Consider the following medical report that includes the patient's historical health records. Use it to predict the disease that the patient is high likely exposed to. 

 Medical Report: allergies: tegretol attending: chief complaint: wound infection major surgical or invasive procedure: 1. removal of previous segmental instrumentation. 2. fusion exploration. 3. incision and drainage. 4. debridement. 5. peg placement history of present illness: patient is a 50 yo female paraplegic, developmentally delayed, with nephrotic syndrome admitted to micu s/p i+d/vac placement for wound infection. during hospitalization from , patient had t10-l4 fusion and l1-l2 laminectomy for vertebral compression fractures resulting in paraplegia. she had a revision during that hospitalization and had a revision in . on clinic visit with dr. on , patient was noted to have wound dehiscence and thus had a scheduled i+d/vac placement on . after her or stay, she developed hypotension responding to small boluses of ivf; she also received 2u prbc for hct drop to 20 (noted to lose 300cc during her operation) and was hypoxic requiring continued intubation overnight. . in addition, her rehab skin swab cultures of her back wound were positive for klebsiella and proteus. admitted to micu for further management. past medical history: 1. osteoarthritis. 2. rheumatoid arthritis. 3. osteoporosis with vertebral compression fractures - normal bmd at the femoral neck, osteopenia at the trochanter, and osteoporosis at the total hip () 4. developmental delay. 5. sleep apnea; since on nocturnal ventilation with bipap at 18/12 cm h20 plus 4 liters of nasal cannular oxygen titrated in, else will desaturate to 45% 6. obesity. 7. history of leg ulcers. 8. leg swelling - since , followed by podiatry and vascular surgery (dr. 9. pilonidal cyst removal - , complicated by wound dehiscence 10. r knee replacement - 11. sle - dx , diagnosis not documented well 12. focal segmental glomerulosclerosis - presented with nephrotic syndrome . dx. via renal biopsy. 13. hx of seizures 14. chronic anemia - not fully worked up 15. vre bacteremia and uti 16. mrsa + 17. hx of perirectal ulcers 18. sacral ulcer - present since 19. gangrenous cholecystitis - s/p open cholecystectomy 20. vertebral compression fractures - s/p t10-l4 fusion with hardware - s/p l1-l2 laminectomy - s/p washout 21. hx of mdr resistant psedomonas uti social history: developmentally delayed. had been living with mother and sister until recent hospitalization, now at . family history: non-contributory physical exam: t: bp: 102/55 p:90s on cpap 5/5 100% gen: pleasant woman, nad. answering questions appropriately. heent: et in place cv: rrr, nl s1, s2, no m/r/g resp: anteriorly with some coarse breath sounds abd: soft, nt nd ext: moderate deformities of bilat hands. moderate nonpitting edema ue/le. some bilat leg atrophy. back/wound:25 cm of linear staples over thoracic vertebra, inferior opening 5cm x 5 cm with packing, 5x5cm gluteul deep ulcer with packing, left gluteal wound with 2 staples present pertinent results: . cxr () et tube tip is 2 cm above the carina. ng tube tip is in the stomach. there are low lung volumes with no consolidations or overt pulmonary edema. there is no pneumothorax or sizeable pleural effusion. note is made that the patient is very rotated. . . tissue culture from or. enterococcus sp.. rare growth. enterococcus sp.. rare growth. second strain. proteus mirabilis. rare growth. enterococcus sp.. rare growth 3rd. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | enterococcus sp. | | proteus mirabilis | | | enterococcus sp. | | | | ampicillin------------ <=2 s <=2 s =>32 r 8 s ampicillin/sulbactam-- 16 i cefazolin------------- 16 i cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 8 s ciprofloxacin--------- =>4 r gentamicin------------ <=1 s linezolid------------- 2 s meropenem------------- <=0.25 s penicillin------------ 2 s 8 s 16 r piperacillin---------- <=4 s piperacillin/tazo----- <=4 s tobramycin------------ 8 i vancomycin------------ <=1 s =>32 r <=1 s anaerobic culture (final ): bacteroides fragilis group. sparse growth. beta lactamase positive. . . wound swab. vwound culture (final ): due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for pseudomonas aeruginosa, staphylococcus aureus and beta streptococcus). enterococcus sp.. sparse growth. staph aureus coag +. sparse growth. enterococcus sp.. rare growth. second strain. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | staph aureus coag + | | enterococcus sp. | | | ampicillin------------ <=2 s <=2 s erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r linezolid------------- 2 s oxacillin------------- =>4 r penicillin------------ 2 s =>0.5 r 4 s rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- s vancomycin------------ <=1 s <=1 s =>32 r anaerobic culture (final ): mixed bacterial flora-culture screened for b. fragilis, c. perfringens, and c. septicum. bacteroides fragilis group. moderate growth. beta lactamase positive. brief hospital course: in summary, 50 year old female with paraplegia vertebral compression fractures, s/p hardware placement now w/ dehisence of post incision at t10-l4, taken to or with findings consistent with osteomyelitis. now s/p removal of hardware and on antibiotics. wound healing is poor due to , peg was placed to supplement nutrtion. . osteomyelitis: reports of wound culture from rehab grew out klebsiella and proteus. she went to the or as described above. intraop findings were consistent with osteomyelitis. all hardware was removed. tissue sample from or grew mrsa, vre, vse, proteus mirabilis, and b. fragilis. blood cultures were negative. meropenem and daptomycin were started and will be continued indefinitely until she can be taken back to the or for further debridement (one month at the earliest) or until her infectious disease doctor of these antibiotics. picc line was placed. she will follow up with infectious disease (dr. ). her lumbosacral and gluteal ulcers were managed as below. a wound vac is recommended and would be changed every three days. . decubitus ulcers (lumbosacral, gluteal): these have been an ongoing problem since her surgery last winter. led to osteomyelitis as above. her surgical wound was initially covered with a wound vac. wound consult and plastics consult were obtained for management of wound. frequent turning and nutritional support were maintained to maximize healing. would recommend placement of a wound vac at rehab, to be changed every 3 days. . malnutrition. calorie counts revealed that her daily caloric intake averaged 800 calories/day. a peg was placed for supplemental feeding on . tube feeds were started on . continue tube feeds (replete with fiber at 70 ml/hour for 12 hours a day. . respiratory failure: patient remained intubated in pacu due to post operative hypoxemia. she was extubated on in micu. following this she was oxygenating and ventilating well. she was able to come off oxygen on the medical floor. per old omr notes she is supposed to be on bipap at night (settings 18/12 with 40%, backup rate 10); however, since coming to the medical floor she has refused to wear it. states she does not always wear it at home. her oxygen sat remained in 90s while on the floor although she occassionally required 2lnc. . hypotension. patient was on standing lasix at home. however, she had several episodes of hypotension with elevated bicarb, suggesting that she was hypovolemic. lasix was stopped. consider restarting lasix if she become fluid overloaded. . anemia. patient has chronic anemia with a baseline in mid-high 20s. likely anemia of chronic disease (with history of rheumatoid arthritis and acute inflammation due to infection). no known ongoing losses. she had intra-op losses requiring prbc transfusion; following this she did not require further transfusion. she was started on epogen to improve her anemia. . nephrotic syndrome: baseline cr around 0.2-0.4. this was stable throughout hospitalization. initilly, urine had 1.4 grams protein/day, however during the admission, this was repeated and found to be only 257 mg/day. she is on standing lasix at home. lasix was eventually stopped due to hypotension and dehydration. . code: full. discussed with hcp by micu team . contacts: the patient's sister and mother are health care proxies. they can be reached at: (mother): (sister): h:, w: medications on admission: vit d 50000u q sunday rocaltrol 0.25mcg daily folic acid 1mg daily mvi daily vit c 500mg daily znso4 200mg daily ppi 20mg daily lasix 40mg kcl 20mg po bid ciprofloxacin 500mg po bid (day ) enlive 240ml po tid remeron 15mg po qhs tylenol prn maalox prn percocet prn discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) inj injection tid (3 times a day). 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 3. hexavitamin tablet sig: one (1) cap po daily (daily). 4. ascorbic acid 500 mg tablet sig: one (1) tablet po daily (daily). 5. zinc sulfate 220 (50) mg capsule sig: one (1) capsule po daily (daily). 6. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 8. acetaminophen 500 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 9. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 12. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical (2 times a day) as needed for itching. 13. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 14. lactulose 10 g/15 ml syrup sig: thirty (30) ml po every six (6) hours as needed for constipation. 15. calcitriol 0.25 mcg capsule sig: one (1) capsule po every other day (every other day). 16. epoetin alfa 10,000 unit/ml solution sig: one (1) injection injection qmowefr ( -wednesday-friday). 17. daptomycin 450 mg iv q24h 18. meropenem 500 mg iv q6h 19. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed. 20. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. discharge disposition: extended care facility: northeast - discharge diagnosis: primary: 1. polymicobial lumbar osteomyelitis vre/mrsa/esbl 2. stage iv sacral decubitus ulcer. 2. malnutrition - severe secondary: 1. ckd stage iii, nephrotic syndrome secondary to fsgs. 2. 1 x 2 cm right adrenal mass - stable 3. paraplegia secondary to traumatic/osteoporotic ls spine fracture 4. s/p t10 to l4 fusion/intrumentation - nonhealing 5. anemia of chronic disease 6. osteoarthritis. 7. rheumatoid arthritis 8. developmental delay 9. sleep apnea bipap 18/12, 4 liters nc 10. obesity 11. pilonidal cyst removal - , c/b by wound dehiscence 12. left tkr 13. sle - , diagnosis unclear discharge condition: fair discharge instructions: you were admitted after having a surgery to treat the wounds in your back. the surgeons found that you had an infection in that area that went down to the bone. the hardware that was near your backbones was removed and we are treating you with antibiotics. . please keep all of your appointments with your doctors and take of your medications as prescribed. . please check weekly ck at rehab as ms. is on daptomycin which can cause elevated ck levels. . please check weekly albumin as patient is malnurished and goal is to raise albumin with tube feeding in addition to eating by mouth. . please continue daptomycin and meropenem indefinitely until she can be taken back to the operating room for further treatment of her wounds or until dr. , you id doctor, recommends that it be stopped. . please care for wounds as above. would recommend placement of wound-vac to be changed every three days. . please return to the hospital or call your doctor if you are having temperature >101, worsening back pain, worsening drainage or bleeding from the wounds in your back, or if you have any new symptoms that you are concerned about. followup instructions: your primary care physician is . (). . you have an appointment with infectious diseases dr. on at 11:30. phone:. . you have an appointment with endocrinologist dr. on at 2 pm. phone: . . you have an appointment with orthopedic surgeon dr. on at 10:30 am. ph. . his office is located on , , . . you have an appointment with plastic surgeon dr. on at 1:45pm. his office is located on , , surgical specialities, . ph . . you have an appointment with nephrologist dr. on at 2:30 pm. phone: procedure: venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] removal of implanted devices from bone, other bones excisional debridement of wound, infection, or burn diagnoses: other postoperative infection acute posthemorrhagic anemia unspecified protein-calorie malnutrition infection with microorganisms resistant to penicillins unspecified osteomyelitis, other specified sites hemorrhage complicating a procedure acute respiratory failure methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site osteoporosis, unspecified pressure ulcer, lower back rheumatoid arthritis paraplegia infection and inflammatory reaction due to other internal orthopedic device, implant, and graft late effect of spinal cord injury late effects of other accidents nephrotic syndrome with unspecified pathological lesion in kidney lack of normal physiological development, unspecified 

Answer: The patient is high likely exposed to