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This patient is experiencing a post-procedure urinary tract infection which may have been introduced into his bloodstream at the time of his cystoscopy. It is likely that the patient is experiencing a sepsis-like syndrome and has a systemic infection with a uropathogen that is resistant to the antibiotic that he has received. Pos-sible bacteria that may be responsible for the patient’s symptoms are methicillin-resistant Staphylococcus aureus, Enterococcus sp., and enteric Gram-negative rods that are resistant to ciprofloxacin such as ESBL-positive E coli or Klebsiella pneumoniae, or other hospital-acquired Gram negative organisms such as Pseudomonas aeruginosa. The patient was treated with vancomycin and meropenem, and blood and urine cultures were both positive for ESBL-positive E coli that was resistant to ciprofloxacin. The patient defervesced and hemodynamically stabilized over the subsequent 48 hours. ESBL-positive E coli is an emerging urinary tract pathogen that may be acquired in the outpatient setting, and oral antibiotic therapy may not reliably be effective; empiric therapy with a carbapenem (ertapenem, doripenem, meropenem, imipenem) is recom-mended for serious infections due to this organism.
Philip J. Rosenthal, MD