Mrs. Bovier is a 72-year-old woman who recently spent 5 days in the hospital for pneumonia, where she received intravenous antibiotics and respiratory therapy. She was discharged 1 week ago and has been at home with her elderly husband, who assists in her care. She has arthritis and typically is not very physically active.
Mrs. Bovier returned to her primary care provider for a checkup and complained of increasing difficulty breathing, headache, and coughing up yellowish colored sputum. On examination she was found to have a low-grade fever, chest auscultation revealed areas of atelectasis, oxygen saturation (Pao2) was 91%, and she was diaphoretic. A sputum specimen was obtained for culture and sensitivity that later revealed the presence of MRSA. Chest x-ray confirmed pulmonary congestion and atelectasis. Laboratory analysis showed an elevated white blood cell (WBC) count, the presence of band cells (immature neutrophils), and an elevated erythrocyte sedimentation rate (ESR).
Mrs. Bovier was again hospitalized because of the severity of her respiratory distress, the need for intravenous antibiotics to manage the MRSA pulmonary infection and pulmonary therapy to assist in resolving her pulmonary congestion, and the need for contact isolation because of her recurrent pneumonia and MRSA infection. Mrs. Bovier’s age and lack of physical activity are complications that may influence MRSA treatment, requiring a more watchful course of initial therapy.
Hospital care for Mrs. Bovier included instruction in methods to improve the productivity of her cough, humidified oxygen to assist with loosening secretions while improving ventilation, and respiratory therapy to help with expectoration and to facilitate lung expansion and air exchange. She received intravenous vancomycin, mucolytic agents, a bronchodilator, and expectorants to treat her pulmonary disease and assist in breathing.
On discharge, Mrs. Bovier received instructions in the proper technique for effective hand hygiene; the importance of avoiding large crowds of people as well as areas where people are smoking, to diminish her exposure to irritating respiratory stimuli; and the need to increase her physical activity, including frequent ambulation in her home, to help stimulate deep breathing and avoid peripheral vascular clot formation. She demonstrated understanding of her medication regimens and the need to maintain adequate food and fluid intake to support her immune system and provide energy while healing. The need for rest to promote healing was also emphasized. Finally, Mrs. Bovier was instructed on warning signs of recurring pulmonary disease or dysfunction.
Case Analysis
Health care-acquired MRSA is the most severe form of MRSA, with life-threatening infections such as bacteremia, surgical site infections, pneumonia, septic arthritis, toxic shock syndrome, and endocarditis as consequences. People at risk for acquiring MRSA infections include patients and visitors of patients in health care settings.
Mrs. Bovier met a number of the criteria that put her at risk for the development of MRSA. She was elderly, had been hospitalized with pneumonia (foreign pathogen), and had received intravenous antibiotics (invasive port of entry for MRSA). When she sought follow-up care to her hospitalization for pneumonia, she was found to have pulmonary congestion, hypoxemia, and fever. Diagnostic data revealed atelectasis on chest x-ray, an elevated white blood cell count, and immature neutrophils indicating the presence of a bacterial infection. These are classic clinical findings associated with infection. Diagnosis and treatment measures were consistent with the standards of care.
Sample Critical Thinking Questions Related to the Case Study
How does the information presented in this case study relate to the required six elements of the infectious process? Describe examples from the case study for each element.
What are contact precautions, and why are they appropriate for Mrs. Bovier?
Answer:
Contact precautions are measures taken to prevent transmission of pathogens by direct or indirect contact with the patient or the patient’s environment. These measures as set forth by the CDC are as follows. Provide rationales for each of the following
Patient Placement
Gloving
Gowning
Patient Transport
5) Patient-care equipment, instruments, and devices
Available at http://www.cdc.gov/mrsa/prevent/healthcare/precautions.html (Accessed July 31, 2012). Contact precautions are appropriate because MRSA is spread through direct contact with a person with active infection, a carrier, or a contaminated object
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