Carbapenem Case 3

GC is an 81 y/o male re-admitted to hospital secondary to development of fever, flank pain and malaise, after having been discharged home 7 days ago following cystoscopy and removal of a large, 6mm renal stone. Although he was initially doing well post-discharge, 2 days ago he has developed chills, rigors and fever, as well as bilateral back pain despite treatment with ciprofloxacin PO.

Current Medical History
Diabetes, well controlled with metformin and insulin Lantus.

Relevant Past History
GC has a 10-year + history of multiple nephroliths. About 3 months ago he was treated by urology with bilateral ureteric stents for hydronephrosis secondary to multiple renal calculi. These, along with another stone, were removed during his last hospital admission 1 week ago. GC has been on multiple courses of antibiotics in the last year, most of which have been with fluoroquinolones. He also has an enlarged prostate with frequent symptoms of nocturia and retention, and is currently being worked-up for a TURP.

Current Status
Ceftriaxone and ciprofloxacin IV are started empirically in the emergency department and on day 2 of his admission, GC is transferred to the ward. He is no longer febrile, but his WBC is elevated at 13 x 10*9 /L. A urinalysis is positive for leukocytes and nitrates. A renal CT reveals 3 small non-obstructing stones in the collecting system of the left kidney, with no hydronephrosis. The prostate is markedly enlarged. A DRE reveals a large, non-tender prostate.

Preliminary urine cultures are positive for ESBL E.coli. Blood cultures are also positive for the same organism. GC is diagnosed with urosepsis post-nephrolithiasis and his therapy is changed to piperacillin-tazobactam. A urinary catheter has also been initiated for his symptoms of urinary retention.

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