I would like to discuss my mother who is currently 74 years old with h/o bronchial asthma for the last 35 years. She is a nondiabetic, non hypertensive with no history of previous CAD. She first presented with Atrial fibrillation 2 years back which was controlled on Diltiazem, initially on 120 mg bd but later on 90 bd. Her respiratory status also decompensated and she started regular requirement for oral bronchodilators, antibiotics as indicated, regular Inhaled corticosteroids which were at times given upto 4000 Ug/day. Rescue therapy with oral steroids were also given off & on.

Her sudden decompensation started in December of 2009, when her nebulization requirements increased and she was initially started on Augmentin for a 10- day period. She then became oxygen dependant . Her work up for Tuberculosis was noncontributory and her autoimmune profile in the form of ANA, pANCA were also normal. Based on the picture of rising oxygen requirements, antibiotics were given as follows:

Antibiotic history

Early Nov, 2009 - Piperacillin + Tazobactum (10 days)

Late Nov, 2009 - Tab Azithromycin (7 days)

Jan 16, 2010 - Injection Clindamycin (7 days) + injection Moxifloxacin (till Mar 8, 2010)

Jan 22, 2010 - injection Moxifloxacin (till Mar 8, 2010) + Tab Faropenem (6 days)

Jan 31, 2010 - tab Moxiflox + Isoniazid + Ethambutol This was empirically stated by the Pulmonologist along with Pulse methylprednisolone CT Scan of her chest revealed picture of Interstitial Lung Disease. She showed some response and her oxygen requirements decreased from 2 l/min to 0.5 l/min. Her general condition stabilized for a few days.

Feb 28, 2010 - tab Moxiflox + Isoniazid + Ethambutol + Injection Ertapenem (1 gm OD up to Mar 8th, 2010) She showed deterioration at this time with pedal oedema which gradually increased to anasarca. Her LFTâ??s were normal but her total protein fell to 6.2 gm. She was started on sidenafil for her Pulmonary artery hypertension and torsemide for her Congestive heart failure which was interpreted as Cor pulmonale. The cardiologist at this point of time reduced steroids as she developed leucocytosis, raised CRP, bandemia on peripheral smear and altered GTT. On stoppage of steroids she slumbered to CO2 narcosis which reached 100 torr and she had to be put on BIPAP. Her counts at admission to the Respiratory ICU were 18, 800 and she was initiated on Mar 8, 2010 - Inj Imipenem + Inj Cilastatin + Injection Teicoplanin (400 mg OD) for 4 days. The counts increased progressively to reach 26,900 with mainly polymorphic response upto 89%. Her procalcitonin levels were high but galactomannan were negative. She was initiated on Mar 10, 2010 - Injection Tazobactum + Piperacillin TDS for 3 days, + Injection Tigecycline 50 mg BD + Inj Voriconazole. Her counts stabilized for 48 hours but are again showing a rise. Her general condition is improving, her cognition has improved, her blood gases show normoxemia with permissible hypercapnia (50-60) Till date cultures sent every day have been sterile.

We would like your advice on further antibiotic therapy and supportive measures. Thanks in advance for anticipatory guidance.