Allergy patient with organism. Mike Cooper Consultant Microbiologist New Cross Hospital, Wolverhampton

Transcription

1 Allergy patient with organism Mike Cooper Consultant Microbiologist New Cross Hospital, Wolverhampton

2 60 year old male Referred to hospital by GP?IE 3/52 history of feeling generally unwell with malaise, low grade fever, shivery, night sweats, SOBOE PMH mitral valve prolapse and regurgitation diagnosed 12 years ureteric stone 13 years ago DU 12 years ago BPH 5 years ago

3 DH (no known drug allergies): omeprazole finasteride tamsulosin O/E T 37.5, P 70 reg, not clinically jaundiced or anaemic Palpable cervical lymph nodes PSM radiating to axilla Chest clear No splinter haemorrhages, clubbing etc.

4 Baseline bloods: Hb 12.7 WCC 9.6 U+E all normal CRP 89 Impression: viral infection but rule out IE! For B/C X3 TTE

5 Day 2 Overnight T 39, required change of bed sheets because of sweating B/C X 1 GPC?Strepts Post take WR consultant gets history of visit to dentist 2/12 earlier (1 st time in >10 years) replace filling, scale and polish no antibiotic prophylaxis given Also finds spleen palpable

6 Day 3 B/C isolate α haemolytic streptococcus Further 2 sets also positive Started on benzyl penicillin 2.4g 4 hrly + gentamicin 1mg/kg tds

7 Day 6 Clinically well CRP 26 B/C isolate = Streptococcus oralis Penicillin MIC = mg/l Advised for 2/52 pen + gent

8 Day 7 TTE: Moderate to severe mitral regurgitation. Mobile structure around mitral valve. Highly suggestive of IE Hickman line inserted CRP 8

9 Day 14 Stop gentamicin Advised to continue iv benzyl penicillin for a further 2 weeks Advised TOE to confirm no abscess or extension of infection

10 Day 15 Pyrexial Chest pain: ECG SVT treated with adenosine reverted to sinus rhythm chest pain settled CRP 29

11 Day 18 Remains pyrexial CRP 36

12 Day 21 Still spiking temperatures Develops rash under right arm CRP 12 Benzyl penicillin continued

13 Day 25 Microbiologists contacted?stop antibiotics

14 Day 26 T 38.8 D/W Microbiologist?line infection?other source advised FBC, CRP, B/C, urine culture, CXR if worried about him, stop ben pen, start meropenem and vancomycin, and consider line removal

15 Results from Day 26 WCC 4.4 CRP 21 MSU nil of note

16 Day 27 (Saturday) am Still pyrexial Rash spreading Contacted on call Microbiologist all repeat cultures negative so far advised to start meropenem and vancomycin get Hickman line removed

17 Day 27 (Saturday) pm Rash became very much worse within 1 hour of first dose of vancomycin very florid over entire body patient very uncomfortable with it can not get Hickman line removed until after the weekend Consultant Microbiologist contacted What advice do you give?

18 Day 28 (Sunday) Previous day Microbiologist had advised to give no more vancomycin and continue with meropenem as single agent consider adding daptomycin if patient deteriorates Rash progressing despite no further vancomycin Patient still pyrexial, CRP now 27 What advice do you give?

19 Day 29 Microbiologist advised stopping meropenem and leaving off all antibiotics Next day patient stable and apyrexial All cultures remain negative

20 Day 31 Patient still well, apyrexial Rash fading CRP 10 Has TOE: no change in appearance of mitral valve prolapse with chordae rupture and severe mitral regurgitation. No obvious masses. No abscess Discussed at MDT requires valve replacement

21 Day 36 Operation Patient extremely nervous pre op about possibility of being given penicillin. Assured allergy status to penicillin, meropenem and vancomycin recorded on all charts, and additional allergy bracelet placed on patient s wrist. What would you advise as prophylaxis? local guidelines: flucloxacillin 4 doses over 24/ X 5mg/kg gentamicin penicillin allergy single dose of teicoplanin

22 Day 36 Has mitral valve replacement (and removal of Hickman line!!!) No vegitations seen at operation Prophylaxis given flucloxacillin 1g qds for 24/ mg gentamicin! No adverse reaction seen no rashes no pyrexia CRP >100 post op (but probably due to op)

23 Is this a clinical incident?

24 Post Operation Patient made a full and uneventful recovery except for complete heart block post op, requiring permanent pacemaker Day 51 PPM fitted teicoplanin given as prophylaxis uneventful, no adverse reactions discharged home following day