A 62-year-old woman is brought to the emergency department w…
A 62-year-old woman is brought to the emergency department with altered mental status after her husband found her difficult to awaken. She is lethargic and cannot provide a history but keeps saying her belly hurts. Her husband says that she was discharged from the hospital 3 weeks ago after an episode of hepatic encephalopathy and that she has a history of decompensated cirrhosis secondary to nonalcoholic steatohepatitis, ascites, type 2 diabetes which requires insulin therapy, and hyperlipidemia. He mentions that she seemed to choke last night when she was drinking her Ensure. Allergies include anaphylaxis to ampicillin Vitals: Heart rate 105 bpm, blood pressure of 84/48 mmHg, temp 101.0*F, respiratory rate 24 breaths per minute, oxygen saturation of 92% on 2L nasal cannula (does not usually require supplemental oxygen). Physical exam: Difficulty maintaining alertness, evidence of asterixis, remaining limited neuro exam is normal. Rhonchi over right posterior and anterior lung fields. Mild diffuse abdominal tenderness with abdominal fluid wave. Slight erythema to sacrum but no ulcers or skin tenderness. Laboratory testing: Elevated WBC, chronic anemia and thrombocytopenia without change from baseline, stable elevations in total bilirubin, PT and INR. Elevated lactic acid. Urinalysis demonstrates 1+ bacteria, 2+ squamous epithelial cells. Chest xray reveals opacity in right lower lung field. Blood cultures are drawn and sputum and urine cultures are ordered. The patient is started on IV crystalloids in the resuscitation of her sepsis. Plans are made to perform a diagnostic paracentesis and administer albumin. What is the most appropriate initial antibiotic regimen for this patient?