This forum seems a little slow, so let's try something to stimulate some discussion. I'll give a case presentation and get to a point where I come to a point where we discuss the pros and cons of a particular treatment. Case #1: 90 yo Female, presents with fever, altered mental status. PMH: recent Clinical dx of herpes encephalitis (bilateral temporal hyperintensities on MRI but family refused LP and no neurosurgeon for tissue dx) treated with 14 days of acyclovier with improvement, last dose 3 days ago. Alzheimer's, HTN, CAD, PMH: Non-contributory Allergies: none social: crazy as a ding bat Presentation: was brought in via paramedics after found slouched down in her bed by nursing home staff. brought in non-responsive (which is different from her baseline) tachycardic, tachypnic, febrile. Diagnostic studies: CXR: mild cardiomegaly, no infiltrates CMP: BUN 41 Cr 1.7, ALT 275, AST 150 rest WNL CBC: WBC 21, toxic granulation, 15% bands UA: +3 ketone, +3 protein, + LE, +Nitrates, Bacteria TNTC, WBC TNTC BC: pending Lactate: pending. ABG: mild resp alk Diagnosis: 1) UTI 2) SIRS 3) end organ damage (elevated Cr/BUN, AST, ALT) 4) severe sepsis 2 to #1 + #2 + #3 5) AMS 2 to #2 6) H/o Alzheimer's 7) recent Herpes encphalitis, last dose of Acyclovir 3 days ago 8) Full code status. 9) usual old person risk factors Plan: 1) ATSO: Dr you 2) IV ABX: empiric: Cipro, Ceftriaxone, and Vanc until C&S is back 3) Prayer Question: Do you institute Xigris? why or why not?