Question

Clark Austin is a 75-year-old retired engineer who lives with his wife Ann. He is admitted to your hospital with acute cholecysitis. He has undergone a cholecystectomy and has been transferred to your floor the second day postop. He has a nasogastric (NG) tube to continuous low wall suction, a Foley catheter in place, one peripheral IV, a large abdominal dressing, a history of emphysema. In addition, he is on O2 2L/min per NC and receives a continuous pulse oximetry monitoring. His orders include: D51/2NS with 20 mEq KCI/L at 125 cc/hr. Morphine 5 mg IV q2hr prn, turn, cough, and deep breathe q2h, incentive spirometer q 2h while awake.

This morning, when you enter his room, Mr. Austin appears quite anxious and coughs a lot. He complains of shortness of breath and pain in his chest and his incision site. He states, "I feel hot, and I am extremely tired."

Your assessment reveals the following: His respiration is labored and shallow with the use of accessory muscles of the neck and abdomen. VS: 142/80, P 120, R 26, T 103.4, 02 sat 88% on O2 at 2L/min per NC. There are scattered crackles throughout the right lung fields and LUL, rhonchi over large airways, and breath sounds are diminished from fourth intercostal space to the base on the left side. His IV is running at the prescribed rate and there are no signs of infection of the IV site. His pain level is 5 on a scale of 1-10. The physician prescribes the following order after you called him or her immediately after your assessment: continue IV of D51/2NS with 20 mEq KCL/L at 125 cc/hr; STAT blood culture and sensitivity (C&S) sputum C & S; STAT chest x-ray (CXR) and ECG; Ampicillin/Sulbactam (Unasyn) 1.5 g IVPB q6h; and Acetaminophen 650 mg po for temp over 102 F.

1. Why does the physician order a culture and sensitivity test? How are the results being used?

Answer 1

Acute cholecystitis (AC), which is strongly associated with retrograde bacterial infection, is an inflammatory disease that can be fatal if inappropriately treated. Currently, bacterial culture testing, which is basically recommended to detect the etiological agent, is a time-consuming (4–6 days), non-comprehensive approach.

Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels are used to evaluate for the presence of hepatitis and may be elevated in cholecystitis or with common bile duct obstruction. Bilirubin and alkaline phosphatase assays are used to evaluate for the presence of common bile duct obstruction.

Culture leaves more than 60% of the microbes undetected in acute cholecystitis. Anaerobic bacteria, Enterobacteriaceae and enterococci among those often missed. Culture independent approaches are needed in routine diagnostics of cholecystitis. Studies on the microbiology of cholecystitis must include metagenomic sequencing. Treatment recommendations must take into account limitations of bacterial culture.