What is the best management plan for a 74-year-old female with a history of severe osteoporosis, invasive ductal carcinoma, psoriasis, and rheumatoid arthritis, currently being treated for a right masticator space infection and experiencing leukocytosis, thrombocytosis, anxiety, and oropharyngeal pain?

Management Plan for 74-Year-Old Female with Masticator Space Infection and Multiple Comorbidities

Infection Management

The patient should continue the current antibiotic regimen of cefepime and metronidazole while discontinuing vancomycin after the planned course ends on 9/20, with adjustment based on final culture results when available. 1

• Continue monitoring daily CBC to track resolution of leukocytosis and thrombocytosis
• Maintain Primrose drain until OMFS recommends removal
• Continue oral care with chlorhexidine mouthwash TID
• Complete the planned course of dexamethasone 4mg BID with last dose this evening

Rationale:

• Blood cultures from 9/11 showed alpha-hemolytic Streptococcus and Gram-negative cocci
• The patient has shown clinical improvement with current therapy as evidenced by:
  • Successful extubation
  • Decreasing leukocytosis
  • Reduced oropharyngeal and palatal edema

Airway and Nutrition Management

• Continue NPO status until SLP evaluation on Monday
• Maintain tube feeds with Vital 1.5 at 35mL/hr with free water flushes 50mL q4h
• Continue Hurricaine spray q4H for throat discomfort
• Implement SLP recommendations after Monday's evaluation for safe transition to oral intake

Chronic Disease Management

Rheumatoid Arthritis

• Hold tofacitinib until complete resolution of infection 1
• Resume tofacitinib only after confirmation of infection resolution and in consultation with rheumatology
• Consider transitioning to alternative DMARD if infection recurs after restarting tofacitinib 1

Osteoporosis

• Resume osteoporosis treatment after infection resolution, with preference for oral bisphosphonate 1
• Consider bone mineral density testing once infection has resolved
• Ensure adequate calcium (1000-1200mg daily) and vitamin D (600-800 IU daily) supplementation 1

Breast Cancer

• Continue letrozole therapy as it does not significantly increase infection risk
• Coordinate with oncology for follow-up regarding invasive ductal carcinoma management

Psoriasis

• Hold any systemic immunosuppressive psoriasis treatments until infection resolves 1
• Consider topical treatments only for active psoriatic lesions

Pain and Anxiety Management

• Continue multi-modal pain management:
  • Acetaminophen scheduled
  • Roxicodone for breakthrough pain
  • Gabapentin for neuropathic pain component
• Maintain Ativan 0.5mg q6h PRN for anxiety
• Consider psychiatric consultation if anxiety persists despite medication

Cardiovascular Management

• Continue home medications:
  • Telmisartan 20mg daily
  • Toprol XL 25mg daily
  • Crestor 20mg daily
• Monitor blood pressure and heart rate

Thrombosis Prevention

• Continue Lovenox for VTE prophylaxis
• Encourage early mobilization as tolerated

Disposition Planning

• Transfer to PCU as planned for continued monitoring
• Anticipate need for SNF placement after hospital discharge
• Arrange for home health services for wound care and medication management
• Schedule follow-up appointments with:
  • OMFS within 1-2 weeks
  • Primary care within 1-2 weeks
  • Rheumatology within 2-4 weeks
  • Oncology per their recommended schedule

Special Considerations

• The patient's multiple immunosuppressive medications (tofacitinib for RA, letrozole for breast cancer) likely contributed to infection severity
• Thrombocytosis is likely reactive to infection rather than primary, but should normalize with infection resolution 2, 3
• Monitor for signs of osteonecrosis of the jaw given history of severe osteoporosis and potential bisphosphonate use 4
• Ensure coordination between specialists (rheumatology, oncology, OMFS) before restarting immunosuppressive therapies