Case Presentation:
A 55‐year old man with a history of diabetes type II and nasopharyngeal cancer on home intravenous antibiotic therapy presented with fever. He had been treated with chemotherapy and resection previously and one month prior to admission he was admitted for tumor recurrence and had repeat resection. By intraoperative biopsy he was found to have MRSA osteomyelitis of the clivus. He was discharged home on intravenous vancomycin, feeding by PEG tube, and tracheostomy in place to be cared for by his wife.
On the day of admission, by report, the wife attempted to flush the PICC line after administration of the intravenous vancomycin. She accidentally grabbed the syringe filled with tap water which had chronically been used to flush his PEG tube and flushed the PICC line. Thirty minutes later the patient developed fever and rigors and was taken to the hospital.
On admission, he had a temperature of 40°C, blood pressure 70/30mmHg, and heart rate 135bpm. He had well‐healed scalp scars, a normal cardiopulmonary exam, and a clean PICC line site. He was treated with aggressive intravenous fluids, broad‐spectrum antibiotics, and required neosynephrine. Two out of two blood cultures subsequently grew Klebsiella pneumoniae, Enterococcus faecalis, Klebsiella oxytoca, Enterobacter cloacae, Candida tropicalis, and vancomycin‐resistant lactobacillus species. He was treated with amoxicillin, ciprofloxacin, vancomycin, and caspofungin. He generally did well and was off vasopressors within 24 hours. Eventually the patient was discharged to home with home care to receive two weeks of the regimen above.
Discussion:
Although contaminated tap water has been associated with nosocomial and community outbreaks, most drinking water in the United States is extremely safe and strictly regulated by the EPA. The nature of the microbiology, rapid onset, and degree of illness instead argue that the “healthcare associated” syringe had become chronically colonized with the pathogenic organisms and a large inoculum was infused.
In that light, the case highlights one of the many potential complications of outpatient parenteral antibiotic therapy (OPAT). As hospitals and hospitalists are under increasing pressure to reduce length of stay (LOS) and costs, there has been an explosion in the use of OPAT. OPAT has been found to be generally efficacious and cost‐effective in appropriate patient populations. Complications are rare and typically minor including mechanical line dysfunction and phlebitis. Line infections and line sepsis are uncommon, occurring in less than 5% of patients, but often require readmission and line removal and clearly add healthcare costs.
Conclusion:
Hospitalists should be aware of the complications associated with OPAT and be sure patients or caregivers are capable, responsible, and have a safe and stable home environment.
Author Disclosure Block:
B.A. Sharpe, None; K. Trivedi, None.