ANSWER:
Presentation of the Patient:
A 42-year-old woman with a history of bladder cancer presents to the emergency department (ED) with a fever and general malaise. She is currently having chemotherapy and has a urinary catheter in place. Urine from the catheter is sparse, black, and foul-smelling. Her vital signs show a 102.2°F fever, a heart rate of 136 beats per minute, a blood pressure of 110/50 mmHg, and a respiratory rate of 28 breaths per minute. The patient has penicillin and sulfa allergies.
Septic shock is the most likely diagnosis based on the patient’s clinical presentation. A septic shock is a severe form of sepsis characterized by a massive systemic response to infection. A urinary catheter, foul-smelling urine, fever, tachycardia, hypotension, and tachypnea suggests a urinary tract infection that has progressed to sepsis and, eventually, septic shock.
Treatment Expected: The doctor is likely to order the following treatment for the patient:
a. Fluid resuscitation: To restore appropriate circulation and perfusion, the patient’s hypotension demands rapid fluid resuscitation with intravenous fluids such as isotonic crystalloids (e.g., normal saline).
a. Empirical antibiotic therapy: Given the patient’s penicillin and sulfa allergies, the doctor may prescribe Bactrim (trimethoprim/sulfamethoxazole) to cover common uropathogens while waiting for urine and blood culture findings. However, patients with sensitivities should exercise caution due to the possibility of severe reactions to sulfa medicines.
c. Source control: The underlying urinary tract infection, which the indwelling urinary catheter may have induced, must be treated. The doctor may remove or replace the catheter to prevent additional disease.
d. Hemodynamic support: If the patient’s blood pressure does not improve with fluid resuscitation alone, other therapies such as vasopressor medicines (e.g., norepinephrine) may be necessary to maintain adequate blood pressure and tissue perfusion in septic shock.
e. Close monitoring: To guide continued management, the patient’s vital signs, urine output, laboratory values (e.g., complete blood count, blood cultures), and response to interventions must be closely monitored.
Patient Education on Infection Prevention: The patient can be taught the following measures to help prevent future infections:
a. Hand hygiene: Stress the necessity of thoroughly cleaning hands with soap and water or using an alcohol-based hand sanitizer before and after any contact with the urinary catheter or its drainage system.
a. Catheter care: Teach the patient about correct catheter care, such as cleaning the catheter insertion site with mild soap and water regularly, maintaining proper hygiene during catheter changes, and avoiding unnecessary catheter manipulation.
c. Hydration: Maintaining appropriate fluid intake can help prevent urinary stasis and lower the risk of urinary tract infections.
d. Recognizing signs of infection: Inform the patient about the signs and symptoms of infection, such as fever, increased pain or discomfort, and changes in urine color or odor, as well as the need to report these symptoms to healthcare practitioners as soon as possible.
Bactrim (trimethoprim/sulfamethoxazole) side effects:
When a patient with a known sulfa allergy is given Bactrim, there is a risk of hypersensitivity reactions ranging from minor rashes to severe allergic reactions such as Stevens-Johnson syndrome or anaphylaxis. As a result, after starting Bactrim therapy, it is critical to monitor the patient for any adverse reactions thoroughly. If the patient develops any symptoms of an allergic response, such as a rash, itching, trouble breathing, or swelling, seek emergency medical treatment and discontinue the medicine.
Bactrim may also cause gastrointestinal disorders (nausea, vomiting, diarrhea), photosensitivity (heightened sensitivity to sunlight), and hematological abnormalities (such as anemia or a reduction in platelet count). The patient should be informed about these potential side effects and instructed to notify their healthcare provider if they have any troubling symptoms.
Bactrim should be used with caution in this circumstance due to the patient’s sulfa sensitivity and constant monitoring for adverse events. To guarantee effective treatment of the underlying infection, the doctor should additionally assess the appropriateness of Bactrim based on the patient’s renal function and local resistance patterns of uropathogens.
QUESTION:
What should you be concerned about? Why?