Re: baffling case
From: Richard Chudacoff, MD (rchudacoff@mylinuxisp.com)
Tue May 31 10:04:55 2005
My thoughts exactly. Hard to convince ID to stop the antibiotics though. If
she spikes today off the anti-pyretics, this is the path I shall follow.
--
Richard Chudacoff, MD
This message is confidential, intended only for the named recipient(s) and
may contain information that is privileged or exempt from disclosure under
applicable law. If you are not the intended recipient(s), you are notified
that the dissemination, distribution or copying of the messages is strictly
prohibited. If you receive this message in error, or are not the named
recipient(s), please notify the sender at either the e-mail address or
telephone number above and delete this e-mail from your computer.
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of art
fougner, md
Sent: Tuesday, May 31, 2005 9:58 AM
To: Multiple recipients of list OB-GYN-L
Subject: Re: baffling case
Not necessarily ... the start - stop - start - stop use of antibiotics
may serve only to foster overgrowth of resistant organisms. Would
reculture off antibiotics, then restart with or without ID consult as
well as heparin.
just my opinion ... i could be wrong.
art
At Tue, 31 May 2005, Charlie Chambers wrote:
>
>--Apple-Mail-6--343904413
>Content-Transfer-Encoding: quoted-printable
>Content-Type: text/plain;
> charset=WINDOWS-1252;
> delsp=yes;
> format=flowed
>
>Richard
>
>I'd definitely go with the septic pelvic thrombophlebitis. Unless she
>has an abcess which you have clearly looked for, the antibiotic
>regimens should have killed most things on the planet.
>
>************************************************************************
>****
>************************************************************************
>
>--
>Charlie Chambers
>Hood River, OR
>cchamber@alumni.rice.edu
>
>"Almost anything you do will seem insignificant but it is very important
>that you do it....You must be the change you wish to see in the world"
> -- Mahatma Ghandi.
>************************************************************************
>*******
>************************************************************************
>
>On May 31, 2005, at 7:13 AM, Richard Chudacoff, MD wrote:
>
>> 21 yo G1, GBS negative, admitted through the midwife service 12 days
>> ago. She arrested in dilation, after IUPC and FSE, and underwent an
>> unremarkable low transverse c-section via Pfannenstiel skin incision
>> 10 days ago. 36 hours post-op she spike to 103 degrees F and hand a
>> tender uterus, and was started on Ampicillin, gentamycin and
>> clindamycin (by the resident on call) for post partum endomyometritis.
>> 48 hours post op she was still febrile. ID was consulted, after
>> another exam which noted a still tender uterus and she was switched to
>> vancomycin and meropenem to cover MRSA as well as the usually
>> culprits. She has a history of IBD and grew out C. diff on stool
>> culture and was started on Flagyl. She also started taking scheduled
>> Motrin and Tylenol. She defervesced for 36 hours and the antibiotics
>> were stopped, except for the Flagyl, as were the anti-pyretics. 4
>> hours later she spiked to 103. Antibiotics and anti-pyrectis were
>> restarted. Pelvic U/S was negative. KUB to r/o foreign body was
>> negative. CT of pelvis was negative, as was chest x-ray, blood
>> cultures and urine culture (from the original workup) and all
>> subsequent cultures have been negative. She defervesed, and was
>> stable for 24 hours. Anti-pyrectics were stopped 48 hours ago, and she
>> then spiked again, despite being on anti-biotics. Repeat CT is
>> negative, as is repeat CXR. Doppler studies of the lower extremities
>> are negative, with great flow bilaterally. GI consults negative. No
>> evidence of cardiac valve abnormalities ruling out SBE.
>>
>> I'm thinking that the only thing left to try is heparin for septic
>> pelvic thrombophelbitis or septic gonadal thrombophelbitis. I thought
>> she might have a drug fever, however she did spike after
>> discontinuation of the wonder drugs.
>>
>> Any thoughts, pearls, questions, and acceptance of transfer to your
>> service would be appreciated.
>>
>> Richard Chudacoff, MD, FACOG
>>
>> Women's Specialists of Houston
>> 6624 Fannin Suite 1800
>> Houston, TX, 77030
>> 713-797-1144
>> 713-425-3071
>>
>> Email: Richard.Chudacoff@obgyn.net
>> rchudacoff.md@womenspecialists.com
>>
>> <unknown.jpg>This message is confidential, intended only for the named
>> recipient(s) and may contain information that is privileged or exempt
>> from disclosure under applicable law. If you are not the intended
>> recipient(s), you are notified that the dissemination, distribution or
>> copying of the messages is strictly prohibited. If you receive this
>> message in error, or are not the named recipient(s), please notify the
>> sender at either the e-mail address or telephone number above and
>> delete this e-mail from your computer.
>>
>--Apple-Mail-6--343904413
>Content-Transfer-Encoding: quoted-printable
>Content-Type: text/enriched;
> charset=WINDOWS-1252
>
><fontfamily><param>Lucida Grande</param>Richard
>
>I'd definitely go with the septic pelvic thrombophlebitis. Unless she
>has an abcess which you have clearly looked for, the antibiotic
>regimens should have killed most things on the planet.
>
></fontfamily>
>
>><fontfamily><param>Helvetica</param>*************************************
**************************************
>
><fontfamily><param>Helvetica</param>*************************************
**************************************
>Charlie Chambers
>
>Hood River, OR
>
>cchamber@alumni.rice.edu
>
>"Almost anything you do will seem insignificant but it is very
>important
>
>that you do it....You must be the change you wish to see in the world"
>
> -- Mahatma Ghandi.
>
>>*************************************************************************
*****
>
>*************************************************************************
*****
></fontfamily>
>
><fontfamily><param>Lucida Grande</param>On</fontfamily>
><fontfamily><param>Lucida Grande</param>May</fontfamily> 31, 2005,
><fontfamily><param>Lucida Grande</param>at</fontfamily> 7:13
><fontfamily><param>Lucida Grande</param>AM</fontfamily>,
><fontfamily><param>Lucida Grande</param>Richard</fontfamily>
><fontfamily><param>Lucida Grande</param>Chudacoff</fontfamily>,
><fontfamily><param>Lucida Grande</param>MD</fontfamily>
><fontfamily><param>Lucida Grande</param>wrote</fontfamily>:
>
><excerpt>
>
><fontfamily><param>Arial</param><x-tad-smaller>21 yo G1, GBS negative,
>admitted through the midwife service 12 days ago. She arrested in
>dilation, after IUPC and FSE, and underwent an unremarkable low
>transverse c-section via Pfannenstiel skin incision 10 days ago. 36
>hours post-op she spike to 103 degrees F and hand a tender uterus, and
>was started on Ampicillin, gentamycin and clindamycin (by the resident
>on call) for post partum endomyometritis. 48 hours post op she was
>still febrile. ID was consulted, after another exam which noted a
>still tender uterus and she was switched to vancomycin and meropenem
>to cover MRSA as well as the usually culprits. She has a history of
>IBD and grew out C. diff on stool culture and was started on Flagyl.
>She also started taking scheduled Motrin and Tylenol. She defervesced
>for 36 hours and the antibiotics were stopped, except for the Flagyl,
>as were the anti-pyretics. 4 hours later she spiked to 103.
>Antibiotics and anti-pyrectis were restarted. Pelvic U/S was negative.
>KUB to r/o foreign body was negative. CT of pelvis was negative, as
>was chest x-ray, blood cultures and urine culture (from the original
>workup) and all subsequent cultures have been negative. She
>defervesed, and was stable for 24 hours. Anti-pyrectics were stopped
>48 hours ago, and she then spiked again, despite being on
>anti-biotics. Repeat CT is negative, as is repeat CXR. Doppler studies
>of the lower extremities are negative, with great flow bilaterally. GI
>consults negative. No evidence of cardiac valve abnormalities ruling
>out SBE.</x-tad-smaller></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf>
>
><fontfamily><param>Arial</param><x-tad-smaller>I'm thinking that the
>only thing left to try is heparin for septic pelvic thrombophelbitis
>or septic gonadal thrombophelbitis. I thought she might have a drug
>fever, however she did spike after discontinuation of the wonder
drugs.</x-tad-smaller></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf>
>
><fontfamily><param>Arial</param><x-tad-smaller>Any thoughts, pearls,
>questions, and acceptance of transfer to your service would be
>appreciated.</x-tad-smaller></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf>
>
><fontfamily><param>Arial</param><x-tad-smaller>Richard Chudacoff, MD,
>FACOG</x-tad-smaller></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf>
>
><fontfamily><param>Arial</param><x-tad-smaller>Women's Specialists of
>Houston</x-tad-smaller></fontfamily>
>
><fontfamily><param>Arial</param><x-tad-smaller>6624 Fannin Suite
1800</x-tad-smaller></fontfamily>
>
><fontfamily><param>Arial</param><x-tad-smaller>Houston, TX,
77030</x-tad-smaller></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller>713-797-1144</x-tad-smalle><
/fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller>713-425-3071</x-tad-smalle><
/fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf>
>
><fontfamily><param>Arial</param><x-tad-smaller>Email:
>Richard.Chudacoff@obgyn.net</x-tad-smaller></fontfamily>
>
><fontfamily><param>Arial</param><x-tad-smaller>
>rchudacoff.md@womenspecialists.com</x-tad-smaller></fontfamily>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf>
>
>><fontfamily><param>Arial</param><x-tad-smaller> </x-tad-smaller></fontf>
>
><<<fontfamily><param>Lucida
Grande</param>unknown.jpg></fontfamily><fontfamily><param>Arial</param><x
tad-smaller>This
>message is confidential, intended only for the named recipient(s) and
>may contain information that is privileged or exempt from disclosure
>under applicable law. If you are not the intended recipient(s), you
>are notified that the dissemination, distribution or copying of the
>messages is strictly prohibited. If you receive this message in error,
>or are not the named recipient(s), please notify the sender at either
>the e-mail address or telephone number above and delete this e-mail
>from your computer.</x-tad-smaller></fontfamily>
>
><fontfamily><param>Times New Roman</param><bigger> </bigger></fontfamily>
>
></excerpt>--Apple-Mail-6--343904413--
>
--
art fougner, md
"If you don't know where you are going, you will wind up somewhere else."
Lawrence Peter Berra
