Q: 54 year old male with history of double lung transplant two years ago, is admitted to ICU with septic shock. Patient also has underlying comorbidity of diabetes mellitus secondary to steroid therapy. Patient was intubated in ER and required pressors. Respiratory Therapist reports "greenish" sputum sample. On clinical exam, patient also noted to have swollen right knee. Patient has documented severe allergy to Penicillin. Also, at least on two occasions previously, patient thought to develop "Red-Man Syndrome" from Vancomycin.  From the following, which antibiotic regimen would be appropriate beside joint drainage?

A) Clindamycin and Ciprofloxacin
B)  Linezolid,  Ciprofloxacin and Gentamicin
C)  Daptomycin and Ceftazidime 
D) Slow infusion of Vancomycin and later adjustment of antibiotics depending on culture
E)   Linezolid,  Daptomycin and Clindamycin


Answer: B

Patient  at this stage requires full broad spectrum antibiotic coverage. Patient may be immunocompromised due to immunosuppressive therapy post lung transplant. Also, patient has a risk factor of diabetes mellitus. With massive septic shock, and report of greenish sputum, pseudomonas aeruginosa need to be covered at least in the beginning.

Now with given severe allergy to penicillin as well as high intolerance to vancomycin -

C) is not a good choice as ceftazidime is a cephalosporin and patient with septic shock may not be able to sustain any further vasoplegia from allergic reaction.

D) is a wrong choice as monotherapy as in septic shock patient, it is not sufficient.

E) is inappropriate as all three drugs cover only gram positive organisms.

A) can be a choice but in severely septic patient with high suspicion of gram negative sepsis, double coverage with added gentamicin would be a better choice. Moreover, with patient's history of previous hospitalizations, methicillin-resistant S. aureus (MRSA) need to be covered, and neither clindamycin nor ciprofloxacin covers it.



 Reference: 

Sharff KA, Richards EP, Townes JM. Clinical management of septic arthritis. Curr Rheumatol Rep 2013; 15:332.