A 40-Year-Old Man Is Brought to the Emergency Department by His

question 50

Multiple Choice

A 40-year-old man is brought to the emergency department by his wife for progressive lethargy, fever, and headache over the last 24-hours.  He underwent craniotomy for meningioma resection 1 week ago.  Since yesterday evening, the patient has had confusion, headaches, and a few episodes of vomiting.  His wife denies any sick contacts, recent travel, flu-like symptoms, or skin rashes.
His temperature is 39.6 C (103.3 F) , blood pressure is 140/90 mm Hg, pulse is 110/min and regular, and respirations are 16/min.  There is no skin rash.  The craniotomy incision is healing normally.  On neurological examination, he is obtunded and does not follow commands.  There is prominent neck stiffness.  He is able to localize to noxious stimuli in the upper extremities and withdraw in the lower extremities.
Stat CT scan of the head shows no bleeding or masses.  Lumbar puncture (LP) shows elevated opening pressure, white blood cell count of 1,200 cells/µL with 90% neutrophils, protein of 200 mg/dL, and glucose of 20 mg/dL.
Which of the following is the best next step in this patient's management?

• A)Cefepime and vancomycin
• B)Ceftriaxone and vancomycin
• C)Ceftriaxone, vancomycin, and acyclovir
• D)Ceftriaxone, vancomycin, and ampicillin
• E)Piperacillin/tazobactam and vancomycin

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