A 63-year-old man with diabetes is hospitalized with right foot methicillin-resistant Staphylococcus aureus osteomyelitis complicated by sepsis and respiratory failure. He spends 3 days in the intensive care unit on mechanical ventilation but is now extubated and has resumed eating. He has generalized weakness, mild cough, and foot pain. The patient has no chest pain, abdominal pain, bleeding, or diarrhea. He has no prior history of pneumonia, heart failure, or coagulopathy. His current medications include intravenous vancomycin, subcutaneous heparin, short- and long-acting subcutaneous insulin, and omeprazole. His vital signs are within normal limits.
Laboratory values show hemoglobin of 12.2 g/dL, creatinine of 1.4 mg/dL, and albumin of 2.5 mg/dL. Coagulation profile is unremarkable.
Which of the following should be strongly considered when transferring this patient to the medical floor?

Question

A 63-year-old man with diabetes is hospitalized with right foot methicillin-resistant Staphylococcus aureus osteomyelitis complicated by sepsis and respiratory failure.  He spends 3 days in the intensive care unit on mechanical ventilation but is now extubated and has resumed eating.  He has generalized weakness, mild cough, and foot pain.  The patient has no chest pain, abdominal pain, bleeding, or diarrhea.  He has no prior history of pneumonia, heart failure, or coagulopathy.  His current medications include intravenous vancomycin, subcutaneous heparin, short- and long-acting subcutaneous insulin, and omeprazole.  His vital signs are within normal limits.
Laboratory values show hemoglobin of 12.2 g/dL, creatinine of 1.4 mg/dL, and albumin of 2.5 mg/dL.  Coagulation profile is unremarkable.
Which of the following should be strongly considered when transferring this patient to the medical floor?

Quizplus · Accepted Answer

Critically ill patients are at increased risk of gastrointestinal (GI) hemorrhage and may benefit from stress ulcer prophylaxis. Studies show that the incidence of bleeding in the intensive care unit (ICU) is approximately 1.5%-8.5% in patients receiving ulcer prophylaxis versus 15% in those not receiving prophylaxis. Nonetheless, ulcer prophylaxis may be associated with adverse effects (eg, nosocomial pneumonia, Clostridium difficile infection) and higher costs and should consequently be limited to high-risk patients. High-risk features include: History of GI bleeding in the past yearEvidence of coagulopathyMechanical ventilation >48 hoursSevere central nervous system injurySevere burnsA combination of sepsis, prolonged ICU stay, or corticosteroid use History of GI bleeding in the past year Evidence of coagulopathy Mechanical ventilation >48 hours Severe central nervous system injury Severe burns A combination of sepsis, prolonged ICU stay, or corticosteroid use Acceptable options for ulcer prophylaxis include proton pump inhibitors (PPIs), histamine-2 receptor antagonists, and oral antacids. Although comparative trials are limited, oral PPIs may be preferred given their effectiveness and low cost. Ulcer prophylaxis should be discontinued once a patient no longer has an indication. (Choice B) Albumin infusion can be considered in the setting of spontaneous bacterial peritonitis or large-volume paracentesis; however, hypoalbuminemia alone is not an indication. (Choice C) Although this patient may need to be switched from subcutaneous insulin to an oral diabetic medication regimen prior to discharge, it is not necessary at the time of transfer from the ICU. (Choice D) The optimal route of therapy (eg, oral versus parenteral) for methicillin-resistant Staphylococcus aureus osteomyelitis is unclear. Intravenous regimens may consist of vancomycin or daptomycin. Antibiotics with oral and intravenous dosing can include trimethoprim/sulfamethoxazole in combination with rifampin, linezolid monotherapy, or clindamycin monotherapy. Oral rifampin alone is not appropriate due to the development of drug resistance. (Choice E) Pharmacological thromboprophylaxis is preferred over mechanical thromboprophylaxis in patients who are not at risk for bleeding. Educational objective: Stress ulcer prophylaxis may be beneficial in high-risk critically ill patients but should be discontinued once the patient leaves the intensive care unit and no longer has an indication. Unnecessary use of proton pump inhibitors may be associated with adverse affects (eg, nosocomial pneumonia, Clostridium difficile infection) and higher costs. __________ References: Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. (http://www.ncbi.nlm.nih.gov/pubmed/21208910) Reducing adverse effects of proton pump inhibitors. (http://www.ncbi.nlm.nih.gov/pubmed/22962914)

A 63-Year-Old Man with Diabetes Is Hospitalized with Right Foot