What further pertinent questions should I ask a patient with recurrent fever, recent cough, a colostomy, and weekly debrided pressure ulcers after completing a 6‑week IV meropenem course for sepsis?

Pertinent Questions for a Patient with Recurrent Fever Post-Meropenem, Pressure Ulcers, and Colostomy

In this complex patient with multiple infection sources—pressure ulcers, colostomy, and recent prolonged meropenem therapy—you must systematically interrogate each potential site for ongoing or recurrent sepsis, focusing on inadequate source control, resistant organisms, and healthcare-associated complications.

Pressure Ulcer and Wound Assessment

Detailed wound characteristics are critical because inadequate source control is the strongest independent predictor of mortality in bacteremia, outweighing even high-dose antibiotic therapy. 1

• Ask about the stage and depth of the pressure ulcer: Is it stage III (full-thickness skin loss) or stage IV (extending to muscle/bone)? 2
• Inquire about drainage characteristics: Is there purulent material, serosanguineous fluid, or foul-smelling discharge suggesting anaerobic infection? 2
• Determine debridement adequacy: Are there signs of residual necrotic tissue, exposed bone, or undermining that weekly debridement may be missing? 2
• Ask about surrounding tissue: Is there expanding erythema, warmth, crepitus, or induration suggesting deep soft tissue extension beyond the ulcer bed? 2

Colostomy-Related Complications

The colostomy represents a potential portal for intra-abdominal infection, particularly given the recent sepsis history.

• Ask about stoma appearance: Is there peristomal erythema, induration, purulent drainage from the stoma site, or fascial dehiscence? 2
• Inquire about abdominal pain: Specifically, is there pain around the stoma site, diffuse abdominal tenderness, or pain with colostomy bag changes? 2
• Determine ostomy output: Has there been a change in volume, consistency, or odor of colostomy output suggesting intra-abdominal pathology? 2
• Ask about previous abdominal surgery complications: Was the original indication for colostomy related to perforation, ischemic bowel, or complicated diverticulitis that might harbor residual infection? 2

Respiratory Source Evaluation

The 6-day history of cough and colds preceding fever recurrence suggests a respiratory source that may represent healthcare-associated pneumonia.

• Characterize the cough: Is it productive? What is the sputum color (purulent green/yellow vs. clear)? Is there hemoptysis? 3
• Ask about dyspnea: Is there new or worsening shortness of breath, increased work of breathing, or orthopnea? 3
• Determine aspiration risk: Does the patient have dysphagia, altered mental status, or episodes of choking during meals? 3
• Inquire about chest pain: Is there pleuritic chest pain suggesting pneumonia or empyema? 3

Prior Antibiotic Course and Resistance Risk

The 6-week meropenem course creates substantial risk for resistant organisms and superinfection.

• Ask about the original sepsis source: What was the indication for the prolonged meropenem course? Was source control achieved? 2
• Determine culture history: What organisms were isolated during the initial sepsis episode? Were there any resistant gram-negatives (ESBL, carbapenem-resistant Enterobacteriaceae) or fungi? 2, 4
• Inquire about clinical response to meropenem: Did fever resolve completely during therapy, or were there breakthrough fevers suggesting inadequate coverage? 2
• Ask about other recent antibiotics: Has the patient received any additional antimicrobials since stopping meropenem that might select for resistance? 4

Healthcare-Associated Infection Risk Factors

Up to 10% of patients with gram-negative bacteremia develop metastatic infections that may not be apparent on initial imaging. 1

• Ask about vascular access: Does the patient have a central venous catheter, PICC line, or other indwelling devices? When were they last changed? 1
• Inquire about urinary catheter: Is a Foley catheter in place? When was it last changed? Is there suprapubic tenderness or cloudy/foul-smelling urine? 3
• Determine joint symptoms: Is there any joint pain, swelling, warmth, or decreased range of motion suggesting septic arthritis—a common metastatic complication? 1
• Ask about back pain: Is there new or worsening back pain, particularly with percussion over the spine, suggesting vertebral osteomyelitis? 1

Fungal Superinfection Assessment

Prolonged broad-spectrum antibiotic therapy substantially increases risk for invasive candidiasis.

• Ask about visual changes: Has the patient experienced blurred vision, floaters, or eye pain that might indicate candidal endophthalmitis? 3
• Inquire about oral thrush: Is there white coating on the tongue or oral mucosa? 3
• Determine candiduria: Has urinalysis shown yeast? 2
• Ask about prior fungal infections: Does the patient have a history of candidal infections or risk factors like total parenteral nutrition? 2

Systemic Inflammatory Response Markers

Persistent fever beyond 5-7 days of appropriate antimicrobial therapy indicates either persistent infection or inadequate source control. 3

• Ask about fever pattern: Is the fever continuous, intermittent with specific timing (suggesting abscess), or associated with rigors? 3
• Inquire about recent vital signs: Has there been persistent tachycardia, hypotension, or increased oxygen requirements? 3
• Determine functional status: Has there been worsening confusion, lethargy, or decreased oral intake? 2

Imaging and Diagnostic Workup Needed

When conventional CT fails to identify a source in bacteremia, advanced imaging may be required.

• Ask if recent imaging has been performed: Has CT abdomen/pelvis been done since fever recurrence to evaluate for undrained collections, particularly around the colostomy site or pressure ulcer? 2, 1
• Determine if echocardiography is indicated: Given the prolonged bacteremia risk, has transthoracic or transesophageal echo been performed to exclude endocarditis? 1
• Consider need for advanced imaging: If conventional CT is negative, FDG-PET/CT identifies an infection focus in 70% of patients with bacteremia of unknown source, with 90.9% sensitivity. 1

Common Pitfalls to Avoid

• Do not assume fever is non-infectious: Recurrent fever after initially successful antibiotic response could represent drug fever, but in this patient with multiple infection portals, assume infection until proven otherwise. 3
• Do not overlook perianal abscess: In patients with colostomy and pressure ulcers, pelvic MRI detects perianal abscesses in 88% of cases when suspected. 1
• Do not delay repeat cultures: Blood cultures should be obtained before any new antimicrobial therapy, as persistent bacteremia beyond 48 hours of appropriate therapy mandates consideration of surgical source control. 3