critically ill 75 year old man with complications

8/12/2019 Critically Ill 75 Year Old Man With Complications

1/20

Critically Ill 75 Year Old Man

with Complications FollowingColonic Perforation and

Surgery


2/20

A 75-year-old male patient presents to theemergency department with acute abdominal

pain. He has received long-term treatmentwith corticosteroids due to severe chronicobstructive pulmonary disease. After thediagnosis of an acute abdomen, the patient

undergoes an emergency laparotomy. Aperforated cancer of the ascending colon isfound and a right-sided hemicolectomy withend-to-end anastamosis is performed.Intravenous antibiotic treatment withampicillin-sulbactam (3.1 g t.i.d) isadministered.


3/20

The postoperative course is initially uneventful.

However on the 7th postoperative day the

patient develops a fever, new abdominaltenderness, increasing dyspnea, a leucocytosis

(22,000/mm3, 25% band forms) and an

increasing C-reactive protein (278 mg/L). Theabdominal CT-scan shows fluid in the

peritoneal cavity and a significant amount of

intraperitoneal fluid. At second-look laparotomy,

a site of anastomotic leakage is found: and

drainage of the operative site and a colostomy

are performed.


4/20

The patient is transferred to the surgical

ICU. The antibiotic treatment is switched

to intravenous imipenem/cilastin (500 mg

q.i.d.). Semiquantitative cultures of the

peritoneal fluid grow E.coli(moderate

quantity), K.pneumoniae(moderate

quantity), B.fragilis(moderate quantity)and C.albicans(small quantity).


5/20

The patient is mechanically ventilated, has

a central venous catheter in the right

subclavian vein and a urinary catheter. He

receives total parenteral nutrition. In thefirst postoperative days he is afebrile and

inflammatory parameters are decreasing.

Surveillance cultures of stool, urine andrespiratory secretions show a small

quantity of C.albicans.


6/20

What are the risk factors or predictors

for systemic candidiasis in this

patient?


7/20

1. The number of broad-spectrum

antibiotics administered

2. The duration of the broad-spectrum

antibiotic treatment

3. The APACHE II score

4. The number of body sites colonized byCandida
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8/20

Which subgroup of ICU patients are at

high risk of developing Candida

peritonitis or intra-abdominal Candida

abscesses?


9/20

1. Patients who underwent surgery for

acute pancreatitis

2. Patients with recurrent gastrointestinal

perforation or anastomotic leakage

3. Patients with heavy initial or increasing

Candidacolonization in semiquantitative

cultures of the intraperitoneal fluid
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10/20

The patient is doing well and is afebrile.

However the Candidacolonization as

assessed by semiquantitative cultures of

the intraperitoneal fluid is increasing(initially small quantity, now in abundant

amounts).

Would you give antifungal prophylaxis?


11/20

1. Yes, with fluconazole, 400 mg/day

2. Yes, with itraconazole, 400 mg/day

3. Yes, with amphotericin B, 0.6 mg/kg4. No
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12/20

This patient was at high-risk and received

fluconazole 400 mg/d for two weeks. The

further course was uncomplicated, the

surgical condition resolved and he wasdischarged 2 weeks later.


13/20

After 48 hours the patient develops fever,

leucocytosis (15,000/mm3, 15% band

forms) and abdominal pain. C-reactive

protein is rapidly increasing (153 mg/L). Asecond Candidaspecies (C.glabrata) is

found in moderate quantity in the most

recent cultures of the intraperitoneal fluid.The patient is mechanically ventilated and

hemodynamically stable.


14/20

What would you do?

1. Abdominal CT-scan

2. Blood cultures and cultures of

intraperitoneal fluid

3. Change the broad-spectrum antibiotic

4. Add fluconazole 400mg/day
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15/20

After 48 hours one aerobic bottle drawn by

peripheral venipuncture grows yeast. The

patient is deteriorating and develops arterialhypotension unresponsive to volume repletion.

The intra abdominal fluid collection seen by CT-

scan undergoes surgical drainage. The centralvenous catheter is removed and cultured. A

new central venous catheter is inserted at a

different site. Further blood cultures are drawn.


16/20

Awaiting species identification and

susceptibility testing would you change

the empirical antifungal treatment toone of the following:

1. Fluconazole 800 mg/d

2. Amphotericin B-deoxycholate 1 mg/kg/d

3. Lipid preparation of amphotericin B

4. Addition of 5 -fluorocytosine
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17/20

Yeast grown in blood cultures are identified as

C. glabrata. MIC to fluconazole is 64 mg/L: the

isolate is resistant. Under amphotericin B-deoxycholate (1 mg/kg/d) the patient is clinically

improving, pressor support has been stopped.

The intraperitoneal fluid is optically clear. Afundoscopic examination shows bilateral Roth

spots. A thoraco-abdominal CT-scan shows

multiple lung nodules and multiple hypodense

lesions in the liver. The tip of the central venous

catheter is sterile. Control blood cultures drawn

48 hours after the positive cultures are sterile.


18/20

What is the recommended duration of

treatment of candidemia with

dissemination to multiple organs?

1. 4-6 weeks

2. 2 weeks3. > 6 weeks
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19/20

The patient is treated for 6 weeks withamphotericin B-deoxycholate (total dose 2

gm). The tolerance to the drug was good: oncompletion of the therapy renal functionreturned to normal. The clinical course isuneventful. At end of treatment, all

inflammatory parameters are normal andcontrol fundoscopy shows a completeregression of Roth spots. The treatment is

stopped and no symptoms or signssuggesting a metastatic recurrence arereported over a 6-month follow up.

A f di i t d didi i i iti ll ill


20/20

A case of disseminated candidiasis in a critically ill

surgical patient. Surgically, the attempt at a

primary end-to-end bowel anastamosis in an

elderly man on long term steroids was probably illadvised. A colostomy would have been a safer

approach from the beginning. Optimal antifungal

therapy for such a patient is currently being

redefined, with the recent addition of voriconazoleand caspofungin to the therapeutic

armamentarium. In this patient, either of these

drugs might have been used preemptively (or

therapeutically) as soon as C. glabratawas knownto be present. Hopefully, in the next few years the

best therapy for this type of patient will be better

defined.

critically ill 75 year old man with complications

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