Scenario 1
A 68-year-old male recipient of a cadaveric liver transplant four years previous for alcohol cirrhosis with good graft function and excellent adherence to immune suppressive regimen was admitted to the hospital for “suspect infection.”
At the time of admission, the patient demonstrated a T 101°F, HR 108 and regular, BP 110/62, R 19 and non-labored, Pox 98% on RA.
Detailed examination was unremarkable. Labs demonstrated a WBC of 17,000 with 86% neutrophils, but were otherwise unremarkable. The patient was placed on empiric broad spectrum antibiotics, including IV vancomycin and IV ceftazidime. He was vaccinated for both Hep A and B.
Evaluation during his 5-day hospital stay included two sets of blood cultures daily through day 3 of hospitalization, CXR and urine culture on admission, CT of chest/abdomen/pelvis, chest CT angiography, bilateral lower extremity doppler ultrasonography, transthoracic echocardiogram, CMV quant, serum HSV cultures, serum EBV IgM /IgG, and HCV quant. All were negative.
By day 3 of hospitalization, the patient became afebrile, and WBC normalized to 8,000. On day 4, antibiotics were changed to oral levofloxacin 750 mg po daily to be continued to complete a course of 14 days.
The patient remained afebrile for the rest of his hospitalization, and he was discharged to home on day 5.
Scenario 2
A 48-year-old female, five days s/p round 3 of systemic chemotherapy for metastatic breast cancer, was admitted to the hospital for “suspect infection.”
At the time of admission, the patient demonstrated a T 100.6°F, HR 99 and regular, BP 120/71, R 16 and non-labored, Pox 99% on RA.
Detailed examination was unremarkable. Labs demonstrated a WBC of 1,200 with absolute neutrophil count (ANC) 480, Hgb 9.3 with normal indices, platelets 137,000.
Comprehensive metabolic profile was unremarkable, and the patient was placed on broad spectrum antibiotics including IV vancomycin and IV ceftazidime, as well as GCSF.
Evaluation during her 6-day hospitalization included two sets of blood cultures daily through day 3 of hospitalization, CXR and urine culture on admission, CT of chest/abdomen/pelvis, chest CT angiography, bilateral lower extremity doppler ultrasonography, and serum viral cultures. All were negative.
On day 2 of hospitalization, the patient became afebrile. IV antibiotics were discontinued on day 4 of hospitalization, at which time, the patient’s absolute neutrophil count was 1,500.
GCSF was discontinued on day 5, and the patient remained afebrile. The patient was discharged to home on day 6 with no antiobiotics.