From the Guidelines
I recommend administering intravenous fluids, specifically lactated Ringer's or normal saline at 10-20 mL/kg, to address the elevated lactic acid level of 3.9 mmol/L (increased from 3.0 mmol/L). Continue the current Cefazolin 2g IV q8h regimen as prescribed, but closely monitor the patient's renal function and adjust dosing if needed, as the current dosage is within the recommended range of 1–2 g every 8 h for Cefazolin, as per the guidelines by the Surgical Infection Society and the Infectious Diseases Society of America 1. Additionally, obtain blood cultures if not already done, check vital signs, and assess for signs of infection or tissue hypoperfusion. The rising lactic acid level indicates potential tissue hypoxia or poor perfusion, which could be due to sepsis, shock, or medication effects. Cefazolin itself is not typically associated with lactic acidosis, so the underlying infection or another process may be causing the elevated lactate. After fluid resuscitation, reassess lactic acid levels within 4-6 hours to evaluate response to treatment. If lactate continues to rise despite these interventions, consider broadening antibiotic coverage, such as adding vancomycin or switching to a different antibiotic regimen as outlined in the guidelines for skin and soft tissue infections by the Infectious Diseases Society of America 1, and consulting critical care for possible vasopressor support. Some key points to consider in managing this patient include:
- Monitoring renal function and adjusting antibiotic dosing as needed
- Assessing for signs of infection or tissue hypoperfusion
- Considering broadening antibiotic coverage if the patient's condition does not improve
- Consulting critical care for possible vasopressor support if the patient's condition worsens.
From the Research
Patient's Condition
The patient is 69 years old and is being attended by Dr. Chengat. The patient's lactic acid level has increased from 3.0 to 3.9.
Current Treatment
The patient is currently receiving Cefazolin 2g every 8 hours intravenously.
Relevant Studies
- A study on lactic acidosis 2 provides information on the metabolism of lactate and the pathophysiology of lactic acidosis, but does not offer direct guidance on treatment.
- A study on the pharmacodynamics of piperacillin-tazobactam/amikacin combination versus meropenem 3 suggests that the combination of piperacillin-tazobactam and amikacin may be effective against extended-spectrum β-lactamase-producing Escherichia coli.
- A study on blood lactate concentrations in people with Multiple Sclerosis 4 found that lactate levels are elevated in people with MS compared to healthy controls, but this study is not directly relevant to the patient's condition.
- A study protocol for a non-inferiority open-label randomized controlled trial comparing piperacillin-tazobactam with meropenem for treatment of bloodstream infections caused by third-generation cephalosporin-resistant Enterobacteriaceae 5 may be relevant to the patient's treatment, but the study has not been completed.
Potential Next Steps
- Consider alternative antibiotic treatments, such as piperacillin-tazobactam or meropenem, based on the patient's condition and the results of relevant studies 3, 5.
- Monitor the patient's lactic acid levels and adjust treatment accordingly.
- Consider consulting with other healthcare professionals to determine the best course of treatment for the patient.