Surgical Critical Care and Emergency Surgery. Группа авторов

of his torso wound appear to have a blue‐green color. What is the appropriate treatment?Cefepime and ciprofloxacinPiperacillin‐tazobactamColistinVancomycinTobramycin and amikacinThis patient has an infected burn wound. Pseudomonas aeruginosa; the blue‐green color and sweet, grape smell are characteristic. This patient with his prolonged hospital stay and previously treated infections is at risk for multidrug‐resistant strains. Wound culture is important to obtain to determine susceptibility. For initial empiric therapy, while there is controversy in monotherapy versus combination therapy, combination therapy is used due to the high risk of drug resistance in Pseudomonas. In combination therapy, the goal is to use antibiotics with two different mechanisms of action (tobramycin and amikacin are both aminoglycosides and share the same mechanism of action, making this an inappropriate choice). Colistin, a polymyxin, should be preserved for serious infection with proven multidrug isolates. Vancomycin is not an appropriate choice since it does not cover Pseudomonas. While piperacillin‐tazobactam covers Pseudomonas, it is a single agent.Answer: ATraugott KA, Echevarria K, Maxwell P, et al. Monotherapy or combination therapy? The Pseudomonas aeruginosa conundrum. Pharmacotherapy. 2011; 31(6):598–608. doi:10.1592/phco.31.6.598Micek ST, Lloyd AE, Ritchie DJ, et al. Pseudomonas aeruginosa bloodstream infection: importance of appropriate initial antimicrobial treatment. Antimicrob Agents Chemother. 2005; 49(4):1306–1311. doi:10.1128/AAC.49.4.1306‐1311.2005Kang CI, Kim SH, Kim H Bin, et al. Pseudomonas aeruginosa bacteremia: risk factors for mortality and influence of delayed receipt of effective antimicrobial therapy on clinical outcome. Clin Infect Dis. 2003; 37(6):745–751. doi:10.1086/377200

      14 A 47‐year‐old man with obesity and diabetes suffers a deep laceration to his left thigh while working on his farm. He presents one day after the injury with severe pain in his left thigh, spreading erythema, and bullae. Necrotic muscle is visible in the wound, and he has crepitus on exam. The patient is started on broad‐spectrum antibiotics and taken to the OR for debridement. Gram stains reveal a gram‐positive rod. What is the most appropriate antibiotic regimen?Vancomycin, piperacillin‐tazobactam, and clindamycinVancomycin and clindamycinPenicillin and clindamycinGentamycin and piperacillin‐tazobactamPenicillin and metronidazoleNecrotizing soft tissue infections (NSTIs) have high morbidity and mortality. The goal is prompt recognition, antibiotics, and surgical debridement. Initially, it is important to start the patient on broad‐spectrum antibiotics that include coverage for MRSA and anaerobes. Gram stains suggest infection with Clostridium species, which is a gram‐positive rod. For Clostridium myonecrosis, the Infectious Disease Society of America (IDSA) currently recommends starting penicillin and clindamycin. Treatment should continue for 10–14 days after source control. Choices A, B, and D do not include penicillin – the appropriate antibiotic for Clostridium. Choice E does not contain clindamycin, which helps prevent exotoxin release.Answer: CStevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2):e10–e52. doi:10.1093/cid/ciu296Stevens DL, Bryant AE . Necrotizing soft‐tissue infections. Longo DL, ed. N Engl J Med. 2017; 377(23):2253–2265. doi:10.1056/NEJMra1600673

      15 A 47‐year‐old woman who is eight months status post a deceased‐donor kidney transplant is admitted with nausea, vomiting, and watery diarrhea. She is tachycardic, afebrile, and normotensive with a leukopenia at 3 × 103/microL. Colon biopsies are positive for CMV. In addition to decreasing immunosuppression, which of the following should be started?Oral valganciclovirIV ganciclovirIV foscarnetOral ganciclovirOral oseltamivirCMV is a major cause of infection in solid‐organ transplant patients. The risk is highest in lung and small bowel transplant recipients. Biopsy is occasionally needed to confirm the presence of tissue‐invasive disease if nucleic acid testing is negative. CMV is treated by decreasing immunosuppressive medications and starting appropriate antiviral therapy. IV ganciclovir is the first line therapy for gastrointestinal CMV. Oral valganciclovir, while effective for CMV, will not be effectively absorbed in a patient with GI disease (Choice A). IV foscarnet is a second‐line therapy for treatment and is highly nephrotoxic (choice C). Oral ganciclovir and oseltamivir are not indicated in CMV infection. Oral ganciclovir should not be used for treating CMV disease as there is concern it may lead to emergence of ganciclovir resistance as its poor bioavailability leads to insufficient systemic levels. Oseltamivir is effective in treating influenza viruses, and there is no data to suggest that it would be an effective treatment for CMV infection.Answer: BRazonable RR, Humar A . Cytomegalovirus in solid organ transplantation. Am J Transplant. 2013; 13(SUPPL.4):93–106. doi:10.1111/ajt.12103Eid AJ, Arthurs SK, Deziel PJ, et al. Clinical predictors of relapse after treatment of primary gastrointestinal cytomegalovirus disease in solid organ transplant recipients. Am J Transplant. 2010; 10(1):157–161. doi:10.1111/j.1600‐6143.2009.02861.x

      16 Which of the following practices is the least effective in reducing central line‐associated bloodstream infection (CLABSI)?Appropriate hand hygiene and skin preparationFollowing a checklist during line insertionDaily bathing of ICU patients with chlorhexidineRemoval of unnecessary linesChoosing the subclavian vein for a central line insertionCentral line‐associated bloodstream infection (CLABSI) is a frequent cause of hospital‐associated infection. A multimodal approach has been shown to be effective in decreasing CLABSI. Hand hygiene is the most important practice in reducing healthcare‐associated infections. Following a checklist during insertion ensures that steps, such as hand hygiene, skin preparation, and use of maximal sterile barrier precautions, should not be forgotten. The risk of developing a line infection increased with each day of use; reassessing their need daily helps remove a nidus for infection. The femoral site has the highest risk of infection followed by internal jugular and subclavian. Daily bathing of ICU patients with chlorhexidine did not demonstrate a reduction in CLABSIs, catheter‐associated urinary tract infections (CAUTIs), ventilator‐associated pneumonia, or Clostridium difficile in a randomized control trail.Answer: CMiller SE, Maragakis LL . Central line‐associated bloodstream infection prevention. Curr Opin Infect Dis. 2012; 25(4):412–422. doi:10.1097/QCO.0b013e328355e4daLatif A, Halim MS, Pronovost PJ . Eliminating infections in the ICU: CLABSI. Curr Infect Dis Rep. 2015; 17(7). doi:10.1007/s11908‐015‐0491‐8Noto MJ, Domenico HJ, Byrne DW, et al. Chlorhexidine bathing and health care‐associated infections: a randomized clinical trial. JAMA ‐ J Am Med Assoc. 2015; 313(4):369–378. doi:10.1001/jama.2014.18400

      17 A 63‐year‐old female with type II diabetes and a recent HbA1c of 9.4 presents to the ED after she noted a foul odor emanating from the sole of her foot. Upon inspection of her foot, she noticed a large ulcer with surrounding erythema and purulence in the wound bed and presented to the ED. Upon evaluation in the ED, her WBC is 14.4 and she is afebrile. She denies being hospitalized or having a wound like this before.Next steps in care for this patient include:Immediate culture of wound, initiation of meropenem, MRI of the footImmediate culture of wound, initiation of vancomycin and piperacillin/tazobactam, MRI of the footCleansing and debridement of the wound followed by culture of the wound, initiation of ertapenem, MRI of the footCleansing and debridement of the wound followed by culture of the wound, initiation of ertapenem, x‐ray of the footImmediate initiation of vancomycin/piperacillin/tazobactam, debridement and culture of the wound, x‐ray of the foot. This patient has a diabetic foot infection and the wound should be evaluated and treated. Prior to antibiotic administration, the wound should be cleansed and debrided with the deep tissue from the wound sent for culture. Failure to do this can lead to the culturing of skin flora that may not be responsible for the infection. The wound should then be classified, and a probe‐to‐bone test can be used to help in making this decision. There are multiple ways to classify diabetic foot infections; two of the most frequently used classifications are mentioned below.Following