03-24-2007, 09:49 AM
A 67-year-old man with a history of chronic obstructive pulmonary disease (COPD), hypertension, and chronic renal failure is admitted to the ICU with community-acquired pneumonia. His treatment includes broad-spectrum antibiotics, corticosteroids, and inhaled ß2 stimulants. Due to a severe ileus and gastric intolerance, total parenteral nutrition is commenced. The patient™s temperature normalizes after the third day in ICU, and his oxygenation improves. However, on the ninth hospital day he develops a fever with an increase in the peripheral leukocyte count. Antibiotics are stopped; and blood, urine, and sputum cultures are performed. Candida krusei is isolated from a single blood culture, and 60,000 CFU/mL of C. krusei is isolated from the urine. Which of the following is the most appropriate next step in the management of this patient?
1. Remove, culture, and replace all vascular catheters.
2. Remove, culture, and replace all vascular catheters and begin intravenous (IV) fluconazole.
3. Remove, culture, and replace all vascular catheters and begin IV amphotericin.
4. Remove, culture, and replace all vascular catheters; replace urinary catheter; and begin amphotericin bladder irrigations.
5. Repeat the blood and urine cultures and observe the patient.
1. Remove, culture, and replace all vascular catheters.
2. Remove, culture, and replace all vascular catheters and begin intravenous (IV) fluconazole.
3. Remove, culture, and replace all vascular catheters and begin IV amphotericin.
4. Remove, culture, and replace all vascular catheters; replace urinary catheter; and begin amphotericin bladder irrigations.
5. Repeat the blood and urine cultures and observe the patient.