Wind, wound, water, and walk

The med student's mantra for working up a post-operative fever. Look for pneumonia, surgical site abscess, kidney infection, or a blood clot in the leg. So when my patient came in this week with a temperature above 102 three weeks after her total hip joint replacement, I checked all four possibilites.

No cough, lungs clear, no redness or tenderness at the hip, legs non-tender and no swelling. But oy, the urine. Full of bacteria and white cells. I put her on the standard big-time antibiotic for pyelonephritis--Levaquin-- and sent her home, and her urine went off to the lab for culture.

Double oy. This E coli in her urinary tract was a bacteria so bad it made the infectious disease consultant flinch. ESBL no less, extended spectrum beta-lactamase producers. That means they eat penicillin for breakfast and look for fluoroquinolones such as Levaquin for dessert. The only antibiotics these bad boys run from are the carbapenems as in IV only, REALLY big guns.

The antibiotic resistance problem is here, now. Some sixty years after penicillin was pressed into service during World War II, that antibiotic is all but useless, and many of the latest and greatest new drugs are also falling to bacterial enzymes. An increasing number of carbapenemase producers (these are bacteria that produce an enzyme that chops carbapenem antibiotics into useless shreds) are being described around the world.

While you are more likely to pick up one of these New Age hideous bacteria in the hospital, they are present in livestock and showing up in community-acquired infections. When possible, forego the antibiotics. We're creating microbial monsters here!