A 40 year old man with poorly controlled Type 2 diabetes develops pain and redness over the dorsum of his foot. He presents to the emergency room the day after these symptoms started. He denies any recent penetrating injuries to his foot, including no animal bites, and denies any water exposure. At the time of presentation, his temperature is 101.1°F, pulse 89, his blood pressure is 124/76, and his respiratory rate is 16. Tender edema, warmth, and erythema extend up to the pretibial area of his right lower leg. Fissures are present between his toes, but he has no foot ulcers. There are no blisters or purulence. When you palpate, you don’t feel any crepitus or fluctuance. He has a strong pulse at both dorsal pedis and posterior tibial arteries. Labs reveal a normal white blood cell count. What is your diagnosis? What antibiotics would you start? A 72 year old man is admitted for a lobectomy. About 6 days after his operation, while still on mechanical ventilation, he develops findings suggestive of pneumonia, based on a new right lower lobe infiltrate on chest x ray, increased secretions and fever (101.1°F). A blood sample and an endotracheal aspirate are sent for culture. He is empirically started on vancomycin and piperacillin/tazobactam. After 3 days of empiric antibiotics, he has had no additional fevers and has been extubated to room air. His WBC count has normalized. Blood cultures show no growth. The respiratory sample shows >25 PMNs and <10 epithelial cells; no organisms are seen on gram stain and there is no growth on culture. Would you make any changes to his antibiotic regimen at this time? If so, how would you justify the change? A 72 year old man presented with a severe Clostridium difficile infection, which resulted in both respiratory and acute renal failure. He gradually improved with supportive care, oral vancomycin, and IV metronidazole. After over a month of being hospitalized in the ICU, his Foley was removed. He was subsequently found to have urinary retention, so he was straight catheterized. The urine obtained from the straight catheterization was cloudy. A urinalysis showed 53 WBCs, positive nitrite, and many bacteria. Urine culture grew >100K ESBL producing E.coli (ESBL=extended spectrum beta lactamase). He wasn’t having fevers. He had no leukocytosis and no signs or symptoms attributable to a UTI. What is you diagnosis? What antibiotics would you start?
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