Case Scenario The patient is a 54-year-old Caucasian male with ulcerative colitis who underwent a total proctocolectomy with end ileostomy in 1997. He developed a parastomal hernia that was becoming increasingly symptomatic. Following a discussion with the patient regarding the risks and benefits of parastomal hernia repair, he underwent an exploratory laparotomy with enterolysis, parastomal hernia repair and re-siting of the ileostomy. The hernia defect was repaired primarily with a biologic mesh underlay (Alloderm, Lifecell®). He received one preoperative dose of cefoxitin; consistent with preoperative antibiotic guidelines. The operation was uneventful. His postoperative course was uncomplicated; on postoperative day 4 he was tolerating a regular diet and had normal ileostomy output. He was subsequently discharged home. Twenty-four hours later, he returned to the hospital emergency department with complaints of abdominal pain and feculent vomiting. Vital signs on arrival were notable for a temperature of 38.5 °C, heart rate of 130 beats per minute and blood pressure of 150/90 mmHg. On physical exam his abdomen was diffusely tender to palpation without peritoneal signs. The ileostomy was viable and there was gas and a small amount of fluid noted in the ostomy bag. A nasogastric tube was placed and returned 1600 mL of feculent effluent. Laboratory examination revealed a white blood cell count of 5400 cells/mm3, hemoglobin of 16 g/dL, and 192 000 platelets/mm3 and a serum lactate of 2.1 mg/dL. An abdominal and pelvic computed tomography (CT) scan obtained in the emergency department revealed mildly dilated, fluid filled small bowel without a transition point. There was a small amount of free fluid and air which was consistent with the history of recent laparotomy. Blood cultures were obtained in the emergency department. He was transferred to the intensive care unit for fluid resuscitation and started on broad-spectrum antibiotics. Serial abdominal exams were performed over the course of the next several hours, and he began to stabilize clinically. Notably, his tachycardia began to resolve and his urine output increased. Additionally, during this time, his ileostomy began to produce copious amounts of fluid and gas requiring frequent ostomy bag changes. The following day, his blood cultures returned positive for Enterococcus and his stool studies from his stoma output were positive for C. difficile. Treatment for C. difficile was initiated with oral metronidazole but was subsequently changed to a combination of intravenous metronidazole and vancomycin enemas as the patient was not tolerating oral intake well. On hospital day 2, the antibiotic regimen used to treat the bacteremia was tailored to intravenous vancomycin alone based on sensitivity information. The patient improved with his antibiotic treatment and was transitioned to oral vancomycin for treatment of C. difficile. He was treated for a total of 14 d and he had complete resolution of his symptoms. Questions: 1. From the study presented, infer and trace the chain of infection. Describe each component from the presented case. 2. Describe the contributing factors to the development of the hospital – acquired infection.
Case Scenario
The patient is a 54-year-old Caucasian male with ulcerative colitis who underwent a total
proctocolectomy with end ileostomy in 1997. He developed a parastomal hernia that was becoming
increasingly symptomatic. Following a discussion with the patient regarding the risks and benefits of parastomal hernia repair, he underwent an exploratory laparotomy with enterolysis, parastomal hernia
repair and re-siting of the ileostomy. The hernia defect was repaired primarily with a biologic mesh
underlay (Alloderm, Lifecell®). He received one preoperative dose of cefoxitin; consistent with
preoperative antibiotic guidelines. The operation was uneventful. His postoperative course was
uncomplicated; on postoperative day 4 he was tolerating a regular diet and had normal ileostomy output.
He was subsequently discharged home.
Twenty-four hours later, he returned to the hospital emergency department with complaints of
abdominal pain and feculent vomiting. Vital signs on arrival were notable for a temperature of 38.5 °C,
heart rate of 130 beats per minute and blood pressure of 150/90 mmHg. On physical exam his abdomen
was diffusely tender to palpation without peritoneal signs. The ileostomy was viable and there was gas
and a small amount of fluid noted in the ostomy bag. A nasogastric tube was placed and returned 1600
mL of feculent effluent.
Laboratory examination revealed a white blood cell count of 5400 cells/mm3, hemoglobin of 16
g/dL, and 192 000 platelets/mm3 and a serum lactate of 2.1 mg/dL. An abdominal and pelvic computed
tomography (CT) scan obtained in the emergency department revealed mildly dilated, fluid filled small
bowel without a transition point. There was a small amount of free fluid and air which was consistent with
the history of recent laparotomy. Blood cultures were obtained in the emergency department.
He was transferred to the intensive care unit for fluid resuscitation and started on broad-spectrum
antibiotics. Serial abdominal exams were performed over the course of the next several hours, and he
began to stabilize clinically. Notably, his tachycardia began to resolve and his urine output increased.
Additionally, during this time, his ileostomy began to produce copious amounts of fluid and gas requiring
frequent ostomy bag changes. The following day, his blood cultures returned positive for Enterococcus
and his stool studies from his stoma output were positive for C. difficile.
Treatment for C. difficile was initiated with oral metronidazole but was subsequently changed to a
combination of intravenous metronidazole and vancomycin enemas as the patient was not tolerating oral
intake well. On hospital day 2, the antibiotic regimen used to treat the bacteremia was tailored to
intravenous vancomycin alone based on sensitivity information. The patient improved with his antibiotic
treatment and was transitioned to oral vancomycin for treatment of C. difficile. He was treated for a total of
14 d and he had complete resolution of his symptoms.
Questions:
1. From the study presented, infer and trace the chain of infection. Describe each component from
the presented case.
2. Describe the contributing factors to the development of the hospital – acquired infection.
Step by step
Solved in 2 steps with 1 images
