Stefan,where r u? - guest78

[ArchivalUser]

A 29-year-old man comes to the emergency department because of a 1-day history of increasing pain in the upper right thigh. Two days ago, he was cutting rebar (steel reinforcement used to strengthen poured concrete) with a power saw when he suddenly developed a sharp pain in his right thigh from a steel splinter thrown by the saw. The pain abated over the next hour, and there were no lesions when he examined the thigh that evening. Medical history is unremarkable.

On physical examination, temperature is 38.4 °C (101.1 °F), pulse rate is 108/min, respiration rate is 16/min, and blood pressure is 96/68 mm Hg. Cardiopulmonary and abdominal examinations are normal. The right thigh is moderately tender in the approximate area where the accident occurred 2 days earlier. There is no erythema or swelling.

Laboratory Studies
Hemoglobin

13.9 g/dL (139 g/L)
Hematocrit

42%
Leukocyte count

18,600/μL (18.6 × 109/L)
Platelet count

520,000/μL (520 × 109/L)
Plasma glucose

98 mg/dL (5.44 mmol/L)
Blood urea nitrogen

18 mg/dL (6.43 mmol/L)
Serum creatinine

0.9 mg/dL (79.58 µmol/L)
Serum electrolytes

Normal

A CT scan of the thigh shows a minute metallic fragment in the fascial plane just beneath the subcutaneous tissue and some stranding and edema in adjacent areas.

The patient is hospitalized, and empiric vancomycin is begun pending blood culture results. Three hours after admission, his blood pressure drops to 60/0 mm Hg. Vasopressors and intravenous fluid resuscitation are administered, and his blood pressure improves. Over the next several days, the patient develops signs of renal and hepatic insufficiency, but these gradually return to normal.

Which of the following is the most appropriate antimicrobial regimen at this time?

A Vancomycin plus clindamycin
B Nafcillin plus aztreonam
C Nafcillin plus clindamycin
D Nafcillin plus piperacillin“tazobactam
E Piperacillin“tazobactam plus clindamycin

[ArchivalUser]

E Piperacillin“tazobactam plus clindamycin

[ArchivalUser]

try again,i did the same mistake.

[ArchivalUser]

c it is

[ArchivalUser]

is it c?

[ArchivalUser]

ans is AAA.

This patient probably has streptococcal or staphylococcal toxic shock syndrome and requires vancomycin and clindamycin. Vancomycin is indicated because of the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in the community. Clindamycin has been shown to improve survival in patients with toxic shock syndrome, presumably because of its effects on the production and release of toxin from bacteria and its antibacterial effects. Some experts would also add intravenous immune globulin because of its possible beneficial effects that presumably result from neutralization of the bacterial toxins elaborated by both staphylococci and streptococci. However, use of intravenous immune globulin remains controversial.

As long as Staphylococcus aureus is one of the possible pathogens, the other antibiotic regimens listed are not acceptable. Although nafcillin is an excellent drug for methicillin-sensitive staphylococci and hemolytic streptococci, it is not effective against MRSA. Aztreonam is effective only against aerobic gram-negative bacilli, which rarely cause toxic shock syndrome (and then only as a component of a mixed, synergistic infection). Although clindamycin alone may be useful in some patients, it may not be effective against all staphylococci and therefore should not be used until drug sensitivities are known. Piperacillin“tazobactam plus nafcillin is incorrect because neither drug is effective against MRSA. In addition, nafcillin is not needed with piperacillin“tazobactam because the latter agent is effective against streptococci and methicillin-sensitive staphylococci. Piperacillin“tazobactam plus clindamycin is incorrect because neither drug is effective against MRSA.