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Antibiotics and an outcome less expected

Antibiotics and an outcome less expected. Author: Ștefăniu ramona Medic rezident geriatrie gerontologie, spitalul clinic “ c.i. Parhon ” iași. patient p.p., 77 years old, iasi.

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Antibiotics and an outcome less expected

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  1. Antibiotics and an outcome less expected Author: Ștefăniu ramona Medic rezident geriatrie gerontologie, spitalul clinic “c.i. Parhon” iași

  2. patient p.p., 77 years old, iasi • Patient presented with sever shortness of breath, cough with purulent sputum (allegedly) and sharp stabbing chest pain on the right side • She had no significant family history. • Personal history included : • 2000 - 64 years old – High blood pressure grade 3 very high risk • 2005 – 69 years old - Permanent VVI pacemaker (for Sinus Node Disease) • 2011 – 75 years old – Change of pacemaker device (with electrodes left in place) • 2013 - 77 years old - Chronic kidney disease stage III • 2013 – 77 years old – Acute tracheobronchitis

  3. pacientap.p., 77 YEARS OLD, iasi • She never smoked and she denied alcohol consumption. • Medication • BISOPROLOL 5mg /day • INDAPAMIDE 1,5 mg /day • ASPIRIN 75 mg /day • FENSPIRIDE (EURESPAL) 80mg x 2/zi • SALBUTAMOL INHALER (VENTOLIN) 1-2 puffs as neaded

  4. HISTORY • Hypertensive patient with significant cardiovascular history, with electrical pacemaker since 2005 for sick sinus node has been recently discharged from an internal medicine clinic (10 days prior), where she received antibiotic treatment (Amoxicillin and clavulanic acid 1g x2/day ) for an upper respiratory tract infection. Treatment was stopped 4 days prior to this admission. • In our clinic, she presented with purulent sputum, sharp, stabbing chest pain and sever dyspnea, symptoms with sudden onset and progressive worsening over 1 week.

  5. Clinical examination • Fair medical condition, afebrile • Jaundiced sclera and skin • Normal chest, dull area on percussion in the inferior 1/3 of the right side, absence of sound in the inferior 1/3 of the right side, rales/crackels in 1/3 medium of the right side and inferior left side. • Arrhythmic heart sounds, no murmurs, Hartzer (-) • BP – 110/70mmHg HR – 70bpm • Inferior liver edge palpable 1cm under de costal ridge, non-tender

  6. Clinical suspicion • Right pneumonia with right pleural effusion • Recent history of upper respiratory tract infection • Shortness of breath, purulent sputum • Modified breath sounds on auscultation of the right lung • Endocarditis • Recent history of infection • 2 electrodes present in the heart • Pulmonary thromboembolism • 2 electrodes present in the heart, no anticoagulant therapy • Atrial fibrillation

  7. Paraclinical testsBlood tests • Inflammatory syndrome • Chronic kidney disease • Hepatic cytolysis • Hyperbilirubinemia • Asymptomatic hyperuricemia

  8. Para-clinical testsimagistic exploration • Chest X-ray • Pleural ultrasound: pleural adhesions and pleural encystation at the base bilateral

  9. Para-clinical testsimagistic exploration • Cardiac ultrasound: 2 electrodes visible in the right atrium and in the left ventricle, no vegetation, medium pulmonary hypertension, Tricuspid insufficiency grade II-III. Espanded right cavities. • Abdominal ultrasound: right supra-diaphragmatic fluid collection, liver size slightly increased with no lesions.

  10. Para-clinical tests • EKG : Atrial fibrilation, HR=80/min, left axis, left anterior hemiblock

  11. Para-clinical tests • During hospitalization the patient became febrile, blood cultures ware taken (negative) and added to the initial treatment plan an antibiotic : second generation floroquinolone (LEVOFLOXACIN) in doses that considered the renal function. • She presents with bloody sputum –sputum culture and analysis came back positive for Streptococcus Pneumonae, so another antibiotic was added to the initial treatment plan – a 3rd generation cephalosporin (ceftazidime) • The patient remained afebrile for 7 days during the antibiotic therapy, with improved medical state, no bloody sputum and better pulmonary function.

  12. Evolution of patient

  13. Evolution of patient

  14. Evolution of patient On discharge On admission - We recommended CT-scan

  15. Evolution of patient

  16. FINAL DIAGNOSIS • SEPSIS WITH NEGATIVE BLOOD CULTURES OF PULMONARY ORIGIN • PERMANENT VVI PACEMAKER (FOR SINUS NODE DISEASE ) • PERMANENT ATRIAL FIBRILATION • LEFT ANTERIOR HEMIBLOCK • HIGH BLOOD PREASURE GRADE 3 VERY HIGH RISK • CRONIC KIDNEY DISEASE STAGE III • ASYMPTOMATIC HYPERURICEMIA • DRUG-INDUCED FEVER • DRUG-INDUCED TOXIC HEPATITIS

  17. Treatment and recommendations • Avoids exposure to low temperatures • Low sodium diet • MEDICATION: • ACENOCUMAROL (SINTROM) 2mg/day (with monitoring of coagulation parameters ) • LIV 52 1tb x 3/day • Low BP during hospitalization, obliged to temporary stop antihypertensive drugs. • Monitoring of coagulation parameters periodically • Reevaluation after CT-scan is taken

  18. On discharge The patient was in better medical state, but her prognosis was reserved because of the unknown etiology of the pulmonary pathology.

  19. Case point • Sepsis with no response to amoxicillin • Efficient antibiotic therapy has sever side effects on the liver and induces fever, fact that forces to stop treatment. • 2 electrodes present in the heart is a high risk factor of sepsis for an elderly patient.

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