A 60-year-old woman has a right hemi-hepatectomy for invasive cholangio-carcinoma. She has been admitted to your unit for postoperative care.

b) On day 3, she has a rigor and blood cultures grow enterococcus faecalis.

How will you manage this?

[Click here to toggle visibility of the answers]

College Answer

The rigor should demand culture of all possible sources: sputum, blood, urine, T Tube and other drains. Consideration of broad spectrum antibiotic cover should occur at that time. Once the definitive culture is known, specific therapy (ie amoxicillin or vancomycin) should be given and also, a reason why this gut organism has been grown should be elicited.

Discussion

This was the second part of one of those old "long answer questions".

Thus, one falls back on the old "approach to an unexplained fever in ICU". In short, you culture everything, and briefly think about non-infectious causes of fever, such as...

  • vasculitis
  • myocardial infarction
  • DVT/PE
  • SAH
  • malignancy, particularly haematological
  • etc, etc...

While looking for the source of infection, one may wish to use broad-spectrum antibiotics. Given the recent history of abdominal surgery, all eyes would be on the abdomen as a potential source, and Tazocin would probably be viewed as a reasonable choice of broad-spectrum antibiotic.

As soon as one has convinced themselves and others that E.faecalis is to blame, one should start specific therapy. For E.faecalis, ampicillin is usually enough according to antimicrobe.org.

Vancomycin is an odd choice. Its penetration into inflamed tissues is notoriously poor. And on top of that, it covers only Gram-positive organisms. Some of which will also be susceptible to ampicillin, so... why not use ampicillin? And some of the organisms - which are resistant to ampicillin - may also be resistant to vancomycin.

Enterococcal bacteraemia should be treated for a minimum of 2 weeks, even if there are no mechanical devices suspended in the bloodstream.

References

References

Poh, C. H., H. M. L. Oh, and A. L. Tan. "Epidemiology and clinical outcome of enterococcal bacteraemia in an acute care hospital." Journal of Infection 52.5 (2006): 383-386.

 

Bota, Daliana Peres, et al. "Body temperature alterations in the critically ill."Intensive care medicine 30.5 (2004): 811-816.

 

MAKI, DENNIS G., and WILLIAM A. AGGER. "Enterococcal bacteremia: clinical features, the risk of endocarditis, and management." Medicine 67.4 (1988): 248.