Table 1.

Significant events in the patient's hospital course.

Hospital day	Significant event	Tmax (°F)	WBC (cells/mm3)	Antibiotics
1	Admission to the medical ICU, being started on norepinephrine for hypotension Blood cultures drawn Right radial A-line and left femoral central line inserted	103.0	4.61	Piperacillin-tazobactam 4.5 g IV every 8 hours Vancomycin IV∗
2	Noncontrast CT scan of abdomen and pelvis showed bilateral pleural effusion, moderate ascites, generalized anasarca, no abscess	100.7	11.16
3	Day 1 blood cultures grew P. aeruginosa  Stool C. difficile enzyme immune-assay positive∗∗	99.8	15.60	Cefepime 2 gm IV daily
4	Rising creatinine (1.8 mg/dL) Urinary catheter removed Femoral line removed PICC line inserted	98.3	17.07
5	Hemoglobin decreased from 7.2 to 6.8 g/dL Platelets decreased from 27 to 16 × 103/microliter 1 unit of packed RBC transfused Repeat blood cultures drawn	97.7	14.29
6	Blood pressure stable off vasopressor, arterial line removed Repeat blood culture negative to date Transferred to general medical floor	97.8	6.38
7	Repeat blood culture × 1, no growth Minimal bleeding from nares, platelets transfused	97.8	12.4
8	Blood culture from Day 5 resistant to cefepime	98.2	11.93	Meropenem 1 g IV every 8 hours
9	1 unit of packed RBC transfused	99.0	9.68
10	Transthoracic 2D ECHO showed possible valvular vegetations HIDA scan, negative Intubated for decreased respiratory rate and apnea, hypotension (75/50), altered mental status Repeat blood cultures were drawn Transferred back to the medical ICU	98.4	5.96	Meropenem 1 g IV every 8 hours + tobramycin∗
11	Hypotension despite fluid resuscitation Phenylephrine started	98.0	6.29
12	Transesophageal echocardiogram did not reveal vegetations PICC line removed and sent for culture Stable respiratory status; patient extubated	98.3	4.35
13	Worsening renal function and oliguria Blood culture from Day 10 grew P. aeruginosa resistant to meropenem; E-test performed for P. aeruginosa isolate from Day 10 showed resistance to ceftazidime-avibactam and ceftolozane-tazobactam	99.3	3.84	Tobramycin 1.7 mg/kg every 12 hours
14	Increasing tachypnea, tachycardia, lethargy	98.5	1.54
15	Absolute neutrophil count dropped to 590 cells/mm3  Reintubated for respiratory distress Hypotension despite fluids; patient on three vasopressors (norepinephrine, phenylephrine, vasopressin) Repeat blood cultures drawn	98.5	2.53	Tobramycin 1.7 mg/kg every 12 hours Anidulafungin 200 mg IV Cefepime 2 gm IV daily Vancomycin IV
16	Family decided to change the patient's code status from full interventions to comfort measures only
	He was extubated and expired

^∗Tobramycin and vancomycin doses were adjusted by pharmacy based on peak and trough blood levels.

^∗∗Patient was on oral vancomycin empirically for C. difficile since Day 1 of hospitalization.

HIDA scan: hepatobiliary iminodiacetic acid scan; IV, intravenous; PICC: peripherally-inserted central catheter; and Tmax, maximum temperature.