Scenario:
A 68‑year‑old man on thrice‑weekly haemodialysis, recently transferred from a nursing home, develops a new fever (38.8 °C), worsening dyspnoea on BiPAP, hypotension (BP 85/50 mmHg) and tachycardia (115 bpm) five days into his admission for heart failure. A chest X‑ray shows a new right lower‑lobe infiltrate. His WBC is 18 × 10⁹/L and procalcitonin is elevated. Blood and sputum cultures are pending.
Question:
Which empiric IV regimen is most appropriate for this critically ill patient at high risk for ESBL‑producing organisms?
A) Vancomycin + Cefepime
B) Vancomycin + Piperacillin–Tazobactam
C) Vancomycin + Meropenem
D) Levofloxacin monotherapy
✅ Correct Answer: C) Vancomycin + Meropenem
📘 Discussion
Why Vancomycin + Meropenem?
Meropenem offers the broadest Gram‑negative coverage, including ESBL‑producing Enterobacterales and Pseudomonas, which is crucial in nursing‑home–associated HAP with prior antibiotic exposure.
Vancomycin reliably covers MRSA, a common pathogen in this setting.
Together they tackle the full spectrum of likely resistant organisms in a septic, high‑risk patient.
Why Cefepime + Vancomycin (A) and Zosyn + Vancomycin (B) are less desirable
Both regimens cover MRSA and Pseudomonas well, but neither reliably covers ESBL producers.
In a critically ill patient with a history of recurrent antibiotics from a nursing home, the probability of encountering ESBL organisms is high—making meropenem the superior initial choice.
Why Levofloxacin Monotherapy (D) is definitely wrong
No MRSA coverage.
Inadequate for Pseudomonas in this high‑risk context.
Monotherapy with a fluoroquinolone notably risks rapid resistance development and treatment failure.
💡 Teaching Pearls
ESBL Risk Factors: Recurrent broad‑spectrum antibiotics, transfer from long‐term care facilities, and severe presentation warrant a carbapenem.
Empiric HAP Regimens: Always pair an anti‑MRSA agent (vancomycin or linezolid) with an anti‑Pseudomonal β‑lactam. In ESBL‐prone patients, prefer meropenem.
Stewardship Note: De‑escalate promptly based on culture and sensitivity data to minimise collateral damage and resistance pressure.
Renal Dosing: Both vancomycin and meropenem require post‑dialysis dosing adjustments—ensure protocols are followed to maintain therapeutic levels.
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