Balancing the benefits and risks of empirical antibiotics for sinusitis: a teachable moment.

Story From the Front Lines A man in his 70s with a history of rheumatoid arthritis being treated with infliximab presented to his primary care physician (PCP) with upper respiratory tract congestion of several days’ duration. He was diagnosed as having acute rhinosinusitis and treated with cefdinir. Two days later, he developed diarrhea. After 24 hours of severe diarrhea, he discontinued taking the antibiotic, and the following day his physician prescribed the combination drug diphenoxylate hydrochloride/atropine sulfate (Lomotil; Pfizer Inc). Five days after the initial visit, he arrived at the emergency department pale, hypotensive, and reporting an “uncountable number of episodes of diarrhea.” He was aggressively treated for presumed Clostridium difficile infection (CDI) and was admitted in critical condition. On hospital day 2, he developed toxic megacolon and underwent small bowel resection and near-total colectomy. The patient subsequently developed multiorgan failure and required intubation, continuous venovenous hemofiltration (CVVH) and vasopressor support. Over the next week he returned to the operating room 3 more times for resection of terminal ileum, cholecystectomy, further washout, repacking, and sequential closure of his open abdomen. Despite aggressive source control, the patient had persistent vasopressor and transfusion requirements, ongoing CVVH, and minimal improvement in mental status. Seventeen days after admission he was transitioned to comfort care, and he died shortly thereafter.