Question of the Week

For December 27, 2016

An 82-year-old man is brought to the emergency department by his daughter. He has had an increasingly severe headache, plus nausea and vomiting, for the past 2 days. The daughter reports that this morning he was difficult to rouse and that he has not seen a doctor in “years” because he has been very healthy. He has no drug allergies. On examination, he is lethargic, with neck stiffness and a temperature of 38.9°C.

After undergoing an urgent lumbar puncture, he receives empiric ceftriaxone, vancomycin, and dexamethasone. Examination of the cerebrospinal fluid reveals a leukocyte count of 1300 per mm3 (75% neutrophils and 25% lymphocytes), a protein level of 110 mg/dL (reference range, 15–45), and a glucose level of 50 mg/dL (40–70). Serum glucose is within normal limits. Gram stain of cerebrospinal fluid reveals what appear to be small gram-positive rods.

Which one of the following antimicrobial treatments should be added to this patient’s treatment?

Rifampin
Ampicillin plus gentamicin
Acyclovir
Chloramphenicol
Trimethoprim–sulfamethoxazole

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