Hey all, I work behind the scenes as a microbiologist, and while I can probably tell you exactly what's growing in a patient's culture simply by sniffing I admittedly don't know a whole lot about what happens after I release their culture results. I'm hoping some of my ER and/or ID colleagues can give me some insight into a case I'm working on. I hope this is allowed, if not feel free to delete.
I have a urine culture from a male in his 30's who reported to the ER for UTI symptoms. Patient requires catheterization due to paraplegia. It looks like it's growing 2-3 different strains of P. aeruginosa and I can tell right away they look like bad ones – really sticky and orange/brown. Pseudo has about a million different flavors but those characteristics are more often associated with MDR strains, in my experience. I take a look at the patient's previous cultures and sure enough, he's had a long history of urine cultures growing MDR Pseudomonas since 2016, and it looks like there have been multiple strains popping up – one is pan-resistant to first and second-line antibiotics and the other is susceptible only to aminoglycosides.
This is starting to look interesting so I take a deeper look at the patient's history to discover he has been coming to the ER every 2 months for the last 2 years, every single visit report says something to the effect of "pt known to ER, complains of recurring UTI, pt self-catheterizes, urine cx ordered" and every time he was sent home with a prescription for either cipro or bactrim, neither of which are appropriate for his infection. Every single culture has grown MDR Pseudomonas, with the exception of a few that were cancelled due to suspected contamination which is our protocol any time we have a urine that grows 3 or more organisms.
To me it appears that no one has even been checking this poor man's history despite complaints of recurring infection and frequent visits to the ER and is just treating him with first line antibiotics? Especially considering how often he's been sent home with bactrim as it's not even effective against Pseudomonas… When we report a MDR organism we always notify the provider, so I would hope that therapy was changed after the results were reported, but considering the recurrence of the infection and the fact that no one has ever inquired about any additional sensitivities (usually I get the Avycaz/Zerbaxa/colistin requests immediately after reporting these guys!), I am concerned that this is not the case.
Generally I try to avoid questioning provider decisions – as I said, I don't know much about what happens outside of the lab – but something seems wrong here. This patient has seen multiple doctors now so I think this is more of a procedural issue than an individual one. Is this a typical protocol for treating CAUTI's in the ER, even when the patient has a previous history? Do ER providers even review culture results after the patient leaves? I am tempted to report this but I don't want to cause trouble if there's something I'm missing.
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