Clinical Review
OUTCOME FOR THE CASE PATIENT
The patient required an 11-day hospitalization; her day-by-day course is described briefly below.
Day 1. Upon admission, abdominal MRI was ordered (see Figure 1) and empiric piperacillin/tazobactam IV was initiated. C-reactive protein (CRP) level and white blood cell (WBC) counts were elevated (see Table 2). Infectious disease, surgery, and urology consults were obtained.
Day 2. Fine-needle aspiration of the abscess was performed for cultures, and 40 mL of purulent fluid was drained. Piperacillin/tazobactam administration was continued, but the patient experienced ongoing fever and vomiting.
Day 3. Preliminary aspirate culture results revealed S aureus infection. Piperacillin/tazobactam was discontinued, and vancomycin IV was started. CRP levels and WBC counts decreased, as did fever and vomiting.
Day 4. Final aspirate culture results identified MRSA infection, sensitive to clindamycin. Vancomycin was discontinued, and clindamycin IV was started. Although the patient’s condition improved somewhat, fever and vomiting persisted.
Day 5. Both CRP levels and WBC counts increased from day 3. A surgical consult was sought.
Day 6. Repeat abdominal MRI revealed a decrease in the size of the abscess (see Figure 2, page 30. CRP levels and WBC counts remained high, with persistent fever and vomiting.
Day 7. The clinical team, in consultation with the parents, determined that placement of a peripherally inserted central catheter (PICC) line for drainage of the abscess was necessary.
Day 8. A 10-French pigtail catheter was inserted into the abscess, 20 mL of purulent fluid was drained, and a PICC line was inserted. Clindamycin IV was continued and, eight hours after the catheter was placed, fever and vomiting resolved.
Day 9. Both CRP levels and WBC counts dropped by half (WBC count was normal), while 10 mL of clear fluid drained from the catheter. The patient remained afebrile, without nausea or vomiting, on clindamycin IV.
Day 10. After 36 hours of clear drainage, the catheter was removed. CRP level further decreased. Clindamycin IV was discontinued, and the patient, now asymptomatic, was started on oral clindamycin.
Day 11. The patient was discharged on a regimen of oral clindamycin for six weeks, with weekly abdominal ultrasounds. She completed her entire course of antibiotics and fully recovered from the infection.
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