Since my undergraduate days, I had an interest in microbiology and infectious disease therapy and as I’ve progressed over the years that interest continues to grow.
Earlier in my P4 year, I was fortunate enough to have been on my Acute Care rotation with Dr. Jason Cota, one of my pharmacy school professors and an extremely talented infectious disease specialist.
It was an absolute pleasure having Dr. Cota as a preceptor; during my time with him, he helped me grow both professionally and personally, and I can honestly say he is one of the coolest people I’ve had the fortune to work with.
One of the things that Dr. Cota has always stressed to his students was the importance of antibiotic stewardship; that is, the practice of tailoring therapy to the specific pathogens causing a patient’s infection, as they are identified and their susceptibilities become known.
With this in mind, that morning during rounds I made the recommendation that J.R.s vancomycin regimen be discontinued based on the preliminary culture results; the attending acknowledged my suggestion and we moved on to the next patient without making a firm decision as to whether or not to cut the vancomycin.
The next day, however, I was disheartened to see that J.R. was indeed still on the same antibiotic therapy and my suggestion to change the therapy had not been taken. Additionally, not only had J.R.s SCr remained around the 9.0 mg/dL mark, his BUN had spiked to a level of 67 g/dL, yielding a BUN/SCr ratio of approximately 7.4.
Since the ratio was less than 10:1, the type of kidney injury was likely intrarenal and my mind immediately jumped to the possibility of vancomycin-induced acute interstitial nephritis. Finally, J.R. had been started on continuous renal replacement therapy (CRRT) necessitating dose adjustments to his antibiotic therapy, which was the hemofiltered icing on the nephrotoxic cake.
With these troubling findings in the back of my mind I decided to check the status of the blood and urine cultures with the hope that they weren’t as dire as I had previously thought; luckily, they weren’t. As I looked at the final results, I breathed a sigh of relief: the offending pathogen in both sets of cultures was E. coli and a relatively pan-susceptible strain at that.
Don’t get me wrong a patient with sepsis and such severely depleted kidney function that required CRRT is by no means a good situation, but at that point, anything positive was good news. As I scanned the report, I quickly realized that the susceptibilities were exactly the same, indicating it was highly likely we were only dealing with one strain.
As I brought the results to Phillips attention, he challenged me (as he normally did) to decide on which was most appropriate for J.R. with the entire clinical picture in mind, I narrowed my choices to ciprofloxacin and ceftriaxone, two antibiotics known for their excellent track record in treating UTIs as well as susceptible blood stream infections.
With some prodding in the right direction from Phillip, I realized what he was thinking ciprofloxacin required dose adjustments for CRRT while ceftriaxone did not. Armed with this new information and after a quick consultation of the appropriate drug references, I chose a dose (1g IV Q12H) and headed upstairs to rounds, going over in my mind how I would lay out my case.
As we arrived to J.R.s room, I brought up the culture results and made my recommendation to the team and the attending physician to completely discontinue both the vancomycin and piperacillin-tazobactam regimens and start ceftriaxone, specifically mentioning the lack of dosing adjustments. To my mild surprise, my attending agreed with my assessment and ordered the recommended change.
With a feeling of self-satisfaction, I continued on with my duties for the rest of the day, hopeful that my change would make a difference. When I arrived at the hospital the following Wednesday morning, I immediately pulled up J.R.s electronic chart and furiously scrolled to his labs.
Success! Not only had his WBC count dropped to 8.6, his BUN/SCr ratio had dropped back down to well within normal limits at 7 g/dL and 0.8 mg/dL, respectively. I was so excited, not only for the fact that J.R. had made such an improvement, but also since I had a hand in steering him in that direction I even got a good call from the attending that morning during rounds.
After the eventful week that had just transpired, that definitely felt good to hear. I’m sure, of course, that the CRRT had a lot to do with J.R.s improvement, but I felt satisfied in myself nonetheless. J.R.s improvement maintained through the next day, but on the following Friday (the last day of my rotation) his status began to decline yet again.
His BUN and SCr values risen back up to 36 g/dL and 2.8 mg/dL overnight. While this was, of course, another cause for concern, I left rounds that morning for the final time feeling guardedly confident that everything would work out for him in the end. I never imagined how wrong I was.
Sometime after I completed the rotation and began gathering information to write this report on how I impacted patient care, I emailed Phillip to say hello and also inquire about J.R.s outcome in order to bring the whole experience full circle. I opened my inbox the next day to find a response from Phillip and as I read the first sentence, I felt my stomach drop like a rock.
J.R. progressed into both hepatic and renal failure the day I left. After being restarted on Piperacillin – Tazobactam the following day, he died that Sunday. It was at that moment I realized, once and for all, everything that had happened the regimen changes, the workups, the labs, the cultures, the recommendations, and my misplaced excitement and pride didn’t matter. In the case of J.R. it just wasn’t enough. What really matters, the only thing that really matters in the end, is ensuring the well-being and health of the patient.
Though I’d make the same recommendations again in a heartbeat, I learned a valuable lesson in the complicated dance that is patient care: the decisions we make, right or wrong, are not for personal satisfaction or acclaim, but rather the person that is lying in the bed in front of you.
Instead of jumping to conclusions or getting ahead of one’s self, it’s paramount to take everything as it presents itself and see the entire clinical picture for what it is. After all, were not treating numbers, but rather living, breathing human beings. Without a doubt, I learned a lesson from this experience that I’ll never forget; I just wish it wouldn’t have taken J.R.s death to make me realize it.