Charles Krasner, M.D. University of NV, Reno School of Medicine Sierra NV Veterans Affairs Medical Center
Kathy Peters is a 63 y.o. patient that presents to your urgent care office today with a history of coughing and wheezing for the past 5 days. Originally, she thought she was getting a cold; however, her symptoms have been getting worse, and she states she has never felt this "wiped out" from a cold. She is here to see you today because she feels like she has become more short of breath over the past 24 hours.
She tells you that she started feeling sick approximately 5 days ago. It started with a dry cough; however, over the past couple days she has expectorated some clear, and more recently, thicker rust-colored, mucous. She denies frank blood in her sputum. She notices some wheezing after coughing spells. This morning, Kathy woke up in a "coughing fit" and she said she felt some sharp pain in her chest. She rates the pain a 5/10 when it occurs. Kathy has felt feverish over the past few days; she sometimes gets the "chills." Her highest temperature was 102 degrees PMH: hypertension Habits: smoker for 30 years
BP: 110/80, HR: 96, RR: 26, T: 101.6, SpO2: 94% on room air Physical exam: fatigued appearing, congested cough Wheezing and rhonchi right lower chest with expiration
As you consider all of her presenting symptoms and history you begin to think that the most likely choice out of your differential diagnosis list is: a. Asthma b. Chronic Bronchitis c. Nosocomial Pneumonia d. Community-Acquired Pneumonia (CAP)
Candida albicans Staph aureus Strep pneumonia (pneumococcus) Pseudomonas aeruginosa Mycoplasma pneumonia
Chest radiography Blood cultures Arterial blood gases Sputum cultures
a. M. pneumoniae b. S. Pneumoniae c. C. pneumoniae d. A virus e. Legionella
The CURB-65 scale is a simple test to determine pneumonia severity, but it is not a substitute for clinical judgment. Clinicians should assign 1 point for each criteria met by the patient. C onfusion Blood U rea Nitrogen (BUN) >20 mg/dl R R >/= 30 B P (systolic <90 mmhg or diastolic </= 60 mmhg) >/= 65 y.o. If the individual scores 0-1 points, outpatient treatment is appropriate. 2 points indicates hospitalization and inpatient treatment. Greater than or equal to 3 points warrants inpatient treatment in the ICU.
The most appropriate antimicrobial for Kathy: A macrolide (azithromycin) OR doxycycline Combination therapy with a macrolide AND doxycycline Combination therapy with a beta-lactam (high dose amoxicillin, Augmentin) AND doxycycline A respiratory fluoroquinolone (levofloxacin, moxifloxacin) If Kathy had taken antibiotics in the last 3 months, ciprofloxacin would be an appropriate choice. True False
Why classify pneumonia? Critical difference between these two types as different organisms can be responsible Pneumonia treatment is almost always initially empiric, therefore knowledge of the likely pathogens is essential in selecting antibiotic regimen
Pneumonia acquired outside the hospital in the immunocompetent host Often have comorbities that make them susceptible to more severe disease and need for hospitalization - CHF, diabetes, COPD, renal insufficiency, stroke
It s Strep pneumoniae (pneumococcus) till proven otherwisefrom mild to severe cases, it s the # 1 cause of CAP. Starts with shaking chills and rusty sputum
Typical (seen on gram stain) Haemophilus influenza Moraxella catarrhalis Atypical (not seen)- diagnosed by serology Mycoplasma pna Chlamydia pna Legionella pna Viruses
Young healthy people, mild disease- Mycoplasma pneumoniae Young healthy people with severe disease- Strep pneumoniae Smokers- Strep pneumoniae, Haemophilus influenza, Moraxella catarrhalis
Empiric treatment must always cover possibility of S. pneumonia: Active against: Strep? Atypicals? Example Penicillin Yes No Augmentin Cephalosporin Yes No ceftriaxone Macrolides Yes (+/-) Yes Z-pak Quinolones Yes Yes Levoquin Doxycycline Yes Yes Doxycycline
Healthy outpatient, no prior antibiotic use: azithromycin, doxycycline for mild pneumonia Outpatient mild-moderate infection, comorbities, prior Z- pak: Levofloxacin (generic) Inpatient Med Ward azithromycin and ceftriaxone iv, transition to oral levofloxacin ICU admit ceftriaxone and azithromycin- consider adding Vancomycin if cavities on CXR;, but follow cultures to quickly adjust meds to micro lab results Watch for empyema/exudative effusion as complication of pneumococcus if patient remains febrile. May need chest tube