T-47 Minutes to Antibiotics Administration

Patient Case Study

MDW biomarker identified a risk of severe infection and reclassified the patient into higher acuity category, in conjunction with current standard of care.

8:24 a.m.

Patient arrived in ED

A 67-year-old male with a history of arthritis presents with a chief complaint: severe pain that radiates from his left hip down to his knee—worse than his chronic arthritic pain.

The night prior, the patient had an acute onset of his pain when he tried to get up from his recliner. The pain worsened and the patient was taken to the ED the following morning.

8:29 a.m.

Initial Assessment: Tachycardia and limited range of motion of left hip due to pain.

The vitals assessed were normal except for an elevated pulse rate of 122 BPM, which was potentially attributed to the patient's pain.

T: 37.8 | BP: 114/59 | P: 122 | RR: 18 | SpO2: 98% (RA)

Considering the patient's age and exhibited tachycardia, complete blood count (CBC) differential and basic metabolic panel (BMP) labs were ordered.

9:13 a.m.

CBC with Differential is Returned from the Lab: severe infection and risk of sepsis added to differential diagnosis.

The white blood cell (WBC) results came back elevated at 22.6, which could be attributed to the vomiting and stress due to significant pain. The monocyte distribution width (MDW) results came back at 30.1.

Due to the abnormal WBC and MDW results, the physicians deduced there might be an underlying infectious etiology. Reconsidering the vital signs abnormality, temperature of 37.8°C and elevated pulse rate of 122 BPM, lactate and blood cultures were ordered. 

9:18 a.m.

Head to Toe Exam Reveals Erythema

With no skin changes, ecchymosis or swelling to the left extremities where the patient felt pain, the doctors were left pondering what they may be missing.

After a comprehensive exam, it was revealed that there was significant erythema of the right lower extremity that was tender and warm to palpation—this was suggestive of cellulitis.

"We've been focused on his left hip, and did not do a head to toe exam, but the exam revealed large infected area of the right lower extremity. Now we have cellulitis. We have abnormal MDW and elevated white count. There's severe infection going on."
Dr. Nima Sarani, M.D.
University of Kansas Medical Center

9:25 a.m.

Antibiotics are Ordered

The comprehensive exam results were reported to the doctor. Due to the cellulitis and the elevated WBC and MDW levels, the doctors infer there is an infection.

The care team is mobilized to initiate antibiotics. Lactate results are pending at this time.

9:45 a.m.

Lactate is elevated at 5.7.

10:00 a.m.

Antibiotics are Administered

IV antibiotic administration begins.

It was a matter of 47 minutes from the time the CBC diff was done to the time antibiotics were administered to the patient. The patient not only needed antibiotics, but he needed them as soon as possible.

The key influencing factor to add severe infection and risk of sepsis to the diagnosis was abnormal MDW plus elevated WBC.

Total Time: 47 Minutes from Presentation to ER

The goal of the Surviving Sepsis Campaign is to administer antibiotics from the time of detection of severe sepsis or septic shock. In this case, the goal was met in less than one hour.

The abnormal MDW levels, coupled with the early signs and symptoms raised the doctors’ suspicions, prompted consideration of infection or sepsis. This led to the comprehensive examination of the patient, which wouldn’t otherwise be conducted in a busy ED environment. The assessment led to the discovery of skin cellulitis.

Without this discovery, the patient may have spent up to five hours in the ED or admitted to the hospital. Subsequentially, the patient would likely develop a fever at that time and likely receive the comprehensive assessment, which would reveal skin cellulitis at that time. 

Watch Dr. Sarani present this specific emergency department case study demonstrating the clinical utility of MDW in an acute care setting. Download video transcript here

Disclaimer: This case study is presented for educational purposes only and is not intended to promote any Beckman Coulter product or service.