What is the likely cause of desaturation and fever in a 71-year-old patient with End-Stage Renal Disease (ESRD), Diabetes Mellitus (DM), Hypertension (HTN), and a history of Coronary Artery Bypass Grafting (CABG), who recently completed a course of vancomycin and meropenem one week ago?

From the Guidelines

This patient requires immediate medical attention for suspected sepsis or infection recurrence, and the most likely cause of desaturation and fever is a catheter-related bloodstream infection (CRBSI) given the recent completion of vancomycin and meropenem one week ago. The patient should be started on empiric antibiotic therapy with vancomycin (15-20 mg/kg IV loading dose, then dosed based on renal function) and meropenem (500 mg IV every 24 hours for ESRD patients on hemodialysis) while awaiting new blood cultures and other diagnostic tests, as recommended by the Infectious Diseases Society of America guidelines 1. Oxygen supplementation should be provided to address the desaturation, and antipyretics like acetaminophen (650 mg orally or IV) can be given for fever.

The patient needs urgent evaluation with:

• Blood cultures (at least two sets from different sites)
• Complete blood count
• Comprehensive metabolic panel
• Chest X-ray
• Assessment of the dialysis access site for signs of infection This presentation of fever and desaturation immediately after hemodialysis in a patient with recent infection suggests either inadequate treatment of the previous infection, a new infection, or a dialysis-related complication such as dialyzer reaction. The timing after dialysis raises concern for possible endotoxin release or bacteremia related to the vascular access. Given the patient's multiple comorbidities (ESRD, diabetes, hypertension, and history of CABG), they are at high risk for severe infection and should be monitored closely for signs of hemodynamic instability or respiratory deterioration, as suggested by the guidelines 1.

Key considerations in management include:

• The infected catheter should always be removed for patients with hemodialysis CRBSI due to S. aureus, Pseudomonas species, or Candida species and a temporary (nontunneled catheter) should be inserted into another anatomical site 1
• For hemodialysis CRBSI due to other pathogens, a patient can initiate empirical intravenous antibiotic therapy without immediate catheter removal, but the catheter should be removed if symptoms persist or if there is evidence of a metastatic infection 1
• Empirical antibiotic therapy should include vancomycin and coverage for gram-negative bacilli, based on the local antibiogram 1
• A 4–6-week antibiotic course should be administered if there is persistent bacteremia or fungemia after hemodialysis catheter removal or for patients with endocarditis or suppurative thrombophlebitis 1

From the FDA Drug Label

ADVERSE REACTIONS ... Patients have been reported to have had ... drug fever ... ADVERSE REACTIONS ... Onset of pseudomembranous colitis symptoms may occur during or after antibiotic treatment The likely cause of desaturation and fever in this patient cannot be directly determined from the vancomycin drug label. However, drug fever is a reported adverse reaction, and pseudomembranous colitis can occur during or after antibiotic treatment, which may lead to fever and potentially desaturation.

• Possible causes may include:
  • Drug fever
  • Pseudomembranous colitis Given the patient's recent completion of a course of vancomycin and meropenem, these possibilities should be considered, but no conclusion can be drawn without further information 2.

From the Research

Possible Causes of Desaturation and Fever

The patient's recent completion of a course of vancomycin and meropenem one week ago may be a contributing factor to the current condition.

• The combination of vancomycin and meropenem has been associated with a lower risk of acute kidney injury (AKI) compared to the combination of vancomycin and piperacillin-tazobactam 3, 4, 5, 6.
• However, vancomycin itself can cause nephrotoxicity, especially in patients with pre-existing renal disease, such as End-Stage Renal Disease (ESRD) 7.
• The patient's history of ESRD, Diabetes Mellitus (DM), Hypertension (HTN), and Coronary Artery Bypass Grafting (CABG) may also contribute to the development of desaturation and fever.

Nephrotoxicity and AKI

• The studies suggest that the combination of vancomycin and meropenem is a safer alternative to vancomycin and piperacillin-tazobactam in terms of nephrotoxicity 3, 4, 5, 6.
• However, the patient's individual response to the medication and underlying health conditions must be considered when evaluating the cause of desaturation and fever.
• The patient's recent completion of antibiotic therapy may have contributed to the development of AKI, which can cause desaturation and fever 3, 4, 5, 6.

Underlying Health Conditions

• The patient's history of ESRD, DM, HTN, and CABG may contribute to the development of desaturation and fever.
• These underlying health conditions may increase the patient's susceptibility to infections, which can cause desaturation and fever.
• The patient's ESRD may also increase the risk of nephrotoxicity associated with vancomycin therapy 7.