Correct!
3. Prior microbiology results and local antibiograms should be reviewed.
4. Antibiotic coverage should be broadened.
5. Point of Care echocardiography should be performed.
Options 3,4 and 5 are the most appropriate immediate actions. The most likely diagnosis is septic shock. The patient is at high risk for infection with multi-drug resistant (MDR) organisms and his mortality is greatly increased if the correct antibiotic is not initiated as soon as possible. Risk factors this patient has for infection with MDR organisms include: ICU admission, bedridden status, presence of invasive devices, prior use of broad-spectrum antibiotics, and surgery. It will be difficult to predict the antibiotic sensitivity of the unknown organism, but review of local antibiograms has revealed that amikacin typically has the highest sensitivity rates (>90%) against MDR gram negative bacilli in blood isolates of hospitalized patients. Detailed review of prior culture results should further inform the choice of antibiotics.
Although his hypotension is likely due to septic shock, other causes might be revealed by a point of care echocardiography. Unexpected findings that could change clinical care include LV dysfunction due to unrecognized ischemic heart disease or stress cardiomyopathy and RV dysfunction due to pulmonary embolism. Other unexpected findings could include pneumothorax or right-sided cardiac vegetations (the patient is at risk for endocarditis with prior fungal dialysis catheter infection).
Most clinicians would consider this patient too unstable to safely transfer him for computerized tomography or to have his tunneled catheter removed, although the later remains a consideration and could perhaps be performed at the ICU bedside.
Stress dose steroids should be continued as he is at risk for iatrogenic adrenal insufficiency due to prolonged use of corticosteroids and his random cortisol level is inappropriately low for the level of physiological stress he is experiencing.
Microbiology results from the referring institution were received and reviewed. This revealed the following positive results over the past four months, (all of which were appropriately and apparently successfully treated): a highly resistant Acinetobacter baumanii in a BAL specimen (sensitive only to amikacin and ampicillin/sulbactam), Candida glabrata in a blood culture and off a central line tip (subsequently removed), and KPC Klebsiella pneumoniae, Mycobacterium abscessus and Stenotrophomonas maltophilia from surgical swabs of the abdomen. Local antibiograms had consistently identified amikacin as the antibiotic with the lowest risk of resistance (<10%) by gram negative bacilli in blood isolates of hospitalized patients over the prior decade.
Which of the following are the most important consideration in regards to the possible administration of amikacin in this patient? (Click on the correct answer to be directed to the second of 4 pages)