University Hospital Augusta
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Bug/Drug Mismatch Patient — Gram Negative
55 yo man on chemotherapy for NSCLC and a chest Port-a-Cath® was admitted to hospital with fever and chills. Vitals: 39°C, 90/60 mm Hg, 110 beats/minute, and 97% oxygen. Alert, normal lung auscultation, tachycardia with no murmurs, soft non-tender abdomen, edema lower right extremity. Normal blood test results, with low hemoglobin
|Empiric therapy||Vancomycin (15 mg/kg every 12h)|
|ID/AST method||Accelerate PhenoTest® BC kit, in parallel with traditional methods (MALDI-TOF MS and VITEK®2)|
|ID result||Pseudomonas aeruginosa|
|AST results||Cefepime (S)|
|Time to AST results||∼6.5h post +BC with Accelerate PhenoTest® BC kit (versus traditional method of ∼45h)|
|Patient outcome||Discharged 3 days later|
A 55-year-old man on chemotherapy for non–small cell lung cancer (NSCLC) was admitted with fever and chills. The patient had a Port-a-Cath® in his chest. On admission vital signs were measured: temperature was 39°C, blood pressure was 90/60 mm Hg, heart rate was 110 beats per minute, and oxygen saturation was 97%. Upon physical examination the patient was alert although mildly distressed, and lung auscultation showed no abnormalities. The cardiovascular exam revealed tachycardia without any presence of murmurs. The abdomen was soft and nontender, and edema was observed in the right lower extremity. Blood tests returned results within normal ranges for white blood cell count (8.5 K/mcL), platelets (195 K/mcL), blood urea nitrogen (20 mg/dL), and creatinine (0.9 mg/dL). Hemoglobin was low (10 g/dL). No infiltrates were found on the chest radiograph.
Blood cultures were taken and treatment with vancomycin (15 mg/kg every 12 hours) was started for suspected infection of the port. Over the following 12 hours, tachycardia and hypotension worsened. The patient received fluid resuscitation and was transferred to the intermediate care unit. An infectious disease specialist consultation was requested. Positive blood cultures were assessed with both the Accelerate Pheno® system and with traditional methods (MALDI-TOF MS and the VITEK® 2 system). The former returned a positive identification for Pseudomonas aeruginosa in 1 hour and 21 minutes. Based on this information and after discussion with the antimicrobial stewardship pharmacist, antibiotic therapy was changed to cefepime to ensure appropriate coverage against Pseudomonas. Pathogen susceptibility to cefepime was confirmed by the Accelerate Pheno system 6 hours and 35 minutes from start time. MALDI-TOF MS and the VITEK® 2 system confirmed the Accelerate Pheno system identification results in 33 hours and the MIC values in 45 hours, respectively. The patient improved and was discharged 3 days later. The Accelerate Pheno system provided correct identification and susceptibilities at least 1 day earlier than traditional methods. This allowed the switch from empiric therapy to appropriate anti-microbial therapy that led to a faster clinical cure.
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