Harvey White (HW) is a 55 year old male patient with a 10 year history of poorly controlled diabetes. He currently manages his diabetes with insulin therapy. His dietary habits include donuts every morning and frequent desserts. He has undergone a left leg amputation due to his history of diabetes. In the previous three months the patient has been on numerous antibiotics following various wound infections and recurrent urinary tract infections (UTIs). The patient presents with complaints of dry, irritated left eye and difficulty seeing. Following a review of history of present infection the cornea of the affected eye was swabbed for specimen collection and a culture and identification was ordered.
After a collection of particular information through interview and objective data from examination a differential diagnosis can be established. Based on the patient signs and symptoms the working differential diagnosis includes: conjunctivitis, keratitis and glaucoma. According to Karen K Yeung, (2017), Keratitis is an inflammation of the cornea. Iritis is the inflammation of the iris which is painful. Iritis is the most common type of uveitis, affect the font eye. The cause is often unknown since it can result from an underlying systemic condition or genetic factor. If untreated, it can lead to vision loss (Mayo Clinic, 2017). Other the other hand, conjunctivitis involves inflammation of the thin layer lining the inner surface of the eye known as conjunctiva (Yeung).
Several key points assist in narrowing the diagnosis. The patient has a history of poorly controlled diabetes, an immune challenging condition, and present with a unilateral dry eye and irritation. The most likely diagnosis is conjunctivitis. With no report of discharge or drainage from eye and or trauma to the eye, the swab can help distinguish the causative organism. We were given a TSA, EMB and MSA culture media. Additionally, gram staining procedure was also necessary for the swab sample and the cultured colonies.
The first culture was Eosin-Methylene Blue (EMB) rule out the presence of a gram-negative bacterial agent. Any growths on the EMB world have indicated the presence of gram-negative bacteria. Mannitol Salt Agar (MSA) is a differential medium that targets pathogenic S.epidermidis. Tryptic Soy Agar (TSA) was to specify any present organism in the eye swab. TSA showed numerous tiny colonies. The EMB agar was colonies, indicating non-mannitol fermenting bacteria. The gram stain revealed gram-positive cocci in a cluster. A catalase test performed using hydrogen peroxide turned positive. Additionally, a novobiocin test was to differentiate between the coagulase negative species of Staphylococcus. Using Bergeyss flow charts it was determined that the causative agent S.epidermidis.
The isolated organism is highly related to the patients condition. The patient has a long history of uncontrolled diabetes, a condition which contributes to a weakened immune status, thus promoting the infection by S.epidermidis. This bacteria is part of the normal of the skin that rarely affects individual with a normal immune response (Kleinsschmidt el al., 2015 p.1859-79). Patients with diabetes are susceptible to many infections because of their weakened immune status. According to (Zaletel, et al., 2015, p.206) the immune system in people with diabetes becomes lower following the development of diabetes. Wound healing is slowed, and individuals are more susceptible to infection. Type 1 diabetes is also an autoimmune disease. This disease initiates destruction of insulin-producing cells from the pancreas (Zaletel, et al., 2015, p.206). Harvey probably have Type 2 diabetes given his age of onset. Type 2 diabetes is a chronic condition that affects the way your body metabolizes (Mayo Clinic, 2017).
The bacteria was found to be sensitive to novobiocin. This information is relevant to choosing the appropriate treatment for S.epidermidis. Novobiocin is antibodies that destroy the growth of Staphylococcus species. Appropriate antibiotics used for treatment of this organism include: vancomycin, azithromycin, tobramycin, sulfamethoxazole/Trimethoprim, penicillin ampicillin and tetracycline and sulfisoxade. S.epidermidis was susceptible to all antibiotics expect penicillin and tetracycline. According to Sanford guide, the best antibiotic to treat for S. epidermidis is vancomycin. To avoid bacterial resistance before administering the above drug a history of antibiotic use should be obtained (WebMD (2017)
Another consideration is the administration of broad-spectrum antibiotics such as vancomycin which is the target agent for S.epidermidis. The cost of specific antibiotics varies and might face with resistance. A broad-spectrum drug may be preferred because it is a very wide range of microbes including gram negative and gram positive. (Milena Lilles slides). In this treatment the target tissue is the eye cornea. Vancomycin can be administered through several routes which include orally. Systemic administration and ocular ointments or eye drops which are topical and non-systemic (Marsden, 2017, p.3), Systemic administration may be affected by ocular blood carrier, but due to inflammation, there will be a drug concentration that will help with absorption. The ocular administration will involve liquid eye drops or application of an ointment to the affected eye (Marsden, 2017, p.3). The side effects of the topical route include pain during administration, irritation of the eye. Side effects of routes that cause systemic influence are nausea.
Following administration of the broad spectrum antibiotics, the expected outcome of this treatment is that the eye will have healed with by the fifth day of treatment. The eye irritation will no longer be experienced. Also good vision will resume with no inflammation and also to check and monitor prognosis, a daily examination will be done to document the likely changes.
Apart from the administration of the antibiotics, the care plan for this patient will also include close monitoring and management of the underlying condition which is the diabetes. The treatment care will involve close checkup of the eye progress on a daily basis, cleaning the eye and the areas surrounding the eye after and before administering the topical drugs. Regarding management of the underlying condition (Felig, 2016, p.113), the patient will also be monitored on his insulin charts and oral medication, providing a balanced diet and avoiding food that will affect his blood sugar.
Regarding the long term management of this patient, he is a diabetic patient who will require proper management of the underlying condition to help the healing process and prevent infection (Felig, 2016, p.113). Since HW has used various antibiotics in the last three months, another important aspect of the care plan will be to closely monitor his use and response to antibiotic drug therapy. As this patient has a weakened immune system, he will require attention to good hygiene to help and to recovery (Felig, 2016, p.113). Concerning hygiene of the patient, he should ideally be placed in a setting free from contagious agents, avoid exposure to people with contagious illnesses. To avoid the spread of this infection, it will be important to avoid sharing towels or items that come in contact with the infected eye.
Work cited
"Common Drugs And Medications To Treat Skin Infection Due To Staphylococcus Epidermidis
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Felig, Philip. "Managing Diabetes." Postgraduate Medicine. 59.1 (2016): 113. Print.
Kleinschmidt, S, F Huygens, J Faoagali, IU Rathnayake, and LM Hafner. "Staphylococcus
Epidermidis As a Cause of Bacteremia." Future Microbiology. 10.11 (2015): 1859-79. Print.
Marsden, M. "Correct Administration Of Topical Eye Treatment. - Pubmed
NCBI". Ncbi.nlm.nih.gov. N.p., 2017. Web. 30 Apr. 2017.
Zaletel, Jelka, Milivoj Piletic, Jaana Lindstrom, Andrea Icks, Ulrike Rothe, Monika Sorensen,
and Marina Maggini. "National Diabetes Plans: Can They Support Changes in Health Care Systems to Strengthen Diabetes Prevention and Care?" Annali Dell'istituto Superiore Di Sanita. 51.3 (2015): 206-208. Print.
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