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Zorluk: KolayGastroenterology and Hepatology

A 62-year-old woman is evaluated in the hospital on hospital day 2. She was admitted with right upper quadrant abdominal pain, fever, and jaundice, and was diagnosed with acute ascending cholangitis. She underwent an urgent endoscopic retrograde cholangiopancreatography (ERCP) with successful biliary stone extraction and stent placement. On admission, blood cultures were drawn, and she was started on empiric intravenous piperacillin-tazobactam. Today, her temperature is 37.1°C (98.8°F), blood pressure is 122/78 mm Hg, and pulse is 78/min. She reports significant improvement in her abdominal pain. The admission blood cultures are now growing *Escherichia coli*. The antimicrobial susceptibility report is as follows:

AntimicrobialSusceptibility
AmpicillinResistant
CeftriaxoneSusceptible
CiprofloxacinSusceptible
MeropenemSusceptible
Piperacillin-tazobactamSusceptible

Which of the following is the most appropriate next step in pharmacotherapy?

  1. Switch to intravenous ceftriaxoneCevap
  2. B
    Continue intravenous piperacillin-tazobactam
  3. C
    Switch to intravenous meropenem
  4. D
    Add intravenous vancomycin
  5. E
    Switch to oral ampicillin

Cevap

Switch to intravenous ceftriaxone
This patient has acute ascending cholangitis that has been appropriately managed with definitive source control (ERCP) and empiric broad-spectrum antibiotics (piperacillin-tazobactam). Now that the causative organism (Escherichia coli) and its susceptibilities are known, and the patient is clinically improving, standard of care dictates de-escalating to a narrower-spectrum antimicrobial. Ceftriaxone is a third-generation cephalosporin that provides excellent, targeted coverage for this susceptible Gram-negative isolate. This core principle of antimicrobial stewardship minimizes collateral damage to the patient's normal flora, reducing the risk of antibiotic resistance and opportunistic infections like Clostridioides difficile.

Adım Adım Çözüm

1
Assess the patient's clinical status and degree of source control.
The patient has undergone a successful ERCP (adequate source control) and is clinically improving with normal vital signs.
Determines if the patient is stable enough to step down or adjust antimicrobial therapy.
2
Review the microbiological culture and susceptibility data.
The infection is caused by a single organism, E. coli, which is susceptible to ceftriaxone, ciprofloxacin, meropenem, and piperacillin-tazobactam, but resistant to ampicillin.
Identifies the specific pathogen vulnerabilities to guide targeted pharmacotherapy.
3
Apply the principles of antimicrobial stewardship.
Intravenous ceftriaxone is selected as the definitive therapy.
Ceftriaxone provides targeted, narrow-spectrum coverage for the susceptible Gram-negative isolate, effectively treating the infection while minimizing the selective pressure for resistance.

Anahtar Kavram

Antimicrobial de-escalation in biliary infections
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Konular

Gastroenterology and Hepatology

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