Hospital-Acquired MRSA - Uncomplicated

Transcription

1 1 Hospital-Acquired - Uncomplicated and Culture if not improving Start Empiric Institute Contact Precautions and Dress wound Suspect Superficial CBC Blood Culture Continue Oral/ topical

2 WKSHEET 1.1: Hospital-Acquired - Uncomplicated 2 HISTY Scenario: Jane is 53-year-old patient who underwent a knee arthroscopy on May 15. She was discharged on May 16 and went for her routine physician follow-up appointment on May 20. At that time she reported pain and redness at the incision. Upon examination, the surgeon noted a low-grade fever and incisional inflammation. The physician admitted Jane to the hospital, blood and skin cultures were obtained, and she was started on empiric oral antibiotic. Based on the culture, Jane s antibiotic therapy was changed to PO Bactrim and the wound is drained, debrided, ded, and dressed. The patient t improved by hospital day 2 with resolution o of fever, e pain, and inflammation. at Jane was discharged the afternoon of hospital day 2 with a prescription for 7 of oral antibiotic therapy and instructions to return to the physician in 3 for an examination of the wound. Start Empiric Institute Contact Precautions and and Dress wound Culture if not improving Suspect Superficial CBC Blood Culture Continue Oral/ topical 1 Complete Blood Count x 2 1 Blood Draw x 2 1 Blood culture x 1 day 1 Wound culture x 1 day Antibiotics: IV Vancomycin x 1 day (q 12 h) PO Bactrim x 2 (q 24 h) Nursing time Wound debridement daily x 2 : Patient discharged with a 7-day prescription for oral Bactrim (CPT 87070) IV Vancomycin (CPT J3370) PO Bactrim Debridement in wound clinic (CPT 97597GP) 2 extra in the hospital Bactrim

3 WKSHEET 1.2: Hospital-Acquired - Uncomplicated 3 HISTY Scenario: A 56-year-old male is admitted for endovascular aortic stent graft placement for an abdominal aortic aneurysm. On the second postoperative day, the area of the left groin became tender and inflamed. Purulent drainage is noted, at the vascular access. Laboratory testing is performed, including blood cultures. Percutaneous drainage of the is done and a drain is placed. The patient is placed on empiric antibiotics intravenously. Blood cultures are negative but the wound cultures reveal. The patient is improved and is dismissed on the fifth hospital day to receive e a 10-day course of Zyvox, and is followed o in the wound clinic c three times weekly for two weeks. Start Empiric Institute Contact Precautions and and Dress wound Culture if not improving Suspect Superficial CBC Blood Culture Continue Oral/ topical 1 Complete Blood Count x 3 1 Blood Draw x 3 1 Blood culture x 1 day 1 Wound culture x 1 day Antibiotics: IV Vancomycin x 1 day (q 12 h) PO Zyvox x 2 (q 12 h) Nursing time Debridement x 3 : Patient discharged with a 7-day prescription for oral Zyvox?] (CPT 87070) IV Vancomycin (CPT J3370) PO Zyvox Debridement in wound clinic (CPT 97597GP) 3 extra in the hospital Zyvox

4 4 Hospital-Acquired - Complicated Pain/swelling Start Empiric IV Isolate Patient and implement Protocols Drain and Dress wound Wound Vacuum Culture Suspect Extensive Infection Cell Count Gram Stain Culture and sensitivity Imaging study (CT, MRI, Ultrasound) Continue Oral for wound debridement Continue IV antibiotics

5 WKSHEET 2.1: Hospital-Acquired - Complicated 5 HISTY Scenario: Frank is a 46-year-old patient who underwent a small bowel resection on January 7. The first two post-op were uncomplicated, but on post-op day 3, Frank spiked a fever and the nurses noted abdominal distention and pain on palpitation. Furthermore, when changing the dressing, the nurses noted drainage. The surgeon ordered blood cultures x 2, culture and sensitivity of drainage fluids, and CBC. The patient was started on empiric IV Vancomycin, and daily wound drainage, debridement, and dressing were ordered. A CT scan was ordered. Based on culture, the antibiotic was changed to IV Zyvox. The wound was reassessed every e 24 hours. The patient s t symptoms s slowly resolved, ed, and by day 6 of treatment the patient was ready for discharge. At discharge, Frank was prescribed oral antibiotics for 10, with instructions to call the surgeon if any symptoms returned. Pain/swelling Start Empiric IV Isolate Patient and implement Protocols Drain and Dress wound Wound Vacuum Culture Suspect Extensive Infection Cell Count Gram Stain Culture and sensitivity Imaging study (CT, MRI, Ultrasound) Continue Oral for wound debridement Continue IV antibiotics Complete Blood Count once a day x 6 Blood Draw x 6 Blood culture x 2 x 1 day CT Scan Antibiotics: IV Vancomycin x 2 (q 12) PO Zyvox x 4 (q 12) Wound vacuum x 5 - Nursing time. Debridement x5 : Patient discharged with a 10-day prescription for oral Zyvox. (CPT 87070) CT Scan (CPT 74170) IV Vancomycin (CPT J3370) PO Zyvox Debridement in wound clinic (CPT 97597GP) Wound Vacuum x 5 (CPT 97605GP) 5 extra in the hospital Zyvox

6 WKSHEET 2.2: Hospital-Acquired - Complicated 6 HISTY Scenario: 57-year-old female is admitted to hospital to undergo a left knee arthroplasty. On the third hospital day, the knee is noted to be inflamed, and purulent drainage is noted at the upper portion of the incision. The patient undergoes diagnostic blood testing and blood cultures, and empiric antibiotics are started intravenously. The knee is more inflamed and swollen on the 4 th hospital day; the patient is taken to the operating room, the prosthesis is lavaged, and the wound is debrided. Culture of the blood is negative, but the wound cultures and cultures taken from the prosthesis s reveal ea. Antibiotic therapy changed to Zyvox. The patient t does not improve, and she is taken back to the operating room and the prosthesis is removed. The patient is dismissed after the 10 th hospital day and will be followed in the infusion clinic to receive a total of twenty-eight of intravenous Vancomycin. A replacement of the knee prosthesis is planned in three months. Pain/swelling Start Empiric IV Isolate Patient and implement Protocols Drain and Dress wound Wound Vacuum Culture Suspect Extensive Infection Cell Count Gram Stain Culture and sensitivity Imaging study (CT, MRI, Ultrasound) Continue Oral for wound debridement Continue IV antibiotics Complete Blood Count once a day x 8 Blood Draw x 8 Blood culture x 2 x 1 Prosthesis culture x 1 Antibiotics: IV Vancomycin x 8 (q 12) Wound vacuum x 7 - Nursing time Return to surgery for lavage, debridement Return to surgery for removal of prosthesis Antibiotics: Patient discharged with a 28-day prescription for outpatient IV Vancomycin therapy (q 12) IV Vancomycin (CPT J3370) (CPT 87070) Debridement in wound clinic (CPT 97597GP) Wound Vacuum x 7 (CPT 9705GP) Wound Debridement Prosthesis removal 7 extra in the hospital Antibiotics IV Vancomycin Infusion Service (CPT 96365)