Clinical Pearls Blog: 54-year-old male w/ fever, malaise, cough

Test your clinical knowledge with this clinical pearl of the month review question.

Clinical Scenario

A 54-year-old man presents in follow-up from an emergency department (ED) visit a day prior. He was told to see his doctor for a recheck, after presenting to the ED with fever, malaise, and occasional cough.

The patient is a long-time smoker of a pack per day. His chronic medical problems include hypertension, hyperlipidemia, and low back pain.

In the emergency department, he was found to have a white blood cell (WBC) count of 16,000 WBC/mm3, with a neutrophil predominance.

He was afebrile when seen, but said that the prior evening he had chills and the feeling of fever.

His chest x-ray was negative, but some wheezing was noted on exam. He was discharged with a prescription for doxycycline 100mg PO for five days for a presumed COPD exacerbation and asked to follow-up with his PCP.

In clinic, the patient is non-toxic appearing and afebrile. He says that, after returning home from the ED, he still felt tired and had some chills, but perhaps not as much as the night prior.

His blood pressure is 132/76 mm Hg. He denies headache, nausea, or vomiting, but still has some occasional nonproductive cough.

On examination, he still has some wheezes on lung exam, but no other findings. No heart murmur or petechial rash is noted.

A review of the electronic medical record (EMR) shows that blood cultures drawn the day prior, in the ED, were both positive for gram positive cocci in clusters.

Question

How should this patient be managed at this point?

Answer Options:

Continue the current doxycycline treatment but extend course to ten days.

Change the antibiotic to levofloxacin orally and see patient in two days for reevaluation.

Hospitalize for intravenous vancomycin therapy, echocardiogram, and Infectious Disease consultation.

Change therapy to once daily intravenous ceftriaxone and arrange outpatient CT scan of chest, abdomen and pelvis.

See the Answer:

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Correct Answer:

Hospitalize for intravenous vancomycin therapy, echocardiogram, and Infectious Disease consultation.

Key Point:

Simple febrile seizures are generalized seizures associated with fever that don’t require extensive workup or treatment if the history and exam are otherwise reassuring.

Explanation:

This patient has Staphylococcus Aureus bacteremia without a clear source. S. Aureus bacteremia has a mortality up to 40%. It can originate in something as benign as a skin scratch.

Presence of S. Aureus in blood culture should arouse concern, and under treatment or lack of evaluation can have serious consequences.

Infectious Disease consultation has been shown to help reduce mortality in S. Aureus bacteremia cases, and should generally be part of the treatment plan.

Until it is known whether it is methicillin-sensitive or methicillin-resistant, the patient should be treated with vancomycin intravenously.

Total treatment duration will depend on whether it is complicated or uncomplicated bacteremia, and will include a minimum of two weeks of intravenous therapy. Therapy will be longer in cases of bone or joint infection.

Evaluation should include echocardiogram, preferably a transesophageal echocardiogram, since 30% of endocarditis cases are caused by Staph Aureus.

Other potential sites of infection include bone, soft tissue, and infected catheters and prostheses. Infection can spread to distant sites hematogenously.

Sometimes, PET scan is used to look for locus of infection when none is found otherwise and infection persists.

The alternative treatment options given for this patient are not intravenous therapy with empiric efficacy for both MSSA and MRSA and should not be used.

References:

Chambers H. Staphylococcal Infections in Goldman L ,Schafer A, eds. Goldman-Cecil Medicine.ed 20.Philadelphia, Elsevier, 2016, 288, 1896-1902

Vogel M, Schmitz RP, Hagel S, et al. Infectious disease consultation for Staphylococcus aureus bacteremia - A systematic review and meta-analysis. J Infect 2016; 72:19.

Goto M, Schweizer ML, Vaughan-Sarrazin MS, et al. Association of Evidence-Based Care Processes With Mortality in Staphylococcus aureus Bacteremia at Veterans Health Administration Hospitals, 2003-2014. JAMA Intern Med 2017; 177:1489

About the Author:

Gerard Kiernan, MD, FAAFP, FHM is a Dartmouth-Hitchcock Clinic hospitalist in Keene, NH. He attended the University of Rochester School of Medicine and Dentistry, followed by a Family Medicine residency at the University of Wisconsin, Madison, where he was a chief resident. Dr. Kiernan is a Lean Six Sigma Greenbelt and has led hospital medicine quality improvement efforts. He is a fellow of both the American Academy of Family Physicians and the Society of Hospital Medicine. He has achieved the Recognition of Focused Practice in Hospital Medicine offered through the AAFP and ABIM via their joint examination pathway.

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