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A 61-Year-Old Woman Comes to the Emergency Department Due to Fever

question 120

Multiple Choice

A 61-year-old woman comes to the emergency department due to fever, chills, and left flank pain that began abruptly last evening. A month ago, the patient was treated for a urinary tract infection with a short course of ciprofloxacin. She otherwise has no medical problems and currently takes no medications. She has no history of hospitalizations or surgeries.
Temperature is 39.4 C (103 F) , blood pressure is 80/40 mm Hg, pulse is 120/min, and respirations are 24/min. Pulse oximetry shows 94% on room air. Mucous membranes are dry and jugular veins are flat. Cardiopulmonary auscultation reveals clear lung fields and normal heart sounds without murmurs. The abdomen is soft and nontender. Left costovertebral angle tenderness is present. Skin examination is normal. The extremities are warm with no edema. Neurologic examination is within normal limits.
Laboratory results are as follows:
Broad-spectrum antibiotics and intravenous fluids are initiated, and the patient is admitted to the intensive care unit. Enoxaparin is given for prophylaxis against deep vein thrombosis. On hospital day 2, urine and blood cultures are positive for Escherichia coli and antibiotics are narrowed based on culture sensitivities. Repeat laboratory testing is similar to admission, except platelet count has dropped to 105,000/mm³.
Which of the following is the most appropriate next step in management of this patient?

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