A 35-year-old woman - pacemaker

[ArchivalUser]

A 35-year-old woman with a history of injection drug use is hospitalized because of a 5-day history of fever and increasing back pain that has not responded to continued use of pain medications. On the day of admission, she noted some weakness and numbness of her left leg.

On physical examination, her temperature is 38.2 °C (100.8 °F), pulse rate is 88/min, respiration rate is 14/min, and blood pressure is 110/68 mm Hg. There is tenderness to palpation of the lumbar spine at the level of L3“L4. Neurologic examination is significant for 3/5 motor strength and diminished pain sensation in the left lower extremity.

MRI of the lumbar spine shows evidence of osteomyelitis at L3“L4 with involvement of the disc space and an epidural collection that is hyperintense on T2-weighted images. The patient is sent to the operating room for laminectomy with drainage of the epidural collection.

Which of the following empiric antimicrobial regimens should be initiated following drainage of the collection?

A Vancomycin
B Vancomycin plus cefepime
C Isoniazid, rifampin, pyrazinamide, and ethambutol
D Amphotericin B lipid complex

[ArchivalUser]

B...

[ArchivalUser]

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[ArchivalUser]

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[ArchivalUser]

Correct Answer = B)...good going guys
Key Point
Vancomycin plus cefepime is the most appropriate empiric antimicrobial therapy for a patient with an epidural abscess and a history of injection drug use.

This patient most likely has a bacterial epidural abscess. The spread to the spine is probably hematogenous because of the involvement of two adjacent vertebrae and the disc space and the presence of an epidural collection. Most epidural abscesses are caused by staphylococci and streptococci, but the possibility of gram-negative bacilli must also be considered in injection drug users. Vancomycin plus cefepime is the only therapeutic regimen listed that treats all these bacteria.

Vancomycin alone would not be effective. Although infection caused by Mycobacterium tuberculosis is possible, antituberculous chemotherapy (isoniazid, rifampin, pyrazinamide, and ethambutol) should not be started unless culture results or histopathologic findings document this infection. Amphotericin B lipid complex is inappropriate because a fungal infection is unusual in an injection drug user, and empiric antifungal coverage is not warranted.