Critical Care Medicine-Neurologic Disorders>>>>>Management Strategies
Question 5#

A 76-year-old man with history of COPD and stage 3 chronic kidney disease underwent elective craniotomy for tumor resection. His postoperative course was complicated by the development of status epilepticus and respiratory failure. On postoperative day 5, he developed a fever of 38.7°C and his WBC increased from 12 000 to 19 500. Blood, urine, and respiratory cultures were obtained.

A CSF sample revealed:

Which empiric antibiotic regimen is most appropriate to initiate at this time? 

a. Ceftazidime and vancomycin
b. Ampicillin, ceftriaxone, and vancomycin
c. Vancomycin, ceftriaxone, and metronidazole
d. Cefepime and vancomycin

Correct Answer is A

Comment:

Correct Answer: A

The patient presents with post craniotomy meningitis. According to the Infectious Diseases Society of America 2017 guidelines, coverage for grampositive bacteria, and gram-negative bacteria including antipseudomonal coverage is required. Vancomycin should be aggressively dosed to achieve a trough concentration of 15 to 20 µg/mL. The recommendation for gramnegative coverage includes: cefepime, ceftazidime, or meropenem. Although cefepime is an option, there is increased risk of seizures associated with its use compared with other beta-lactams. The risk is especially significant in older patients with renal impairment. For these reasons it is preferable not to choose cefepime in this elderly patient with chronic kidney disease and seizures (option D is incorrect). Option B represents a common empiric coverage regimen for community acquired bacterial meningitis, which is not relevant for this patient. Option C does not cover pseudomonas. The correct answer is Option A: ceftazidime and vancomycin.

References:

  1. Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious disease Society of America’s clinical practice guidelines for healthcare associated ventriculitis and meningitis. Clin Infect Dis. 2017 64:e34-e65.
  2. https://www.fda.gov/Drugs/DrugSafety/ucm309661.htm.