12-06-2008, 04:32 AM
A 76-year-old man is hospitalized for complications related to chemotherapy for non“Hodgkin's lymphoma. His medications on admission are fluconazole, ciprofloxacin, and metoclopramide. A Hickman catheter is in place that was used to treat dehydration related to vomiting that persisted even after his leukocyte count normalized.
On admission, oral medications are stopped, and saline, 3 liters intravenously, is given through the Hickman catheter. The patient improves. However, on the third hospital day, he develops fever, slight confusion, and loss of appetite. On physical examination, he appears ill. Temperature is 38.7 °C (101.7 °F), pulse rate is 112/min, respiration rate is 18/min, and blood pressure is 110/70 mm Hg. General examination is normal. There is no redness or tenderness over the site of the Hickman catheter.
Laboratory Studies
Hemoglobin
11 g/dL (110 g/L)
Leukocyte count
4000/μL (4 × 109/L)
Platelet count
94,000/μL (94 × 109/L)
Serum creatinine
0.9 mg/dL (79.58 μmol/L)
After blood culture samples are drawn, broad-spectrum intravenous antibiotic therapy is begun for suspected bacteremia. The next day, the laboratory reports that two culture bottles are growing what appears to be a yeast.
In addition to removing the Hickman catheter and continuing supportive care, which of the following is most appropriate at this time?
A Monitor temperature for 24 hours before beginning specific therapy
B Await blood culture species identification before beginning specific therapy
C Begin oral flucytosine now
D Begin intravenous caspofungin now
E Begin intravenous fluconazole now
On admission, oral medications are stopped, and saline, 3 liters intravenously, is given through the Hickman catheter. The patient improves. However, on the third hospital day, he develops fever, slight confusion, and loss of appetite. On physical examination, he appears ill. Temperature is 38.7 °C (101.7 °F), pulse rate is 112/min, respiration rate is 18/min, and blood pressure is 110/70 mm Hg. General examination is normal. There is no redness or tenderness over the site of the Hickman catheter.
Laboratory Studies
Hemoglobin
11 g/dL (110 g/L)
Leukocyte count
4000/μL (4 × 109/L)
Platelet count
94,000/μL (94 × 109/L)
Serum creatinine
0.9 mg/dL (79.58 μmol/L)
After blood culture samples are drawn, broad-spectrum intravenous antibiotic therapy is begun for suspected bacteremia. The next day, the laboratory reports that two culture bottles are growing what appears to be a yeast.
In addition to removing the Hickman catheter and continuing supportive care, which of the following is most appropriate at this time?
A Monitor temperature for 24 hours before beginning specific therapy
B Await blood culture species identification before beginning specific therapy
C Begin oral flucytosine now
D Begin intravenous caspofungin now
E Begin intravenous fluconazole now
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