A 75-year-old woman is admitted to the ICU after coronary artery bypass graft complicated by cardiogenic shock. She is improving on ICU day 4, and her ventilator settings are pressure support 10 cm H2O, PEEP 8 cm H2O, and FiO2 0.4. She is noted later that day to have increased frequency of thick secretions requiring suctioning through her endotracheal tube and develops a new fever at 39°C. Over the course of the evening, she experiences frequent oxygen desaturation, requiring an increase in her FiO2 to 0.6. A chest radiograph reveals a new opacity in the right lower lung field, and she is started on vancomycin and levofloxacin. Sputum culture grows Acinetobacter baumannii after 48 hours without other organisms identified over the next 24 hours.
What is the BEST next step in her management?
A. Continue levofloxacin, discontinue vancomycinCorrect Answer: B
This patient is presenting with VAP, as indicated by the development of fevers, increased sputum production, radiographic infiltrate, and worsening respiratory status after 4 days of mechanical ventilation. Common organisms in VAP include methicillin-resistant S. aureus, P. aeruginosa, and other gram-negative bacilli including Acinetobacter species. Although empiric coverage for Acinetobacter is not necessary unless there is a high degree of suspicion based on past infections, the isolation of this organism in sputum culture warrants appropriate antibiotic coverage. The treatments of choice for Acinetobacter species are either a carbepenem or ampicillin/sulbactam, with further treatment guided by antimicrobial susceptibility testing and local antibiogram data (answer B is correct; answers A, C, and D are incorrect). Ongoing empiric coverage for other organisms is not necessary in VAP once cultures have resulted (answer E is incorrect).
Reference: