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: no known allergies / adverse drug reactions attending: chief complaint: increased tracheal secretions major surgical or invasive procedure: trach change - history of present illness: this is a 53 year old lady with tracheomalacia s/p tracheostomy, mental retardation, dm, htn, peripheral vascular disease who presents with increased tracheal secretions, fever to 103 and dyspnea. per ems, patient was noted to have a high fever with elevated blood sugars to 500s this am at nursing facility. she was given 10 units of insulin per sliding scale and 650mg tylenol rectally at her facility. when ems arrived, pt was found to be tachycardic 140s and tachypneic to the 40s with o2 sats in the 80s on unclear o2 delivery. en route to , ems stopped at for increasing dyspnea in the ambulance. vitals on arrival were to osh were 156/70 133 103.8 97 pm vent. at osh cxr was concerning for rll pna. she was given 1.5 grams of unasyn and 1 liter of ns was started at 100cc/hr. blood sugar on ems arrival was 160. there she was suctioned and given more tylenol. of note she was most recently admitted in with similar symptoms of dyspnea. she presented with a leukocytosis, fever and lactate of 4.5. the etiology of her presenting sepsis was felt to be secodary to urosepsis versus pseudomonal/mrsa pneumonia for which as treated with a 14 day course of vancomycin and cefepime. her sputum culture grew pseudomonas and mrsa although it was initially unclear whether these cultures reflected chronic colonization of her trach. treatment for pneumonia was based on ct evidence of rll consolidation. her urine grew pansensitive ecoli in addition to her blood. her hospital course was complicated by altered mental status and delirium. at the time of discharge she was alert and able to answer yes-no questions by nodding her head. per her pcp, is able to answer questions, read and write normally. she at baseline lives at northeast - . she has co-guardian ship with her father and brother. in the ed inital vitals were, 120 104/73 36 92% on ??. initial labs were significant for wbc 24.3, hct 34.0, creatinine 1.0, lactate 2.1. a ua was positive for large leukocytes, moderate blood, negative nitrates. blood cultures were sent. initial abg 7.4/53/218/34. a chest xray demonstrated no effusion or consolidation and low lung volumes. she was given 750mg levofloxacin, zosyn 4.5 and vancomycin 1g. vitals on transfer: 101.8, 110-120s, 112/82, 28 (36 on arrival) 96% on 4l (2l on arrival). unknown baseline o2 requirement. she was placed on assist control ventilatory support prior to transfer. on arrival to the icu, initial vital signs were: 115 115/70 18 95% on ac 50% peep 5 tv of 0.3. review of systems: (could not obtain) (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: mental retardation tracheomalacia s/p tracheostomy h/o aspiration pneumonia diabetes mellitus h/o c. difficile infection, glaucoma hypertension hld osteoarthritis depression/anxiety, constipation psychosis . past surgical history: tracheostomy and peg , r total knee replacement r hip replacement right common iliac artery stent placement and right external iliac recanalization with stent placement x2. social history: lives at nursing home in , ma. father and brother are -guardians family history: unable to obtain physical exam: admission exam: vitals: 115 115/70 18 95% general: arousable, responds to simple commands by nodding her head heent: sclera anicteric, mucous membrane dry neck: supple, jvp difficult to appreciate obesity, but does not appear elevated lungs: anterior lung field, diffused expiratory wheeze, diminished air movement, no rhonchi or crackles cv: tachycardic, difficult to appreciate any murmur, rub, or gallops breath sounds abdomen: large well healed scar in the ruq. soft, non-tender, non-distended, obese, bowel sounds present, no guarding, no organomegaly. g-tube in place gu: foley, clear yellow urine ext: warm. distal pulses (dp and pt) non-palpable but dopplarable. black 3rd digit of right foot, non tender, non erythematous appearing. pertinent results: labs on admission: 11:00am blood wbc-24.3*# rbc-3.78*# hgb-11.1* hct-34.0*# mcv-90 mch-29.4 mchc-32.6 rdw-15.7* plt ct-251 11:00am blood glucose-88 urean-15 creat-1.0 na-137 k-3.5 cl-96 hco3-35* angap-10 11:26am blood type-art rates-/14 tidal v-350 peep-5 fio2-100 po2-218* pco2-53* ph-7.40 caltco2-34* base xs-6 aado2-448 req o2-76 -assist/con 11:12am blood lactate-2.1* . labs on discharge: 04:29am blood wbc-8.6 rbc-2.92* hgb-8.8* hct-27.3* mcv-94 mch-30.0 mchc-32.1 rdw-15.4 plt ct-148* 04:29am blood glucose-136* urean-16 creat-0.9 na-142 k-4.5 cl-105 hco3-36* angap-6* 04:29am blood calcium-8.9 phos-2.9 mg-2.4 . micro: : blood culture, routine (preliminary): escherichia coli. final sensitivities. cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. piperacillin/tazobactam sensitivity testing performed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s aerobic bottle gram stain (final ): gram negative rod(s). . cxr: : impression: increased bronchovascular markings could reflect bronchitis. no lobar consolidation. . brief hospital course: 53 year old lady with tracheomalacia s/p tracheostomy, mental retardation, dm, htn, peripheral vascular disease who presents with increased tracheal secretions, fever to 103 and dyspnea. . # dyspnea/increased secretions: etiology of increased dyspnea/secretions w/ associated leukocytosis, fever and increased rr meeting sirs criteria concerning for infectious etiology. growing gnrs which was found to be pan sensitive e. coli. improved ventilatory status; tolerating trach mask, with some short requirements for pressure support. initial antibiotic regime of vancomycin/ zosyn/ tobra was stopped and po ciprofloxacin was started (14 day course). albuterol/ipratropium nebs q4hrs were started for wheezing. . # gnr bacteremia: patient meets sirs criteria with leukocytosis, fever, and increased respiratory rate to 36. likely etiology of inflammatory reaction was pulmonary given increased secretions and dyspnea. urinary and stool etiologies also possible, h/o pansensitive ecoli infx in w/ similar pyuria. h/o cdiff in past. dry gangrene on toes look stable to improved. no evidence of decubs on skin exam. e. coli x 2 grew from blood smaples drawn in the ed and the pt was started on cipro. . # tracheomalacia s/p tracheostomy: patient is trach dependent given the severity of her tracheomalacia and requires trach changes every 6 months for the rest of her life. she was s/p emergent intubation with a size #5 ett last . she currently has a #7 portechs. trach was changed by pulmonary fellow/rt on the floor. . # diabetes: insulin dependant diabetes melitus. she was hyperglycemic this am to 500 likely in setting of infection. s/p 10 units insulin sliding scale w/ improvement to 160 in ed. continued insulin sliding scale, lantus qhs 56 units and nph 4 units qam. . # mental retardation/psychosis: continued home anti-psychotics: seroquel and valproic acid. . # hypothyroidism: continued levothyroxine. . # vascular disease/: patient had bilateral iliac stents placed by vascular in 2/. chronic issue. . # peripheral dry gangrene: stable to improved from review of prior notes. non tender or erythematous to suggest source of infection. . #transitional issues: - please continue ciprofloxacin through - trach changed on . medications on admission: 1 aspirin 325 mg tablet daily 3 cholecalciferol (vitamin d3) 400 unit tablet daily 4 valproic acid (as sodium salt) 250 mg/5 ml syrup 750mg qhs, 500mg qam 6 quetiapine 250mg tid 7 levothyroxine 25 units qdaily 8 fenofibrate 54 mg tablet sig: one (1) tablet po once a day. 9 calcium carbonate 500 mg/5 ml (1,250 mg/5 ml) suspension 5ml daily 10 lantus 100 unit/ml solution sig: fifty six (56) units sc qhs 11 insulin nph 100unit/ml, 4 units sc qam. 12 insulin humun regular 100units/ml 1 dose sc as directed per iss 13 levothyroxine 25 units qdaily 14 lactobacillus acidophilus 100 million cell capsule sig: daily 15 acetaminophen 650 mg q4hrs prn 16 guaifenacin prn congestion 17 milk if mag prn constipation 18 multivitamin dily 19 loperimide prn 20 lorazepam 1mg q6hrs for anxiety 21 lanotprost 0.05% opth 1 drop qam both eyes 22 albuterol 0.083 neb q8hrs as needed for congestion 23 artificial tears prn 24 biacodyl per rectum prn 25 fleets per recutum prn 26 ipratropium nebs 0.02% inh every 8 hrs prn wheeze discharge medications: 1 aspirin 325 mg tablet daily 3 cholecalciferol (vitamin d3) 400 unit tablet daily 4 valproic acid (as sodium salt) 250 mg/5 ml syrup 750mg qhs, 500mg qam 6 quetiapine 250mg tid 7 levothyroxine 25 units qdaily 8 fenofibrate 54 mg tablet sig: one (1) tablet po once a day. 9 calcium carbonate 500 mg/5 ml (1,250 mg/5 ml) suspension 5ml daily 10 lantus 100 unit/ml solution sig: fifty six (56) units sc qhs 11 insulin nph 100unit/ml, 4 units sc qam. 12 insulin humun regular 100units/ml 1 dose sc as directed per iss 13 levothyroxine 25 units qdaily 14 lactobacillus acidophilus 100 million cell capsule sig: daily 15 acetaminophen 650 mg q4hrs prn 16 guaifenacin prn congestion 17 milk if mag prn constipation 18 multivitamin dily 19 loperimide prn 20 lorazepam 1mg q6hrs for anxiety 21 lanotprost 0.05% opth 1 drop qam both eyes 22 albuterol 0.083 neb q8hrs as needed for congestion 23 artificial tears prn 24 biacodyl per rectum prn 25 fleets per recutum prn 26 ipratropium nebs 0.02% inh every 8 hrs prn wheeze 27 ciprofloxacin hcl 500 mg po/ng q12h duration: 14 days order date: discharge disposition: extended care facility: northeast - discharge diagnosis: e. coli bacteremia pneumonia discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: ms. was admitted for increased secretions and respiratory distress. she was found to have e. coli bacteremia and was started on po cipro to complete a total 14 day course (through ). her trach was changed on . followup instructions: - please ensure completion of course of ciprofloxacin through . procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours enteral infusion of concentrated nutritional substances replacement of tracheostomy tube diagnoses: acidosis unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled severe sepsis unspecified acquired hypothyroidism peripheral vascular disease, unspecified other and unspecified hyperlipidemia acute respiratory failure pneumonitis due to inhalation of food or vomitus septicemia due to escherichia coli [e. coli] atherosclerosis of native arteries of the extremities with gangrene knee joint replacement gastrostomy status hip joint replacement unspecified intellectual disabilities other diseases of trachea and bronchus attention to tracheostomy 

Answer: The patient is high likely exposed to