A 72-year-old man was diagnosed with a catheter-associated urinary tract infection (CAUTI) due to Escherichia coli, which is susceptible to ceftriaxone, ciprofloxacin, nitrofurantoin, and trimethoprim-sulfamethoxazole (TMP/SMX). He completed 3 days of intravenous ceftriaxone with prompt clinical improvement and has been afebrile for 48 hours. His estimated creatinine clearance is 45 mL/min, and he has a gastrostomy tube in place for medication administration. He also has a history of ciprofloxacin-induced Achilles tendon rupture. Guidelines recommend a total of 7 days of therapy for uncomplicated clinical response in CAUTI. Which oral regimen is most appropriate to complete 4 more days of therapy?

A 72-year-old man (height 175 cm; weight 80 kg; IBW 68 kg) is admitted to the medical ICU for septic shock secondary to a catheter-associated urinary tract infection (CAUTI) due to Escherichia coli. He is on assist-control ventilation and a continuous norepinephrine infusion via a central line. His indwelling Foley catheter was replaced on admission. Initial urine cultures grew E. coli susceptible to trimethoprim-sulfamethoxazole (TMP/SMX), and he was started on TMP 15 mg/kg/day (based on IBW) plus SMX 75 mg/kg/day IV, divided every 12 hours. On hospital day 3, his creatinine has risen from a baseline of 0.9 to 2.8 mg/dL, potassium is 6.1 mEq/L, and urine output has decreased to 0.3 mL/kg/hr over the last 6 hours. Which antimicrobial therapy intervention is most appropriate?

A 72-year-old man is admitted to the critical care unit for septic shock secondary to pneumonia and is on mechanical ventilation. He has had an indwelling urinary catheter in place for 10 days for strict input/output monitoring. On morning rounds, the nurse reports a new fever of 38.5°C (101.3°F) and a white blood cell count of 16,000/mm³. A urine specimen sent for culture returns positive for >10^5 CFU/mL Escherichia coli. The patient has no new suprapubic or flank pain, and his mental status remains at his sedated baseline. Given this clinical context, which of the following is the most appropriate interpretation of the positive urine culture?

A 62-year-old man presents with septic shock secondary to a urinary tract infection. His history includes poorly controlled diabetes and a recent discharge from a skilled nursing facility, where he received a short course of antibiotics for a prior UTI. He reports stopping the antibiotic after a few days because he felt better and wanted to avoid paying for the remainder. On admission, he is febrile (39 °C), hypotensive (85/50 mm Hg), tachycardic (120 bpm), and has costovertebral angle tenderness. Urine cultures grow Escherichia coli resistant to the prior agent. Which social determinant of health most directly contributed to progression of his UTI to septic shock?

A 65-year-old woman in the neuro–intensive care unit for subarachnoid hemorrhage has an indwelling urinary catheter. On hospital day 5, she develops fever (38.5 °C), suprapubic tenderness, and a white blood cell count of 15,000/mm³. Urinalysis shows significant pyuria, so the urinary catheter is exchanged and a culture is obtained. Empiric meropenem is started given the unit’s high prevalence of ESBL-producing organisms. Forty-eight hours later, she is afebrile and her tenderness has resolved. The final urine culture grows Escherichia coli (>10^5 CFU/mL) susceptible to ceftriaxone, cefepime, meropenem, and nitrofurantoin. Which of the following is the most appropriate next step in antimicrobial therapy?

A 72-year-old male, intubated and on assist-control mechanical ventilation, is receiving a norepinephrine infusion via a right internal jugular central line for septic shock. He has had an indwelling Foley catheter in place for 7 days. Over the past 12 hours, he developed a new fever of 39.2°C (102.6°F), leukocytosis (WBC 18,500/mm³ with 85% neutrophils), and new onset altered mental status, now only responding to painful stimuli. His urine output has remained adequate. A urine dipstick from the Foley catheter shows positive leukocyte esterase and nitrites. There are no other clear sources of infection identified on initial workup. Given the patient’s clinical presentation and the presence of a long-term indwelling urinary catheter, which of the following represents the MOST appropriate initial management strategy for a suspected catheter-associated urinary tract infection (CAUTI)?

A 78-year-old man with advanced dementia, severe congestive heart failure, and end-stage renal disease on hemodialysis is admitted to the ICU for aspiration pneumonia. He is intubated and on PRVC mechanical ventilation, receiving a continuous norepinephrine infusion at 0.1 mcg/kg/min through a central venous catheter for septic shock. A Foley catheter has been in place for 10 days. Over the past 24 hours, he developed a fever of 39.2 °C (102.5 °F) and his white blood cell count rose to 18,000/mm³. A urine culture collected after catheter exchange grew Pseudomonas aeruginosa resistant to piperacillin-tazobactam but sensitive to cefepime and meropenem. The team is considering meropenem and percutaneous nephrostomy for source control. The family has previously expressed a desire for comfort-focused care, emphasizing avoidance of aggressive, life-prolonging interventions. Given his clinical status and previously stated goals, what is the most appropriate next step?

A 72-year-old man with no known drug allergies and normal renal function (serum creatinine 1.1 mg/dL, estimated creatinine clearance ∼60 mL/min) is in the ICU for severe sepsis from pneumonia. He is on mechanical ventilation, a central venous catheter, and an indwelling urinary catheter. This morning he developed a fever of 38.8 °C and his urine appears cloudy. His WBC count is 16,000/mm³, and a urine dipstick is positive for leukocyte esterase and nitrites. He remains hemodynamically stable on a low-dose norepinephrine infusion. A urine culture is pending. Which of the following is the most appropriate initial empiric antimicrobial regimen for suspected catheter-associated urinary tract infection (CAUTI) in this patient?

A 62-year-old man with end-stage renal disease on hemodialysis is admitted to the critical care unit for septic shock. He is intubated on assist-control ventilation with a norepinephrine infusion titrated to maintain a mean arterial pressure >65 mmHg. He has a tunneled central venous catheter in his right internal jugular vein. During evening rounds, the patient develops a new fever of 39.2 °C (102.6 °F) with an increasing white blood cell count. Blood cultures drawn simultaneously from his central line and a peripheral vein return positive for Staphylococcus aureus. The central line culture flagged positive at 10 hours, while the peripheral culture flagged positive at 12.5 hours. Which of the following is the most appropriate initial management for this patient’s bloodstream infection?

A 72-year-old man (weight 70 kg, baseline creatinine clearance 45 mL/min) in the intensive care unit is intubated and on assist-control ventilation. He has a central line and an indwelling urinary catheter that was exchanged upon admission. He develops fever to 38.9 °C, new-onset delirium, and a white blood cell count of 18,000/mm³. Urinalysis shows positive leukocyte esterase, nitrites, and >100 WBC/hpf. Empiric IV ceftriaxone was started for suspected catheter-associated urinary tract infection (CAUTI). After 48 hours, he remains febrile. Urine culture grows Escherichia coli resistant to ceftriaxone but susceptible to ciprofloxacin and gentamicin. Which of the following is the MOST appropriate next step in management?