for a white blood cell count of >100,000 and is positive for leukocyte esterase. Urine culture subsequently grows >100,000 Pseudomonas aeruginosa, resistant to ciprofloxacin. You begin appropriate antibiotic therapy with a beta-lactam antibiotic.
For how long should she be treated?
Correct Answer: C
This patient has an acute complicated urinary tract infection. Patients presenting with complicated urinary tract infections should have urine culture performed to confirm the microbiologic cause of the infection and antimicrobial susceptibility of the pathogen(s) causing the infection. Total antibiotic duration depends on the antibiotic class used to treat the infection. Fluoroquinolones are given for 5 to 7 days, trimethoprim/sulfamethoxazole for 7 to 10 days, and beta lactams for 10 to 14 days. Longer durations may be appropriate for patients with an ongoing nidus of infection (eg nonobstructing stone).
What diagnostic test is MOST appropriate to evaluate for perinephric abscess?
The diagnosis of perinephric or renal abscess should be confirmed by imaging. The most commonly used imaging modality is CT scan (Answer B), which has the added advantage of diagnosing extension of infection to adjacent structures, which is more difficult to see on ultrasound imaging (Answer A). MRI (Answer C) is highly sensitive for detecting changes in the urinary tract, but is generally less accessible than CT or ultrasound imaging, and is the least often used. Choice of imaging modality to confirm the diagnosis of renal or perinephric abscess should be tailored to the individual patient and their clinical situation.
Which indication below is NOT an appropriate indication for indwelling bladder catheterization in the ICU?
Correct Answer: A
Unwarranted urinary catheter placement is very common, occurring in approximately 20% to 50% of hospitalized patients. Urinary catheters should not be placed for the management of urinary incontinence alone (Answer A). Answers B, C, and D represent appropriate indications for catheter placement. Other appropriate indications include management of urinary retention, hematuria associated with clots, open wounds of the sacrum or perineum with associated urinary incontinence, surgery of the genitourinary tract and associated structures, end-of-life care, and occasionally for management of patients with persistent urinary incontinence after conservative, behavioral, pharmacologic, and surgical measures have failed. Regardless of the indication for catheter placement, catheters should be removed as soon as the condition leading to the indication for catheterization has resolved.
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