Story
M.S. was an 89-year-old woman whose medical history was consistent with chronic mesenteric ischemia (weight loss, postprandial abdominal pain, diarrhea), and a 6-cm infrarenal aortic aneurysm for which she had previously declined surgery. She was admitted to the hospital with increased abdominal pain (constant, and unrelated to meals), bloody stools, nausea with emesis, a profound leukocytosis (WBC, 56,000 cells/mcL) and renal insufficiency (creatinine ratio, 1.63 mg/dL). One week prior to this admission, she had been discharged from the same hospital following treatment for urosepsis. She had just finished 10 days of antibiotics (ceftriaxone and cephalexin) the day before this admission.
CDC / Jennifer Hulsey
A portrait of a C. diff bacillus.
M.S. was admitted to a regular nursing floor by Dr. Hospitalist 1 and started on intravenous fluids (2L, then hep-lock) plus oral metronidazole (for suspected Clostridium difficile infection [CDI]) and oral ciprofloxacin (for possible infectious colitis/diverticulitis). No abdominal imaging was performed by the emergency room or Dr. Hospitalist 1.
For the next 2 days, M.S. was seen daily by Dr. Hospitalist 2 in conjunction with a GI consultant. The GI consultant discontinued the ciprofloxacin and both were awaiting the results of the C. difficile toxin assay. M.S. continued to have leukocytosis (WBC 36,000 cells/mcL) with a heart rate consistently greater than 90 beats/min. However, M.S. was able to achieve adequate abdominal pain control with oral acetaminophen, and she was taking a liquid diet. Dr. Hospitalist 2 commented in his progress notes that M.S. was improving clinically.
At 11 p.m. of hospital day 2, M.S. suffered a fall from her bedside commode and hit her head, causing a laceration. Nurses noted she was lethargic and hypotensive (BP 80/50 mm Hg) with labored breathing. Dr. Hospitalist 3 was contacted, but deferred a physical assessment in favor of restarting intravenous fluids (the IV fluids ordered on admission had been discontinued earlier that afternoon) and obtaining an arterial blood gas. One hour later, M.S. had a BP 102/65 mm Hg with saline running at 150 cc/hr. The arterial blood gas demonstrated a mixed respiratory and metabolic acidosis (pH, 7.06; PaCO2 21 mm Hg). Dr. Hospitalist 3 continued to defer a physical assessment and ordered a repeat arterial blood gas that showed a worsening respiratory and metabolic acidosis (pH, 7.00; PaCO2 37 mm Hg).
At 3 a.m., the nurses called a rapid response team for lethargy and tachypnea, and M.S. quickly lost her pulse. M.S. was a "Do not resuscitate/Do not intubate" patient, and she was therefore pronounced dead. No autopsy was performed.
Complaint
Although M.S. was 89 years old, the family was surprised at her passing. Prior to her last two admissions (urosepsis and this index event), M.S. was independent, lived in her own home, hosted a weekly bridge club, and routinely interacted with family and friends.
The family was particularly troubled by the laceration on her forehead, which at the time of her death, was a deep enough wound to have required stitches for closure (which had not been performed antemortem). The laceration led to discovery of the fall, which the led to the realization that no physician went to see M.S. prior to her death. The family was suspicious and contacted an attorney who had the case reviewed and subsequently filed suit.
The complaint alleged that all of the hospitalists failed to appreciate, appropriately monitor, and appropriately treat severe CDI with severe sepsis. The complaint further alleged that Dr. Hospitalist 3 breached the standard of care by failing to attend to M.S. after her fall and initiating therapies for her acidosis.
Scientific principles
C. difficile infection is one of the most common hospital-acquired (nosocomial) infections and is an increasingly frequent cause of morbidity and mortality among elderly hospitalized patients. Patients with acute CDI may develop signs of systemic toxicity with or without profuse diarrhea warranting admission to an ICU or for emergency surgery.
Guideline parameters for severe CDI include WBC count of more than 15,000 cells/mcL or a serum creatinine level equal to 1.5 times the premorbid level. Patients with severe disease should be treated with oral vancomycin (125 mg to 500 mg q.i.d.). In the setting of ileus, addition of IV metronidazole (500 mg every 8 hours) is appropriate. Intracolonic vancomycin may be considered in patients with profound ileus. Some severely ill patients with CDI require surgical intervention as a result of toxic megacolon, perforation, or impending perforation, necrotizing colitis or rapidly progressive and/or refractory disease with systemic inflammatory response syndrome leading to multiorgan system failure
Complaint rebuttal and discussion
Without an autopsy (or abdominal imaging of any kind), defense experts first argued that M.S. died from a progression of her mesenteric ischemia (gangrene, with or without perforation), not CDI. The defense further argued that if M.S. did have severe CDI, then she ultimately would have needed surgery (regardless of appropriate fluid resuscitation, ICU care, and appropriate antibiotics), and she was not an operative candidate. If M.S. had gone for surgery, she would have in all probability died intraoperatively.
