1. Treatment options in a mechanically ventilated young patient
Mechanically ventilated young patient who develops pneumonia A 23-year-old male motorcycle passenger was involved in a road accident. He was not wearing a helmet. The patient has a closed head injury with multiple facial fractures and is intubated on admission to hospital.
Learning's:
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Treatment options in a mechanically ventilated young patient

2. History and examination
A 23-year-old male motorcycle passenger was involved in a road accident. He was not wearing a helmet. The patient has a closed head injury with multiple facial fractures and is intubated on admission to hospital.
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3. Questions 1 & 2 What would be your next course of action and why?
Would you administer prophylactic antibiotics? Please specify your reasons.
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4. Treatment
The oromaxillary facial surgeon administers cefazolin as anti-bacterial prophylaxis.
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5. Question 3
Do you agree with the surgeon’s choice of cefazolin as prophylactic antibiotic? Please give reasons for your answer.
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6. OUTCOME
On Day 4 of cefazolin therapy, the patient develops a fever (38.4°C) together with:
Increased serum creatinine correlating with a reduced creatinine clearance (~30 mL/min), which could be due to exposure to contrast media or trauma
A slight increase in sputum production (12 300/μL) with no increase in bands (ie no left shift)
a slightly elevated white blood cell (WBC) count of 12.3 x 109/L
A chest X-ray is taken to determine whether the patient has an infection, fluid overload or contusion. The chest X-ray reveals pneumonia.
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7. Question 4
What are the most important factors to consider in the management of infections such as this?
Why are these factors important?
Leibovici et al. J Intern Med 1998;244:379–386
Vincent. Lancet 2003;361:2068–2077
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8. Question 5
Would you change or modify the patient’s antibiotic regimen?
Please specify reasons for your decision.
Rello et al. Chest 2001;120:955–970
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9. Question 6
If you decide to change or modify therapy, what empiric therapy would you choose and why?
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10. Question 7
What are the most important organisms for which antibiotic coverage should be provided and why?
Are these organisms prone to developing resistance on therapy?
Cosgrove et al. Arch Intern Med 2002;162:185–190
Kollef. Chest 1999;115:8–11
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11. Question 8
What pharmacokinetic/pharmacodynamic parameters do you think should be considered when making treatment decisions?
Drusano et al. Clin Microbiol Infect 1998;4(Suppl. 2):S27–S41
Drusano & Craig. J Chemother 1997;9:38–44
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12. Clinical Course
On Day 4, ceftriaxone is added to the patient’s antibiotic regimen. Cefazolin therapy is continued
The patient’s condition is stable on Days 5–13
On Day 14, ceftriaxone and cefazolin are discontinued
On Day 18, a chest X-ray reveals a possible new infiltrate
A temperature spike occurred during the previous night — the morning WBC count is 18.5 x 109/L (18 500/μL) — there is a change in the quality and consistency of the patient’s sputum.
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13. Question 9
Do you agree with the decision to add ceftriaxone to the patient’s antibiotic regimen?
Explain the reasons for your answer.
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14. Question 10
At this point, would you administer a cephalosporin or another class of antibiotic?
Give reasons for your decision.
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15. Clinical Course (continued)
Ceftazidime is administered
Enterobacter spp. are reported on Day 20
Clinical deterioration (fever, increased WBC count, worsening infiltrates on chest X-ray and a change in ventilation requirements) is reported on Day 22
Ceftazidime is discontinued and therapy is started with an aminoglycoside and piperacillin–tazobactam.
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16. Question 11 Do you agree with the change in antibiotic therapy?
Give reasons for your answer.
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17. Clinical Course (continued)
On Day 25, the patient’s condition stabilises and the Enterobacter spp. are reported to be resistant to ceftazidime
Between Days 26 and 36, the patient’s pneumonia resolves; he completes the 14-day course of combination therapy.
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18. Question 12
What are the potential clinical and economic implications of drug- resistant bacterial pneumonia?
Abramson. Infect Control Hosp Epidemiol 1999;20:408–411
Carmeli et al. Arch Intern Med 1999;159:1127–1132
Cosgrove et al. Arch Intern Med 2002;162:185–190 Stosor et al. Arch Intern Med 1998;158:522–527
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19. Additional Questions What are the key learning points from 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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20. What if ... P. aeruginosa was the documented pathogen?
P. aeruginosa culture persisted?
The antibiotic dose was incorrect?
The patient suffered from renal failure?