• 64-year-old woman with percutaneous silastic catheter (PSC)
• Managed with percutaneous biliary drainage and intermittent antibiotics
• Drain removed 1 month ago, last antibiotics were 4 months ago, and peripherally-inserted central catheter removed 2 months ago
• Presents to emergency department

• Shaking, chills, fever of 38.8°C, and lethargy
• White blood cells 14 400 cells/mm^₃; 32% bands
• Heart rate, 110 bpm; respiratory rate, 24 breaths/min; blood pressure, 130/90 mm Hg

First 24 hours

• Started on vancomycin and piperacillin-tazobactam
• Developed hypotension within 24 hours
• Arterial blood gas, 7.32/24/70 on 80%, lactate 8
• Blood cultures: gram-positive cocci in pairs and chains
• Prior nasal swab and rectal swabs negative for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci 6 months ago

Primary Sclerosing Cholangitis Requiring Right and Left Percutaneous Transhepatic Cholangiography Drainage

Suggested Discussion Points

• Is this a healthcare-associated infection?
• Is there a finite time of healthcare nonexposure that places the patient back into the “community” stratum?
• What antimicrobial modification(s) is necessary?
• Other diagnostics you would order?
• Other therapeutics you would order?
• Comments/Questions?

Discussion Forum: