What is the appropriate management for an 80-year-old woman with sepsis secondary to urinary tract infection (UTI), nephrolithiasis of the right ureter with hydronephrosis, and complications including recurrent hypothermia, bradycardia, and encephalopathy?

From the Guidelines

The patient's management should prioritize the treatment of sepsis and septic shock, with a focus on vasopressor therapy to target a mean arterial pressure (MAP) of 65 mm Hg, as recommended by the Surviving Sepsis Campaign guidelines 1. Given the patient's bradycardia and elevated blood pressure, the use of norepinephrine as the first-choice vasopressor is recommended, with the option to add epinephrine or vasopressin as needed to maintain adequate blood pressure 1. The patient's heart rate remains in the 40s, which may require careful consideration of the choice of vasopressor, with dopamine potentially being considered as an alternative in highly selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia 1. The patient's sepsis was treated with a 7-day course of ceftriaxone, which is consistent with the guidelines for antimicrobial therapy in sepsis and septic shock, which recommend administration of effective IV antimicrobials within the first hour of recognition of septic shock and severe sepsis without septic shock 1. The patient's acute kidney injury on chronic kidney disease stage 3 secondary to vancomycin has resolved with discontinuation of the medication, highlighting the importance of careful consideration of medication choices in patients with renal impairment. The plan to discharge the patient home with family support and physical therapy is appropriate, with ongoing monitoring and management of her condition as needed. Key considerations in the patient's management include:

• Vasopressor therapy to target a MAP of 65 mm Hg
• Choice of vasopressor, with norepinephrine as the first-choice and consideration of dopamine in highly selected patients
• Antimicrobial therapy, with administration of effective IV antimicrobials within the first hour of recognition of septic shock and severe sepsis without septic shock
• Careful consideration of medication choices in patients with renal impairment
• Ongoing monitoring and management of the patient's condition, with adjustment of the treatment plan as needed.

From the FDA Drug Label

Patients with Renal or Hepatic Impairment Ceftriaxone is excreted via both biliary and renal excretion (see CLINICAL PHARMACOLOGY). Therefore, patients with renal failure normally require no adjustment in dosage when usual doses of ceftriaxone are administered Dosage adjustments should not be necessary in patients with hepatic dysfunction; however, in patients with both hepatic dysfunction and significant renal disease, caution should be exercised and the ceftriaxone dosage should not exceed 2 grams daily.

The patient has CKD 3 and was treated with 7 days of ceftriaxone. According to the drug label, no adjustment in dosage is required for patients with renal failure when usual doses of ceftriaxone are administered. However, since the patient has CKD 3, which is considered significant renal disease, and there is no mention of hepatic dysfunction, caution should be exercised. The patient's renal function returned to baseline after vancomycin was stopped, suggesting that the ceftriaxone treatment did not cause significant renal impairment 2.

From the Research

Patient's Condition and Treatment

• The patient is an 0-year-old woman admitted with sepsis secondary to UTI, nephrolithiasis of right ureter with hydronephrosis, and a complicated hospital course including recurrent hypothermia, bradycardia, and encephalopathy.
• She was treated with ceftriaxone for 7 days and her blood cultures remained negative.
• The patient's hematuria has improved significantly, and she will continue her Eliquis.
• Her Coreg was stopped due to bradycardia and will be discontinued at discharge.

Bradycardia and Atrial Fibrillation

• The patient's bradycardia is a concern, and according to the study 3, bradycardia could facilitate the emergence of atrial fibrillation.
• The study suggests that pacing at rates ~80-110 bpm can prevent bradycardia-related long-short-long sequence triggering ventricular arrhythmias.

Discharge Planning and Patient Education

• A standardized patient-centered discharge planning protocol can improve patients' understanding of their discharge instructions, as shown in the study 4.
• The study found that patients who received a standardized discharge planning protocol had a better understanding of their diagnosis, medication side effects, and follow-up appointments.

Anticoagulation Therapy and Bleeding Risk

• The patient is taking Eliquis, and according to the study 5, apixaban dosing in patients with atrial fibrillation and severe chronic kidney disease is associated with a higher risk of bleeding.
• The study 6 found that incident NSAID use was associated with an increased risk of major bleeding and clinically relevant nonmajor bleeding in patients with atrial fibrillation taking apixaban or warfarin.
• The study 7 suggests that apixaban is preferred over VKA in patients with atrial fibrillation and recent acute coronary syndrome or percutaneous coronary intervention, and that aspirin use immediately and for up to 30 days results in an equal tradeoff between an increase in severe bleeding and a reduction in severe ischemic events.