A 65-year-old former Vietnam War veteran male was admitted to the intensive care unit with shock. He

A 65-year-old former Vietnam War veteran male was admitted to the intensive care unit with shock. He had underwent orthotopic liver transplantation 3 months ago for cirrhosis due to alcohol abuse and hepatitis C infection. His posttransplant course had been complicated by graft-versus-host disease treated with pulse dose methylprednisolone for 3 days followed by prednisone 60 mg daily, which he was currently on. He presented to the emergency room with complaints of headache and wheezing for the last 2 days and was also found to be somnolescent. On the first day of admission, he was noted to

A 65-year-old former Vietnam War veteran male was admitted to the intensive care unit with shock. He had underwent orthotopic liver transplantation 3 months ago for cirrhosis due to alcohol abuse and hepatitis C infection. His posttransplant course had been complicated by graft-versus-host disease treated with pulse dose methylprednisolone for 3 days followed by prednisone 60 mg daily, which he was currently on. He presented to the emergency room with complaints of headache and wheezing for the last 2 days and was also found to be somnolescent. On the first day of admission, he was noted to have intermittent bouts of cough with two episodes of small volume hemoptysis. Chest x-ray showed bilateral patchy nodular opacities for which he was started on vancomycin and piperacillin/tazobactam. However, on the second day of admission, his condition acutely worsened with tachycardia, hypoxemia, and hypotension requiring vasopressor support. Lactate was elevated raising suspicion of sepsis, and workup for an infectious source was initiated. Urinalysis was unremarkable, stool Clostridioides difficile PCR was negative, and CMV PCR was undetectable in blood. CT scan of the head was unremarkable. Two sets of blood cultures were sent. Gram stain of cerebrospinal fluid (CSF) showed gram-negative rods identified later the same day as Escherichia coli by PCR, and consequently piperacillin/tazobactam was changed to cefepime. Chest imaging the next day showed marked worsening of opacities on the left upper lobe and right lower lobe, and he was intubated for worsening hypoxia. The tracheal aspirate was sent for culture; however, you received a call from the microbiology lab the same day informing you of an unexpected finding on the gram stain of tracheal aspirate. A representative image follows. Which of the following describes the best treatment plan for this patient? A. Continue cefepime B. Continue cefepime and add ivermectin C. Discontinue cefepime and start ivermectin D. Discontinue cefepime, reduce the dose of prednisone and start ivermectin E. Continue cefepime, reduce the dose of prednisone and start ivermectin

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