1. Case Study: An elderly man with diabetes and chronic renal failure develops complications
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2. History
A 72-year-old man was admitted to the Emergency Department from a haemodialysis centre with:
Fever
Confusion and obtundation (clouding of consciousness)
Hypotension
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3. Examination in the emergency department
The patient is:
Awake, confused, non co-operative and disorientated
He has:
Poor perfusion
No oedema and no jugular venous distention
Clinical examination:
Blood pressure (BP) 88/40 mmHg; heart rate 112/min; respiratory rate 30/min; temperature 39°C; sat O2 94%
Pulmonary examination reveals normal breath sounds and no crackles
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4. Examination in the emergency department (cont’d)
He has normal heart sounds and a 2/6 systolic murmur at the left sternal border (LSB)
Abdominal examination is normal
No pain on percussion of the costovertebral angle
No meningeal or focal neurological signs
Arterial blood gas findings: pH 7.23; PaO2 72 mmHg; PaCO2 22 mmHg; HCO3- 10 mmHg; sat O2 94% (FiO2 0.21); lactate 6 mmol/L (54 mg/dL)
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5. Past medical history
Patient was doing well until 2 days previously when he developed a fever, anorexia and malaise; there were no respiratory or genitourinary symptoms
Background:
Patient was independent for daily activities
Diabetes mellitus type 2 and hypertension
Received haemodialysis for the past 8 years for chronic renal failure
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6. Past medical history (cont’d)
Following thrombosis of 3 arteriovenous fistula (AVF), he had a femoral AV prosthesis inserted 8 months ago
Medications: insulin, lisinopril, erythropoietin, folic acid, vitamin B; no antibiotics in the last 3 months
No skin lesion and no inflammatory signs in the AV prosthesis area
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7. Question 1
Which of the following diagnoses would you consider probable for this patient?
Systemic inflammatory response syndrome (SIRS)
Sepsis
Severe sepsis
Septic shock
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8. Which of the following diagnoses would you consider probable for this patient?
Systemic inflammatory response syndrome (SIRS)
Sepsis
Severe sepsis
Septic shock
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Answers from AIM meetings in 2007

9. Question 2
Which of the following do you think is the best therapeutic strategy?
Vasopressors
Fluids
Fluids + antibiotics
Antibiotics + vasopressors + oxygen
Fluids + oxygen + antibiotics
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10. Which of the following do you think is the best therapeutic strategy?
Vasopressors
Fluids
Fluids + antibiotics
Antibiotics + vasopressors + oxygen
Fluids + oxygen + antibiotics
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Answers from AIM meetings in 2007

11. SIRS or sepsis?
Fever, tachycardia, tachypnoea, hypotension, confusion, high serum lactate levels
Severe sepsis
Lactate 6 mmol/L (54 mg/dL)
Cryptic shock?
Shock?
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Depending on fluid response

12. Question 3 Should a central venous line be inserted? Yes No Don’t know
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13. Should a central venous line be inserted?
Yes No
Don’t know
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Answers from AIM meetings in 2007

14. Fluid resuscitation
Started immediately in a patient with sepsis and a high lactate level
Goals:
Mean arterial pressure (MAP) ≥65 mmHg
Central venous pressure (CVP) 8–12 mmHg (non-ventilated)
Diuresis rate ≥0.5 mL/kg/h
Central venous O2 saturation (ScvO2) ≥70%
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15. Clinical case Central venous line inserted
Fluids (normal saline 1500 mL; CVP 12 mmHg)
Hypotension (BP 88/40 mmHg) + hyperlactacidaemia (5.6 mmol/L [50 mg/dL])
Noradrenaline (0.2 µg/kg/min)
MAP ≥65 mmHg
Lactate 5.4 mmol/L (49 mg/dL)
ScvO2 65%
Haematocrit 27%
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16. Question
Which of the following do you think is the next therapeutic step?
More fluids
More noradrenalin
Red blood cell transfusion
Dobutamine
3 + 4
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17. Which of the following do you think is the next therapeutic step?
More fluids
More noradrenalin
Red blood cell transfusion
Dobutamine
3 + 4
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Answers from AIM meetings in 2007

18. Fluid resuscitation: What else should be done?
Haematocrit 27%
Red blood cell transfusion
If ScvO2 <70%, transfuse until haematocrit >30% (CVP 8–12 mmHg, MAP >65 mmHg)
After one unit of blood, ScvO2 72%
Inotropes
If ScvO2 <70% → dobutamine
(CVP 8–12 mmHg; MAP >65 mmHg and haematocrit >30%)
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19. Results of additional examinations
Haemoglobin
6.7 mmol/L (10.8 g/dL)
WBC
18 x 109/L (18 000/µL)
Platelets
152 x 109/L ( /µL)
C-reactive protein
360 mg/dL
Urea
7 nmol/L (42 mg/dL)
Creatinine
866 µmol/L (9.8 mg/dL)
Sodium/potassium
132/4.5 mmol/L (132/4.5 mEq/L)
GOT/GPT
27/32 U/L
Glucose
80 mmol/L (450 mg/dL)
Albumin
39 g/L (3.9 g/dL)
Blood cultures; three sets
Chest X-ray reveals no pleural or pulmonary changes
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GOT, glutamic-oxaloacetic transaminase; GPT, glutamic pyruvic transaminase; WBC, white blood cell

20. Question What do you think is the most probable focus of infection?
Bloodstream
Urinary tract
Lungs
Other
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21. What do you think is the most probable focus of infection?
Bloodstream
Urinary tract
Lungs
Other
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Answers from AIM meetings in 2007

22. What is the most probable focus of infection?
Use of an AV prosthesis during haemodialysis is a risk factor for infection (namely to the endocardium) with or without septic embolisation
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23. Question Which antibiotic therapy would you choose? Ceftriaxone
Levofloxacin
Amoxicillin/clavulanate
Antipseudomonal carbapenem
Vancomycin + gentamicin
Vancomycin + antipseudomonal carbapenem
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24. Which antibiotic therapy would you choose?
Ceftriaxone
Levofloxacin
Amoxicillin/clavulanate
Antipseudomonal carbapenem
Vancomycin + gentamicin
Vancomycin + antipseudomonal carbapenem
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Answers from AIM meetings in 2007

25. What is the most probable focus of infection?
Use of an AV prosthesis during haemodialysis is a risk factor for infection (namely to the endocardium) with or without septic embolisation
Which antibiotic therapy to choose?
Risk of infection with the following if there is a prosthesis-related infection with or without endocarditis:
Staphylococcus aureus
Staphylococcus epidermidis
Enterococci
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26. Antibiotic therapy
The patient was started on vancomycin plus gentamicin
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27. Results of further subsidiary examinations
Transoesophageal echocardiogram:
Mild aortic stenosis; normal ventricular function; no thrombi or vegetations
Ultrasound scan of AV prosthesis:
No signs of periprosthetic fluid or abscess
Ultrasound scan of abdominal and renal areas:
Normal liver and biliary tract; kidneys with signs of chronic nephropathy but no hydronephrosis; no intra-abdominal fluid
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28. Follow-up: 36 hours later
Patient is admitted to the ICU
Fever (39°C)
Confused and disorientated
Noradrenaline (3 µg/kg/min)
Gas exchange deteriorates
Laboratory values deteriorate:
WBC count 28 x 109/L (28 000/µL);
C-reactive protein 500 mg/dL;
Platelets reduce to 80 x 109/L (80 000/µL)
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Cardiovascular dysfunction Respiratory dysfunction Haematological dysfunction

29. Follow-up: 36 hours later (cont’d)
A urinary catheter was fitted:
60 mL of purulent urine was collected and sent for microbiological examination
Pyocystitis
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30. Question Should the antibiotic regimen be changed? Yes No Don’t know
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31. Should the antibiotic regimen be changed?
Yes No
Don’t know
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Answers from AIM meetings in 2007

32. Follow-up: 36 hours later (cont’d)
A urinary catheter was fitted:
60 mL of purulent urine was collected and sent for microbiological examination
The antibiotic therapy was changed to vancomycin plus meropenem
Pyocystitis
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33. Further follow-up Three days after admission Four days after admission
Blood cultures:
Escherichia coli susceptible to third-generation cephalosporins, ciprofloxacin and carbapenems, amoxicillin/clavulanate and piperacillin/tazobactam
Four days after admission
Urine cultures:
E. coli susceptible to third-generation cephalosporins, ciprofloxacin, carbapenems, amoxicillin/clavulanate and piperacillin/tazobactam
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34. Question Do you think the antibiotic regimen should be changed now?
Yes No
Don’t know
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35. Do you think the antibiotic regimen should be changed now?
Yes No
Don’t know
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Answers from AIM meetings in 2007

36. Further follow-up (cont’d)
The antibiotic regimen was changed to amoxicillin/clavulanate for 14 days
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37. Follow-up: Six days after admission
Patient is awake and co-operative
He is afebrile
No longer receiving noradrenaline
Gas exchange is improving
C-reactive protein level is decreasing
Platelet count is increasing
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38. Additional Questions What are the key learning points for this case?
Which of the AIM core principles could be applied to this case?
How could the educational value of this case be improved?
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39. Key learning points Importance of complete, early resuscitation
Treatment should be guided by clear goal variables
Cover all likely pathogens
Locate the source of the infection
Followed by source control, if possible
De-escalation – drug and duration
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Pyocystitis with Escherichia coli bacteraemia in a patient with diabetes and chronic renal failure on HD through vascular prosthesis