Can a patient with acute kidney injury, diastolic dysfunction, and decubitus ulcers, who is dependent on norepinephrine and nearing completion of meropenem and vancomycin, be discharged home?

Discharge Home is Not Appropriate for This Patient

A patient dependent on norepinephrine cannot be safely discharged home, regardless of antibiotic completion status. Vasopressor dependency indicates ongoing hemodynamic instability requiring continuous ICU-level monitoring and intravenous support that cannot be replicated in a home setting 1.

Critical Barriers to Home Discharge

Vasopressor Dependency

• Patients requiring norepinephrine have signs of peripheral hypoperfusion and systolic blood pressure inadequate to maintain organ perfusion 1
• Treatment with vasopressors must be used in conjunction with fluids in patients with vasomotor shock, but this requires continuous IV access and hemodynamic monitoring 1
• The ACC/AHA guidelines explicitly state that patients should not be initiated on neurohormonal antagonists (ACE inhibitors, beta-blockers) if they have systolic blood pressure less than 80 mm Hg or signs of peripheral hypoperfusion—conditions necessitating vasopressor support 1
• Patients cannot be discharged until hemodynamic stability is achieved without inotropic or vasopressor support 1

Unresolved Clinical Instability

• The combination of diastolic dysfunction, AKI, and inability to wean from vasopressors indicates end-organ hypoperfusion 1
• Patients should not be discharged from the hospital until a stable and effective treatment regimen is established and clinical stability is achieved 1
• Your patient's refusal of debridement for infected decubitus ulcers creates an ongoing source of sepsis, perpetuating the need for vasopressor support 1

Antibiotic Nephrotoxicity Considerations

Current Regimen Risk

• The combination of vancomycin and meropenem carries significant nephrotoxic risk, though substantially less than vancomycin with piperacillin-tazobactam 2, 3, 4
• In critically ill patients, vancomycin plus meropenem resulted in 23.5% AKI incidence compared to 39.3% with vancomycin plus piperacillin-tazobactam 4
• Your patient has already developed AKI on this regimen, which is an expected complication 2, 3

Post-Antibiotic Management

• Small or moderate elevations of blood urea nitrogen and serum creatinine should not lead to minimization of therapy intensity, provided renal function stabilizes 1
• If creatinine rises above 265 μmol/L (3.0 mg/dL) but below 310 μmol/L (3.5 mg/dL), medication doses should be halved and chemistry monitored closely 1
• Patients discharged while requiring renal replacement therapy need weekly assessment of pre-dialysis creatinine values and regular assessment of residual kidney function 1

Alternative Management Pathways

Palliative Care Transition

Given the patient's refusal of definitive surgical management (debridement), multiple comorbidities, and prolonged critical illness:

• Palliative care consultation should be initiated for patients with severely limited life expectancy, low quality of life, or progressive deterioration due to untreatable disease 1
• Shared decision-making discussions should address goals of care, including the option of conservative management without aggressive interventions 1
• For patients with refractory conditions who refuse definitive treatment, long-term antimicrobial suppression may be considered as an alternative to cure-directed therapy 1

Long-Term Acute Care Hospital (LTACH) Transfer

If the patient and family desire continued aggressive management:

• Transfer to an LTACH facility capable of providing prolonged vasopressor support, IV antibiotics, and wound care
• These facilities can manage patients requiring extended ICU-level interventions who are not candidates for acute hospital discharge 1
• Patients dependent on vasopressors require continuous monitoring that exceeds home care capabilities 1

Hospice Consideration

If vasopressor weaning fails and the patient/family accept comfort-focused care:

• Hospice provides symptom management without life-prolonging interventions
• Discontinuation of vasopressors in the hospice setting with focus on comfort measures is appropriate when cure is no longer achievable 1

Key Clinical Pitfalls

• Never discharge a vasopressor-dependent patient to home—this represents an absolute contraindication regardless of other clinical factors 1
• Do not assume antibiotic completion alone determines discharge readiness; hemodynamic stability is paramount 1
• Avoid premature discontinuation of antibiotics due to AKI if renal function is stabilizing, as undertreated infection perpetuates shock 1
• Recognize that patient refusal of definitive treatment (debridement) fundamentally alters the treatment trajectory from curative to palliative/suppressive 1