Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 74-year-old man with fever and chills

mksap
Conditions
January 17, 2015
202 Shares
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 74-year-old man is evaluated in the emergency department for a 3-day history of fever and chills as well as confusion. He has a 5-week history of a nonhealing ulcer on the plantar surface of his left foot. He has diabetes mellitus, hypertension, and peripheral vascular disease for which he takes metformin, glyburide, lisinopril, chlorthalidone, and aspirin. He has no known medication allergies.

On physical examination, temperature is 39.0 °C (102.2 °F), blood pressure is 92/60 mm Hg, pulse rate is 108/min, and respiration rate is 18/min. He appears ill and is slow to respond. Examination of the left foot discloses a 3.5 × 2.5-cm ulcer with surrounding erythema and warmth. A foul odor and edema and tenderness involving the entire foot are noted. Pedal pulses are absent. The underlying bone is detected with a metal probe.

Laboratory studies indicate a leukocyte count of 21,500/µL (21.5 × 109/L) with 18% band forms. Serum electrolyte levels and kidney function tests are normal.

A radiograph of the left foot indicates no subcutaneous gas or foreign bodies.

Which of the following is the most appropriate empiric antimicrobial regimen?

A. Aztreonam and metronidazole
B. Cefazolin and metronidazole
C. Clindamycin and gentamicin
D. Vancomycin and meropenem

MKSAP Answer and Critique

The correct answer is D. Vancomycin and meropenem.

The most appropriate empiric treatment of this patient is vancomycin and meropenem. This patient is experiencing a septic syndrome and limb-threatening foot infection. Limb-threatening infections are characterized by extensive spreading cellulitis, extending far beyond the wound or ulcer, with systemic illness and possible sepsis with ulcers extending deep into the subcutaneous tissue, as well as tissue ischemia. Limb-threatening infections are polymicrobial, including staphylococci, streptococci, enteric gram-negative rods, Pseudomonas aeruginosa, and anaerobes. Ideally, a biopsy of the affected bone and deep soft tissues should be attempted before empiric antimicrobial therapy is initiated. However, in the setting of sepsis and a limb-threatening infection in a patient with diabetes mellitus, antimicrobial therapy using agents directed at suspected pathogens should urgently be administered. Surgical debridement will also be required. Patients with severe infections should receive parenteral therapy. Pending the results of microbiologic cultures, vancomycin and meropenem would be an appropriate combination of agents, predictably supplying broad coverage against the potential pathogens of concern.

Because they are not active against gram-positive cocci, aztreonam and metronidazole would not provide coverage against streptococci and staphylococci. Although metronidazole has excellent activity against anaerobic gram-negative bacilli, the narrow spectrum of activity of cefazolin versus many gram-negative bacilli, as well as its inactivity against methicillin-resistant strains, may be inadequate.

Because of clindamycin’s methicillin-resistant activity, this agent cannot reliably treat serious infections potentially involving staphylococci.

The use of gentamicin or other aminoglycosides to provide coverage against aerobic gram-negative bacilli in empiric antibiotic regimens for treatment of complex diabetic foot infections is not currently recommended because of the narrow toxicity-to-benefit ratio with such use. In addition, aminoglycosides may exhibit diminished antimicrobial activity in a necrotic, anaerobic environment.

Key Point

  • In the setting of sepsis and a limb-threatening infection in a patient with diabetes mellitus, antimicrobial therapy with agents directed at suspected pathogens should urgently be administered.

This content is excerpted from MKSAP 16 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

How to drive doctors to suicide: A step-by-step guide

January 16, 2015 Kevin 64
…
Next

Why is diagnosing ear infections so hard?

January 17, 2015 Kevin 12
…

Tagged as: Diabetes, Infectious Disease

Post navigation

< Previous Post
How to drive doctors to suicide: A step-by-step guide
Next Post >
Why is diagnosing ear infections so hard?

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

More in Conditions

  • Debating the role of psychiatric assessments in medical decisions

    Christian Youssef & Francisco M. Torres, MD
  • 5 things to know about weight from a bariatric surgeon

    Maria Iliakova, MD
  • Physician autonomy and patient interactions in corporate health care

    Michele Luckenbaugh
  • Vague criteria can lead to misdiagnosis and prison

    L. Joseph Parker, MD
  • U.S. maternal mortality crisis: a deep dive

    Alan Lindemann, MD
  • Contemporary weight loss: Unveiling the quest for elusive elixir

    Osmund Agbo, MD
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • I’m tired of being a distracted doctor

      Shiv Rao, MD | Tech
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • Balancing motherhood and medicine [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Misunderstandings about opioid use disorder

      Amy Baxter, MD | Conditions
  • Recent Posts

    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • Debating the role of psychiatric assessments in medical decisions

      Christian Youssef & Francisco M. Torres, MD | Conditions
    • Navigating adulthood in the digital age

      Eleanor Menzin, MD | Physician
    • 5 things to know about weight from a bariatric surgeon

      Maria Iliakova, MD | Conditions
    • Out-of-office infusions in oncology care [PODCAST]

      The Podcast by KevinMD | Podcast
    • The power of business knowledge for medical professionals

      Curtis G. Graham, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • New Cardiology Board to Come; 2nd Pig-Heart Xenotransplant; Uric Acid as Stroke Tx?
  • Postmenopausal Fracture Risk for SGLT2 Inhibitors Similar to Other Diabetes Drugs
  • Record-Breaking Obesity Certifications; 365-Day CGM Data; Med Spa Mounjaro Lawsuits
  • When Screening Guidelines Collide, Who Wins?
  • New Schizophrenia Treatments Are Coming: Don't Panic

Meeting Coverage

  • New Schizophrenia Treatments Are Coming: Don't Panic
  • Loneliness Needs to Be Treated Like Any Other Health Condition, Researcher Suggests
  • Stopping Medical Misinformation Requires Early Detection
  • AI Has an Image Problem in Healthcare, Expert Says
  • Want Better Health Outcomes? Check Out What Other Countries Do
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • I’m tired of being a distracted doctor

      Shiv Rao, MD | Tech
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • Balancing motherhood and medicine [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Misunderstandings about opioid use disorder

      Amy Baxter, MD | Conditions
  • Recent Posts

    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • Debating the role of psychiatric assessments in medical decisions

      Christian Youssef & Francisco M. Torres, MD | Conditions
    • Navigating adulthood in the digital age

      Eleanor Menzin, MD | Physician
    • 5 things to know about weight from a bariatric surgeon

      Maria Iliakova, MD | Conditions
    • Out-of-office infusions in oncology care [PODCAST]

      The Podcast by KevinMD | Podcast
    • The power of business knowledge for medical professionals

      Curtis G. Graham, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...