# The 48-year-old client with acute myeloid leukemia is on day 10 after induction chemotherapy. At presentation 12 hours ago, the client had new rigors and unusual weakness, absolute neutrophil count 180/mm3, temperature 38.4°C (101.1°F), blood pressure 92/54 mm Hg (baseline 118/70 mm Hg), heart rate 118/min, respiratory rate 22/min, oxygen saturation 96% on room air, lactate 2.8 mmol/L, and creatinine 0.8 mg/dL. Blood cultures were drawn from the central line and from a peripheral vein, and IV cefepime was started. The central-line site has no erythema or drainage, and the client had 2 loose stools this week. Now, at 12 hours, both blood-culture sets grow ESBL-producing Klebsiella pneumoniae reported as susceptible to cefepime and meropenem. Blood pressure is 98/58 mm Hg, and creatinine has risen to 1.7 mg/dL. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617377&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## Question The 48-year-old client with acute myeloid leukemia is on day 10 after induction chemotherapy. At presentation 12 hours ago, the client had new rigors and unusual weakness, absolute neutrophil count 180/mm3, temperature 38.4°C (101.1°F), blood pressure 92/54 mm Hg (baseline 118/70 mm Hg), heart rate 118/min, respiratory rate 22/min, oxygen saturation 96% on room air, lactate 2.8 mmol/L, and creatinine 0.8 mg/dL. Blood cultures were drawn from the central line and from a peripheral vein, and IV cefepime was started. The central-line site has no erythema or drainage, and the client had 2 loose stools this week. Now, at 12 hours, both blood-culture sets grow ESBL-producing Klebsiella pneumoniae reported as susceptible to cefepime and meropenem. Blood pressure is 98/58 mm Hg, and creatinine has risen to 1.7 mg/dL. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition Select 1 Blood culture contamination ESBL bloodstream infection with sepsis Febrile neutropenia without an identified source Hypovolemia from chemotherapy-related diarrhea Actions to take Select 2 Continue cefepime because the isolate tests susceptible Administer the prescribed IV meropenem now Administer the prescribed filgrastim injection Infuse the prescribed crystalloid fluid bolus Repeat blood cultures before changing antibiotics Parameters to monitor Select 2 Absolute neutrophil count Stool frequency Mean arterial pressure Serum lactate Central-line site appearance ## Explanation Two concordant blood-culture sets growing ESBL-producing Klebsiella, with blood pressure still below baseline, a presenting lactate of 2.8 mmol/L, and creatinine rising to 1.7 mg/dL, indicate an ESBL bloodstream infection with sepsis. IDSA guidance recommends a carbapenem such as meropenem even when cefepime tests susceptible, and ongoing hypoperfusion calls for the prescribed crystalloid bolus. Mean arterial pressure and lactate show whether perfusion is improving. ## In-depth explanation Quick answer ESBL bloodstream infection with sepsis. Actions: administer the prescribed IV meropenem now; infuse the prescribed crystalloid fluid bolus. Monitor: mean arterial pressure, and serum lactate. Why this is correct Growth of the same organism in both sets, including a peripheral set, makes contamination unlikely. The isolate is an ESBL producer, and the IDSA antimicrobial-resistance guidance advises against relying on cefepime for ESBL infections even when laboratory testing reports susceptibility; a carbapenem is preferred, with the dose matched to the current creatinine. Hypotension at presentation with lactate 2.8 mmol/L, a blood pressure still below baseline at 12 hours, and a rising creatinine signal ongoing hypoperfusion that needs fluid resuscitation and close reassessment. Easy analogy or mental picture ESBL enzymes are shredders for many cephalosporins; the lab test may show the key fits the lock, but in the body the shredder chews it up. Meropenem is a key the shredder cannot cut. Memory hook ESBL = carbapenem; low pressure + lactate = fluids, then trend MAP and lactate. NCLEX decision rule When cultures identify a resistant organism in an unstable client, switch to the agent recommended for that organism without delay and support perfusion at the same time. Why the other choices are wrong Contamination is unlikely when both sets, including a peripheral draw, grow the same organism. Febrile neutropenia without a source no longer fits because a source is identified. Two loose stools do not explain lactate 2.8 mmol/L with fever and rigors, so stool frequency tracks the wrong problem. Continuing cefepime relies on in-vitro susceptibility that guidelines consider unreliable for ESBL organisms. Repeating cultures before changing therapy delays active treatment. Filgrastim and the neutrophil count address marrow recovery, not the response of the bloodstream infection. A clean line site does not reflect bacteremia response. References 1IDSA Guidance on the Treatment of Antimicrobial-Resistant Gram-Negative InfectionsCarbapenems are preferred for ESBL infections outside the urinary tract; cefepime is not recommended even if susceptible. 2ASCO/IDSA Guideline: Outpatient Management of Fever and Neutropenia in Adults With CancerFebrile neutropenia is a medical emergency requiring prompt empiric antibiotics and assessment. ## Clinical scenario Case update Twelve hours after presentation, both blood-culture sets from a profoundly neutropenic client on cefepime grow ESBL-producing Klebsiella; blood pressure is 98/58 mm Hg and creatinine has risen from 0.8 to 1.7 mg/dL. ## Key concepts - **ESBL** — Extended-spectrum beta-lactamase, an enzyme that makes bacteria resistant to penicillins and most cephalosporins. - **Carbapenem** — A beta-lactam class, such as meropenem, that remains active against ESBL-producing organisms. - **Lactate** — A marker of tissue hypoperfusion; a level above 2 mmol/L in infection signals sepsis-related hypoperfusion. ## Related questions - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=en) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. 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