Guidelines enforcement and clinical outcome

Abstract

A.F., a 61-year-old man, was admitted to our department for severe and persistent fever [body temperature(BT) 40.0 C] with chills, associated with sore throat and cough. The patient had a history of arterial hypertension, mixed dyslipidemia and hyperuricemia, treated respectively with ramipril plus hydrochlorothiazide, rosuvastatin, n-PUFAs and allopurinol. Ten years before admission, he underwent cardiac surgery with aortic valve replacement (mechanical prosthesis Sorin Carbomedics Orbis 25) for severe valvular stenosis. Six years later he again underwent cardiovascular surgery for a thoracic aortic aneurysm with implantation of a prosthetic tube (Vascutek-28). After these procedures, he received permanent oral anticoagulation (warfarin). Blood tests performed at hospital admission showed ESR 102 mm/h, neutrophilic leukocytosis, hypoalbuminemia with polyclonal hypergammaglobulinemia, and severe hypoxaemia with hypercapnia. Blood and urine cultures were obtained (several consecutive collections performed before the start of antibiotic therapy), chest X-ray study, 12-lead electrocardiogram (ECG), abdominal and pelvic ultrasonography, pharyngeal tampons, and the analysis of antiviral antibodies showed no clinically significant findings. Despite these results, considering the life-threatening condition, we decided to start oxygen therapy and antibiotic therapy. During the first days of hospitalization, the patient continued to show severe intermittent fever (B.T. max 40.5 C), despite the introduction of two consecutive i.v. broad spectrum antibiotic therapies (initially ceftriaxone, followed by piperacillin plus tazobactam i.v.).