每日一题_2022.08.20

A 54-year-old man is admitted to the ICU for hypotension. One month ago, he was discharged from the hospital after a two-week course of vancomycin and cefepime for healthcare-associated pneumonia. Three days ago, he underwent a transrectal ultrasound-guided prostate biopsy, after which he visited the emergency department for fever and chills and was sent home with oral ciprofloxacin. He returned to the emergency department this morning with worsening fatigue, fever, chills, and hypotension, and was admitted to the ICU. He was started on IV piperacillin/tazobactam. Forty-eight hours later, he has a blood pressure of 80/50 mm Hg and tachycardia. Preliminary blood cultures are pending. He is receiving fluid resuscitation and vasopressor support.

Which of the following is the most appropriate next course of treatment for this patient?

A. Add a fourth-generation cephalosporin.

B. Add vancomycin for gram-positive coverage.

C. Switch his antibiotic to a carbapenem.

D. Add colistin.

E. Continue piperacillin/tazobactam.

答案解析:

考虑到该患者近期的手术史以及近期的抗生素暴露,他存在产超广谱β-内酰胺酶革兰氏阴性病原体感染的风险。目前对此的首选治疗药物是碳青霉烯类抗生素家族(亚胺培南、美罗培南、多利培南和厄他培南)。他已经用第四代头孢菌素治疗了两周,现在可能耐药了。可以考虑使用万古霉素,但根据他的程序,他不太可能发生革兰氏阳性感染。粘菌素应仅用于极端耐药微生物。鉴于他持续的休克,继续他目前的抗生素治疗是不合适的。

正确答案:C

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