No but if you're concerned enough about bacteremia to order blood cultures, they're tachycardic, acidotic and have a leukocytosis with a left shift, it doesn't seem unreasonable to order antibiotics.
Maybe. The tachycardia, leukocytosis, and acidosis in ED were all described as mild. Not sure what that means. Generally, leukocytosis (especially if mild) has poor test characteristics. Not sure what it's like at your hospital, but at my hospital a pre-occupation with occult sepsis results in everyone with SIRS getting BCX/Vanc/Zosyn, which can't be good. This patient was getting admitted, and didn't seem that sick at admission. Observation without antibiotics seems reasonable. I agree with you that 1 or 2 doses of abx is not a big deal in terms of stewardship, but I would reserve that for "sick" patients. Maybe if I saw the patient and lab values, I would agree this patient was "sick."
I think the biggest mistake here should be "assuming" ? Everyone assumed that the other treating doctor has already started on antibiotics, so no one bother to check
This is a bad miss. Anchoring and other cognitive biases can be deadly in the hospital. We all need to continually rescrutinize patients' presentations and take all sign outs with a healthy grain of salt. It's so easy to take the "UTI" or whatever from the ED and run with it without reconsidering the diagnosis
The admitting doc is at fault. First for not starting abx and second for a crappy sign out. The receiving doc has a responsibility to double check orders.
Do you hold the admitting doc and the ED doc equally responsible? Or does the admitting doc have more responsibility because the patient became febrile shortly after admission?
hmmmm...leucopenia with bandemia and toxic granulation, low platelet count, lactic acidosis, genlized weakness, fevers....blood cultures + for GPC in less than 24 hours and EVERYBODY missed/ignored the obvious diagnosis!
hard for me to imagine an institution in which there could be such a protracted failure chain.
Doesn't make much sense. I'm going to guess that he had the vague "generalized weakness" presentation that ends up getting described in a million different ways ranging from "my knees gave out" to "my arms are tired" to "i'm just sick", and they were kind of shotgunning at that point.
My feeling is that the hospitalists intentionally omitted ABx as they were utterly convinced that this was a viral infection, and that the BC represented a contaminant.
Both bottle positive and WCC left shift should have made them reconsider.
Highly risky to assume viral with positive blood cultures!
I heard of a baby dying recently due to a paediatrician assuming coag neg staph was a contaminant (it wasn’t).
Easier to argue that with one positive bottle! Thats a scary story about the coag neg staph... I've seen it before but only related to infections of implanted medical devices. And not in kids.
I disagree with you on this one. I'm not sure why you would assign blame to the EP. The patient wasn't septic at that time (only mild leukocytosis and tachycardia) and did not warrant antibiotics. The EP ordered a broad infectious workup including blood cultures that ultimately led to the final diagnosis.
I went back and forth about assigning any responsibility at all. I think you have a good point. There were some indicators that he might be septic but nothing specific. I might have gotten carried away with the Monday morning quarterbacking.
So, every ED patient with generalized weakness and leukocytosis needs antibiotics? That does not seem like good medicine.
No but if you're concerned enough about bacteremia to order blood cultures, they're tachycardic, acidotic and have a leukocytosis with a left shift, it doesn't seem unreasonable to order antibiotics.
Maybe. The tachycardia, leukocytosis, and acidosis in ED were all described as mild. Not sure what that means. Generally, leukocytosis (especially if mild) has poor test characteristics. Not sure what it's like at your hospital, but at my hospital a pre-occupation with occult sepsis results in everyone with SIRS getting BCX/Vanc/Zosyn, which can't be good. This patient was getting admitted, and didn't seem that sick at admission. Observation without antibiotics seems reasonable. I agree with you that 1 or 2 doses of abx is not a big deal in terms of stewardship, but I would reserve that for "sick" patients. Maybe if I saw the patient and lab values, I would agree this patient was "sick."
I think the biggest mistake here should be "assuming" ? Everyone assumed that the other treating doctor has already started on antibiotics, so no one bother to check
You know what they say about assuming...
This is a bad miss. Anchoring and other cognitive biases can be deadly in the hospital. We all need to continually rescrutinize patients' presentations and take all sign outs with a healthy grain of salt. It's so easy to take the "UTI" or whatever from the ED and run with it without reconsidering the diagnosis
Agree 100%, especially if you're super busy. Hard to start with a fresh mental view but its critical.
The admitting doc is at fault. First for not starting abx and second for a crappy sign out. The receiving doc has a responsibility to double check orders.
Do you hold the admitting doc and the ED doc equally responsible? Or does the admitting doc have more responsibility because the patient became febrile shortly after admission?
I think the upper body weakness distracted everyone from a strong suspicion of sepsis.
I agree. They seemed to anchor on localizing the weakness when (in hindsight) it was generalized weakness from sepsis.
hmmmm...leucopenia with bandemia and toxic granulation, low platelet count, lactic acidosis, genlized weakness, fevers....blood cultures + for GPC in less than 24 hours and EVERYBODY missed/ignored the obvious diagnosis!
hard for me to imagine an institution in which there could be such a protracted failure chain.
Very hard to understand how so many people could miss this. All the holes of the swiss cheese lined up at once.
Not really relevant to the case in the end, but why was a lumbar MRI ordered when the primary concern was about upper extremity weakness?
Doesn't make much sense. I'm going to guess that he had the vague "generalized weakness" presentation that ends up getting described in a million different ways ranging from "my knees gave out" to "my arms are tired" to "i'm just sick", and they were kind of shotgunning at that point.
My feeling is that the hospitalists intentionally omitted ABx as they were utterly convinced that this was a viral infection, and that the BC represented a contaminant.
Both bottle positive and WCC left shift should have made them reconsider.
Highly risky to assume viral with positive blood cultures!
I heard of a baby dying recently due to a paediatrician assuming coag neg staph was a contaminant (it wasn’t).
Easier to argue that with one positive bottle! Thats a scary story about the coag neg staph... I've seen it before but only related to infections of implanted medical devices. And not in kids.
I disagree with you on this one. I'm not sure why you would assign blame to the EP. The patient wasn't septic at that time (only mild leukocytosis and tachycardia) and did not warrant antibiotics. The EP ordered a broad infectious workup including blood cultures that ultimately led to the final diagnosis.
I went back and forth about assigning any responsibility at all. I think you have a good point. There were some indicators that he might be septic but nothing specific. I might have gotten carried away with the Monday morning quarterbacking.
Why would you assign fault to the ED doc?
Maybe its a bit harsh. There were definitely some red flags but nothing super concrete. To be honest I may have done the same thing myself.