Management of an Elderly Patient with Sepsis
The patient is presenting with sepsis and requires immediate placement in droplet precautions with influenza testing, followed by fluid resuscitation and vasopressor therapy if hypotension persists.
Initial Assessment and Stabilization
The patient's presentation with fever (101.5°F), hypotension (BP 85/40), tachycardia (HR 120 bpm), and symptoms of cough, malaise, fever, nausea and vomiting during influenza season strongly suggests sepsis, likely from influenza or secondary bacterial pneumonia 1.
The fluid bolus already being administered is appropriate as the first step in management, as immediate fluid resuscitation is critical for addressing hypotension in hemodynamically unstable patients 1.
Vital sign monitoring should continue, with special attention to response to fluid resuscitation and oxygen saturation 1.
Infection Control Measures
Place the patient in droplet precautions immediately and perform influenza testing (answer choice A) 2, 3.
During influenza season (January), an elderly patient from a long-term care facility with fever, respiratory symptoms, and systemic symptoms should be presumed to have influenza until proven otherwise 2, 4.
Rapid influenza diagnostic testing has high specificity (98%) and sensitivity (94%) compared to laboratory-based testing, allowing for quick implementation of appropriate isolation and treatment 3.
Droplet precautions are essential to prevent transmission to other patients and healthcare workers 2, 5.
Further Management After Initial Stabilization
If hypotension persists after two fluid boluses, vasopressor therapy with norepinephrine should be initiated (which would require central line placement) 1.
Blood cultures should be obtained before starting antibiotics, but should not delay antimicrobial therapy 1.
Empiric broad-spectrum antibiotics should be started immediately after blood cultures are drawn 1.
Consider antiviral therapy (oseltamivir) if influenza is suspected, especially since the patient is in a high-risk group (elderly) 2, 4.
Diagnostic Workup
Complete blood count, comprehensive metabolic panel, lactate, blood cultures, and chest radiography should be performed 1.
Pulse oximetry should be performed, as oxygen saturation <90% is an important predictor of short-term mortality and respiratory failure 2.
Nasopharyngeal swab for rapid influenza testing and other respiratory viruses should be obtained 2, 6.
Why Other Options Are Not Appropriate
Option B (metronidazole 500mg TID): Not indicated as first-line therapy for suspected respiratory infection; would be appropriate for C. difficile or anaerobic infections, but not for the presenting symptoms 2.
Option C (central line and norepinephrine): While vasopressors may eventually be needed if fluid resuscitation fails, infection control measures and diagnostic testing should be implemented first 1.
Option D (loperamide): Contraindicated in infectious diarrhea and not appropriate for this presentation which suggests respiratory infection rather than viral gastroenteritis 2.
Special Considerations for Elderly Patients from Long-Term Care Facilities
Elderly patients from long-term care facilities are at high risk for influenza complications and secondary bacterial pneumonia 2.
The presentation of infection in elderly patients may be atypical, with fewer classic symptoms and more functional decline 2.
Fever in elderly patients is defined differently: a single oral temperature ≥100°F (37.8°C), repeated oral temperatures ≥99°F (37.2°C), or an increase in temperature of ≥2°F (≥1.1°C) over baseline 2.
Rapid diagnostic testing for influenza has been shown to reduce antibiotic use and increase appropriate antiviral prescribing 6, 7.
Conclusion
The patient is presenting with sepsis, likely due to influenza or pneumonia given the season and symptoms. The correct next step is to place the patient in droplet precautions and perform influenza testing (option A) while continuing fluid resuscitation. If hypotension persists after adequate fluid resuscitation, vasopressor therapy should be initiated.