Question 13

A 50 year old man presents to hospital with fever and an acute abdomen. He undergoes an emergency laparotomy. The findings at laparotomy include :
-     a perforated carcinoma in the splenic flexure
-     generalised faecal soiling of the peritoneum.
He undergoes a left hemicolectomy with a defunctioinng  colostomy.  Postoperatively he is transferred to intensive care because of septic shock.

a)  What antibiotic regime  will you consider and why?

b) Despite a 5 day course of antibiotics, he remains unwell with fever upto 38.50C, WCC 16.7 X 109/L. He is unable to tolerate oral feeds and is on TPN. List the likely intra-abdominal causes of persistent fever and leukocytosis?

c)  What investigations will you perform?

d) Blood cultures grow candida glabrata in one of the 3 bottles. List 4 factors which may have predisposed this patient  to develop this infection.

e) What antimicrobial therapy will you commence whilst waiting for sensitivities and why

f) Based on the culture report, list 1 other investigation you will perform the results of which might influence the prognosis and duration of antifungal treatment.

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College Answer

a)  What antibiotic regime  will you consider and why?

Triple therapy or Timentin or Tazocin – to cover enterococcus, gram negatives and anaerobes. Some may consider adding fluconazole empirically, although this is not common. Vancomycin/gent flagyl if pen allergy

b) Despite a 5 day course of antibiotics, he remains unwell with fever upto 38.50C, WCC 16.7 X 109/L. He is unable to tolerate oral feeds and is on TPN. List the likely intra-abdominal causes of persistent fever and leukocytosis?

-     intra-abd collection / wound infection / abd wall cellulitis/acalculous cholecystitis, pancreatitis, stomal necrosis

c)  What investigations will you perform?

- Blood/urine/sputum/wound swab cultures
- CT abdomen
- Consider line change and line tips for c/s
Consider screening for a DVT
-consider a diagnostic relook laparotomy (this will carry a higher mark)

d) Blood cultures grow candida glabrata in one of the 3 bottles. List 4 factors which may have predisposed this patient  to develop this infection.

- Malignancy, abdominal soiling, TPN, recent broad spectrum therapy, presence of foreign body -CVL
-

e) What antimicrobial therapy will you commence whilst waiting for sensitivities and why

Voriconazole or amphotericin B, caspofungin. Fluconazole may not cover glabrata.

f) Based on the culture report, list 1 other investigation you will perform the results of which might influence the prognosis and duration of antifungal treatment.

Echocardiography – for vegetation. ophthalmic examination for retinal absecesses CT abdominal scan - liver abscess

Discussion

This question very closely resembles Question 18 from the second paper of 2011.