A 67-Year-Old Woman Is Hospitalized for Sepsis Secondary to a Urinary

question 1364

Multiple Choice

A 67-year-old woman is hospitalized for sepsis secondary to a urinary tract infection.  Medical history is significant for hypertension, type 2 diabetes mellitus, ischemic stroke, and neurogenic bladder with chronic indwelling Foley catheter.  The patient is admitted to the intensive care unit and treated with intravenous fluids and broad-spectrum antibiotics.  Blood and urine cultures grow Escherichia coli that are sensitive to all tested antibiotics.  The patient's condition gradually improves with the treatment, and antibiotics are changed to oral ciprofloxacin on the 3rd day of hospitalization.  On the 7th day of hospitalization, the patient progressively becomes confused, and she also has 6 watery bowel movements with lower abdominal pain.  Temperature is 38 C (100.4 F) , blood pressure is 111/89 mm Hg, and pulse is 108/min.  The abdomen is soft and mildly tender in the left lower quadrant with normoactive bowel sounds.  There is no guarding or rebound tenderness.  Chest x-ray reveals no new infiltrates.  Laboratory evaluation shows a white blood cell count of 14,200/mm³ compared to 8,700/mm³ 2 days earlier.  A repeat urinalysis shows occasional yeasts.  Which of the following is the best next step in management of this patient?

• A)Change Foley catheter and start fluconazole
• B)Send repeat blood cultures and start intravenous gentamicin
• C)Send stool studies and start oral vancomycin
• D)Stop ciprofloxacin and start intravenous vancomycin
• E)Obtain urgent surgical consultation

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