A 62-year-old man presents to his new primary care physician for a first visit. The patient has not seen a doctor for more than 10 years. He has mild intermittent bronchial asthma. The patient is sexually active with a single long-term partner. He does not recall receiving any vaccines since childhood. Which of the following vaccines should be offered?
Assessment for adult vaccination should be based on age, comorbidities, immunization history, and other risk factors like travel plans and sexual behaviors. Adults should get tetanus and diphtheria vaccine (Td) every 10 years. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine should replace one of the Td vaccines if not given before or during adult life. Zoster vaccine is indicated for individuals over 60 years of age. The influenza vaccine is recommended for all persons aged 6 months and older, including all adults. Pneumococcal vaccine is indicated in patients with chronic illnesses such as heart failure, bronchial asthma, chronic obstructive pulmonary disease, chronic kidney disease, and diabetes mellitus. Otherwise, the pneumococcal vaccine is administered once at the age of 65. Human papillomavirus (HPV) vaccine is indicated in females who are 11 to 28 years of age. The meningococcal vaccination is recommended for adults with anatomic or functional asplenia or persistent complement component deficiencies, as well adults with human immunodeficiency (HIV) virus infection. Meningococcal vaccine is also indicated for patients traveling to meningitis endemic areas.
A 60-year-old female patient is admitted to the hospital in septic shock secondary to a urinary tract infection. The patient is started on antibiotics awaiting culture results. She improves with complete resolution of her symptoms. The patient continues to have a urinary catheter in place. On the 10th hospital day, the patient is discharged to a rehabilitation facility. As a part of the routine admission orders, urinalysis and culture are ordered. The patient denies fever, abdominal pain, nausea, or vomiting. The urinalysis shows 5 to 10 white blood cells and a negative dipstick for nitrite and leukocyte esterase, but the culture grows more than 10 5 colonies of Candida albicans. Which of the following is the best course of action?
Every positive culture requires interpretation. A positive culture could represent a pathogen, a colonizer, or a contaminant. The presence of symptoms and signs of infection in addition to supportive laboratory and radiologic data makes a cultivated microbe a pathogen. The patient has no symptoms or signs of infection and her urinalysis shows no pyuria. In this case, C albicans is a colonizer, and no antifungal therapy is indicated. Predisposing risk factors need to be eliminated to reduce the chances of colonization and to prevent a colonizer from becoming a pathogen. Removing a Foley catheter, controlling hyperglycemia and stopping broad-spectrum antibiotics, when feasible, represent some examples of risk factor elimination. Antifungal therapy (such as with fluconazole or amphotericin B) is inappropriate for fungal colonization alone.
An 18-year-old high school student presents to the emergency room with 1-day history of right knee pain, swelling, and redness. He is a quarterback in the school’s football team. He remembers falling on the knee while practicing 2 days ago. The knee is tapped and 15 mL of cloudy fluid is sent for cell count, Gram stain, and culture. The Gram stain shows gram-positive cocci in clusters. Which of the following is the best course of action?
The patient has right knee septic arthritis caused by bacteria that form gram-positive cocci in clusters. This is an orthopedic emergency requiring prompt management. Staphylococcus aureus is the most likely agent. Involvement in a contact sport puts the patient at risk for infections caused by community acquired methicillin-resistant S aureus (CA-MRSA). Consulting orthopedic surgery and starting an antibiotic with activity against MRSA while awaiting culture results is the most appropriate course of action. Antibiotics with activity against MRSA include vancomycin, linezolid, daptomycin, and telavancin. Appropriate antibiotics alone without getting orthopedic surgery involved is not enough. Antibiotics are much less effective in purulent secretions and pus. Joint drainage through daily closed-needle aspiration, arthroscopy, or arthrotomy helps in removing thick purulent material and lysis of adhesions. Ceftriaxone is not active against MRSA. Further testing, such as magnetic resonant imaging, will not add useful information at this point.
A 40-year-old male patient presents to the emergency room with a 1-week history of fever, rigors, and generalized weakness. The patient denies recent travel or sick contacts but admits to intravenous drug use. On examination, he has splinter and subconjunctival hemorrhages. Cardiac examination shows a holosystolic murmur over the left lower sternal boarder. There are no other localizing signs. Chest x-ray and urinalysis are negative. After obtaining blood cultures, the patient is started on intravenous antibiotics and admitted to the medical floor. Twenty-four hours later, all sets of blood culture grow gram-positive cocci in clusters. A transthoracic echocardiogram is negative for vegetations. Which of the following is the best course of action?
The patient is an intravenous drug user who presents with fever, gram-positive bacteremia, a murmur, and evidence of systemic embolization—a picture consistent with infective endocarditis (IE). The positive blood cultures in this case are highly unlikely to represent contaminants. Ordering transesophageal echocardiogram (TEE) despite the negative transthoracic echocardiogram (TTE) is appropriate, given the former test’s higher sensitivity. Repeating blood cultures 3 to 4 days after initial positive cultures and as needed thereafter is recommended to document clearance of bacteremia. In the case of gram-positive bacteremia, the duration of treatment is counted from the first negative blood culture. Placing long-term intravenous catheters like peripherally inserted central catheter (PICC) should be delayed, if possible, until the gram-positive bacteremia clears. It is not appropriate to treat IE with oral or bacteriostatic antibiotics. Once IE is confirmed, the patient at hand will require 6 weeks of IV antibiotics. There is nothing in the patient’s presentation that is suggestive of osteomyelitis to require a bone scan.
A 20-year-old female patient presents with a 2-day history of dysuria, lower abdominal pain and low-grade fever. Her urine is cloudy with pyuria and abundant gram-positive bacteria. She is a college student who is sexually active with no previous history of sexually transmitted diseases. Which organism is most likely responsible for this woman’s symptoms?
The patient’s urinary tract infection (UTI) is caused by gram-positive bacteria. This excludes E coli and N gonorrhoeae, both of which are gram-negative, and C albicans, which is a yeast. Enterococcus faecalis and S saprophyticus are gram-positive bacteria that can cause UTI, but the second agent is a more likely cause of UTI in young women. Staphylococcus saprophyticus colonizes the rectum or the urogenital tract of approximately 5% to 10% of women and is second only to E coli as the causative agent of uncomplicated urinary tract infections in young sexually active women. Such infections are successfully treated with fluoroquinolones or trimethoprim-sulfamethoxazole.
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