Avoiding Unnecessary Administration
of Antibiotics

Patient arrives at ED

A 63-year-old male with a history of prostate cancer and use of a suprapubic catheter presents to the emergency department (ED).

Over the past 24 hr, the patient has experienced two episodes of vomiting along with mild periumbilical pain, generalized weakness, nausea and decreased appetite. He denies fever or chills, shortness of breath, or chest pain.

7:08 a.m.

Initial assessment

Mildly dry mucous membranes, mild TTP of the periumbilical region, tachycardic and irregular rhythm.

T: 37.4 (99.3 F) | BP: 122/91 | P: 127 | RR: 21 | SpO2: 97% (RA)

The vitals assessed were normal except for an elevated pulse rate of 127 BPM.

7:35 a.m.

EKG is performed

Patient’s EKG showed atrial fibrillation with a rapid ventricular rate (RVR) at 130.

8:10 a.m.

CBC with Differential and MDW results returned

The white blood cell (WBC) results come back elevated at 13.1, but the MDW is normal at 16.7 normal (less than 20 cut off).

8:35 a.m.

Basal Metabolic Panel (BMP) results obtained

Creatinine level of 2.67, increased from creatinine level of 1.03 last month.

Lactate elevated at 2.8.

8:38 a.m.

Cardiac markers returned

Both Troponin and BNP were normal.

8:55 AM

Chest X-ray resulted

Chest X-ray showed no acute findings.

9:35 a.m.

Urinalysis (UA) results returned

WBC 5-10 | RBC 10-20 | Epithelial Cells = Moderate | Leukocyte esterase = 2+ | Few bacteria

Results suggested a possible urinary tract infection (UTI).

10:43 a.m.

CT abdomen/pelvis results come in

CT results showed no acute findings.

A decision was made to admit the patient and await urine culture results. After 5 days, urine culture did not return any growth. But by the time this is recognized, the patient could have received at least five days of broad-spectrum antibiotics.

Recap:

Prompt initiation of antibiotics to treat sepsis reduces morbidity and saves lives. However, the unnecessary use of antibiotics can cause harm to the patient and eventually lead to increased antibiotic resistance.

In this case, CBC demonstrated an elevated WBC count, which combined with the patient's tachycardia meant SIRS criteria were met. Further, SIRS + elevated lactate + creatinine = Signs of organ injury. And UA showed some WBC, some RBC, epithelial cells, 2+ leukocyte esterase and a few bacteria, suggestive of UTI.

This combination could mean the patient has urosepsis. However, the MDW was normal, suggesting a low risk of severe infection.

Ultimately, the patient's tachycardia was attributed to dehydration and Afib with RVR, and he was given IV fluids and rate control medication. His repeat lactate improved, and his creatine eventually went back to his baseline. The patient improved and was eventually discharged without the unnecessary administration of broad-spectrum antibiotics.

Watch Dr. Sarani present this specific emergency department case study.

 

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