Read the case below and identify what is the likely cause of fever and what is the next course of action?
A 88 year old male patient (57kg) with Bactrim allergy (facial rash with urticaria)had the following past medical history: Diabetes mellitus, Hypertension, Hyperlipidemia, CKD stage 5 (decline dialysis), IHD s/p CABG 2010, Gout, sick sinus syndrome s/p pacemaker insertion.
He had no recent hospitalization and currently admitted for giddiness and lower limb weakness
Patient is being worked up for benign paroxysmal positional vertigo (BPPV) and possible stroke. On day 3 of admission, patient developed fever (Tmax 38.5oC), and complains of swollen right ankle resulting in pain on ambulation. Patient was started on IV Piperacillin-tazobactam 4.5g Q6h for fever likely secondary to healthcare associated infection (HAI).
On examination, the right ankle was swollen with increased warmth but no overlying erythema.
Mild tenderness on palpation along ankle joint, some crepitus noted on passive extension and flexion of right ankle joint.
Chest X-ray: no consolidation
Left hand plug: intact, no phlebitis
Laboratory markers done on day of fever:
Procalcitonin (PCT) 0.50 ug/L
C-Reactive Protein (CRP) 205 mg/L
Total White Cell Count (TW) 10.5 x 109 cells/L
Serum creatinine (Cr) 320umol/L
What is the likely cause of fever and what is the next course of action?