You're a couple hours into your shift at a 25 bed community ED and it's been a modestly busy day. You just finished up performing a dental block on a patient with pulpitis and maybe the start of a periapical abscess and admitting a patient with unstable angina who had some lateral ST-depressions but a normal troponin.

2 patients just checked in while you were off doing the dental block and a squad just rolled in with your next patient, a transfer from a nursing home. Linda, 79 years old, was sent in for altered mental status, which was initially noticed last night. She hasn’t said anything on the ride over, and glancing over at the cot, she appears frail and confused. They think it’s a UTI.

“Easy,” you think, “check a urine, order antibiotics, admit.”

Then you get her vitals – 122, 82/60, 97%, 95.8°...

She gets rolled to the trauma bay. Glancing at her chart, you see she’s had multiple UTIs: lots of pan-sensitive E. coli, a couple of proteus infections (sensitive to most things), some yeast, and one previous nasty Pseudomonas infection about 7 years ago which was resistant to nearly everything except meropenem.

You get a urine quickly and her urinalysis returns with positive leucocyte esterase, but nitrite negative, with a pH of 5.5, and 20 protein. Her blood work is all pending.