The most effective postexposure prophylaxis for a surgeon stuck with a needle while operating on an HIV-positive patient is:
Postexposure prophylaxis for HIV has significantly decreased the risk of seroconversion for health care workers with occupational exposure to HIV. Steps to initiate postexposure prophylaxis should be initiated within hours rather than days for the most effective preventive therapy. Postexposure prophylaxis with a two- or three-drug regimen should be initiated for health care workers with significant exposure to patients with an HIV-positive status. If a patient's HIV status is unknown, it may be advisable to begin postexposure prophylaxis while testing is carried out, particularly if the patient is at high risk for infection due to HIV (eg, intravenous narcotic use). Generally, postexposure prophylaxis is not warranted for exposure to sources with unknown status, such as deceased persons or needles from a sharps container.
What is NOT an early goal in treatment of severe sepsis?
Patients presenting with severe sepsis should receive resuscitation fluids to achieve a central venous pressure target of 8 to 12 mm Hg, with a goal of mean arterial pressure of >65 mm Hg and urine output of >0.5 cc/kg/h. Delaying this resuscitative step for as little as 3 hours until arrival in the ICU has been shown to result in poor outcome. Typically this goal necessitates early placement of central venous catheter.
A patient in the ICU has been on ventilator support for 3 weeks. He has new onset elevated WBC count, fever, and consolidation seen on chest X-ray.
What is an appropriate next step?
Prolonged mechanical ventilation is associated with nosocomial pneumonia. These patients present with more severe disease, are more likely to be infected with drug-resistant pathogens, and suffer increased mortality compared with patients who develop community-acquired pneumonia. The diagnosis of pneumonia is established by presence of a purulent sputum, elevated leukocyte count, fever, and new chest X-ray abnormalities such as consolidation. The presence of two of the clinical findings, plus chest X-ray findings, significantly increases the likelihood of pneumonia. Consideration should be given to performing bronchoalveolar lavage to obtain samples for Gram stain and culture. Some authors advocate quantitative cultures as a means to identify a threshold for diagnosis. Surgical patients should be weaned from mechanical ventilation as soon as feasible, based on oxygenation and inspiratory effort, as prolonged mechanical ventilation increases the risk of nosocomial pneumonia.
Patients with severe, necrotizing pancreatitis should be treated with:
Current care of patients with severe acute pancreatitis includes staging with dynamic, contrast -enhanced helical CT scan with 3-mm tomographs to determine the extent of pancreatic necrosis, coupled with the use of one of several prognostic scoring systems. Patients who exhibit significant pancreatic necrosis should be carefully monitored in the ICU and undergo follow-up CT examination. The weight of current evidence also favors administration of empiric antibiotic therapy to reduce the incidence and severity of secondary pancreatic infection, which typically occurs several weeks after the initial episode of pancreatitis. Several randomized, prospective trials have demonstrated a decrease in the rate of infection and mortality using agents such as carbapenems or fluoroquinolones that achieve high pancreatic tissue levels.
A patient with a localized wound infection after surgery should be treated with:
Effective therapy for incisional SSIs consists solely of incision and drainage without the addition of antibiotics. Antibiotic therapy is reserved for patients in whom evidence of severe cellulitis is present, or who manifest concurrent sepsis syndrome. The open wound often is allowed to heal by secondary intention, with dressings being changed twice a day. The use of topical antibiotics and antiseptics, to further wound healing, remains unproven, although anecdotal studies indicate their potential utility in complex wounds that do not heal with routine measures.
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