Quote:
Originally Posted by PedOncoDoc
This depends on what is on hand.
I doubt we have vancomycin available, and his hydration status keeps me from wanting to further stress his kidneys.
I would choose clindamycin (good coverage for oral bacteria, covers some strains of MRSA and also effective against malaria) - given the clinical scenaria I would give IV if possible/available. I would dose at 600mg IV q8hrs.
Prior to starting Abx can we draw a blood sample for culture (to be analyzed at the facility to which we are heading)? It's best to ID the bug so treatment can be tailored based upon sensitivities (if available).
The reason some of us want to rule out bacterial endocarditis is because transient bacteremia during/following dental work can lead to cardiac bacterial vegetations that shower off bacteria, may cause septic emboli and persistent bacteremia which would put him at risk of further end-organ infections.
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Absolutely agree on the endocarditis! Ruling it out is crucial, and continued surveillance is also crucial. I just objected to it being the presumptive diagnosis and cause of the osteomyelitis.
I'm happy with that treatment plan. Clindamycin seems reasonable if you have it. Rocephin would also be a reasonable broad spectrum agent a medic is likely to have available. Start treating this right away!
So, treatment plan:
Start IV antibiotics immediately (agent selected based upon availability)
Pain Control?
Medevac imediately
Reassess, reassess, reassess
Unanswered questions:
1. What, precisely, is a "night sweat?"
2. What does "pain greater on flexion than extension" suggest in the context of vertebral back pain? How does this fit with our differential at this point?
3. Renal pathology is absolutely a consideration for low back pain, but there are a number of findings in our history and physical at this point that make renal issues less likely in this patient. What are they?
4. Since we're talking about sepsis as a possible complication, what is it and how would we recognize it?