Board Review: Bugs and Drugs


A 40-year-old woman with a history of hysterectomy 2 months ago presents with 3 days of fever and productive cough. Her vitals are as follows: T 101.2F HR 95 RR 18 BP 125/74 SpO2 99%. Her initial blood work is unremarkable and she is well appearing. CXR reveals a left lower lobe infiltrate. What is the best plan for this patient?


A. Discharge to home now with oral antibiotics

B. Draw blood cultures and then discharge to home with oral antibiotics

C. Obtain a CT chest

D. Start IV antibiotics and admit to medicine



























D.  This patient has healthcare-associated pneumonia based on her recent hospitalization within the last 90 days. Despite the fact that she is well appearing she requires IV antibiotics given her higher risk of resistant organisms such as MRSA and pseudomonas





Community Acquired Pneumonia

Healthcare- Associated Pneumonia and 

Hospital- Acquired Pneumonia

Ventilator- Associate Pneumonia

Clinical Definition

Outside of the hospital or extended- care facility

Healthcare-Associated: Hospitalization for >2 days in the last 90 days 

Hospital-Acquired: Patient of long- term care facility (nursing home), Hemodialysis, outpatient chemo, or wound care; Pneumonia that develops after 5 days of hospitalization 

     Pneumonia that develops > 48 hrs from endotracheal intubation 


Most common organisms

Typical: Streptococcus pneumoniae, Haemophilus influenza, Staph aureus, Group A Strep, Moraxella


Atypical: Legionella, Mycoplasma pneumonia, Chlamydia pneumonia, Chlamydia psittaci 

Pseudomonas, Klebsiella, E.coli, Enterobacter, Serratia, Acinetobacter, Staph aureus, and MRSA

Staph aureus, Pseudomonas, Klebsiella, Enterobacter, Acinetobacter baumannii, E.coli, Stenotrophomonas maltophilia

Empiric Treatment

Outpatient: Doxycycline

Outpatient with patient that have comorbidities or recent abx use: Amoxicillin or Augmentin or Cefpodoxime or Cefuroxime AND Macrolide or Doxycycline OR Monotherapy with Fluoroquinolone 

Inpatient: Ceftriaxone or Cefotaxime or Ceftaroline or Ertapenem or Unasyn AND Macrolide or Doxycycline OR Levaquin or Moxifloxacin 

No MDR risk factors: Zosyn or Cefepime or Levaquin or Imipenem or Meropenem


Risk Factor for MDR Gram negative rods or MRSA: Zosyn or Cefepime or Ceftazidime or Imipenem or Meropenem or Aztreonam  AND aminoglycoside or Fluoroquinolone AND Vancomycin or Linezolid or Telavancin

No MDR risk factors (no RF for increased mortality or MDR Pseudomonas or MRSA): Zosyn or Cefepime or Levaquin or Imipenem or Meropenem 


Risk Factor for MDR Gram negative rods or MRSA: Zosyn or Cefepime or Ceftazidime or Imipenem or Meropenem or Aztreonam  AND aminoglycoside or Fluoroquinolone  AND Vancomycin or Linezolid or Telavancin 


File, T,  et al. “Treatment of community acquired pneumonia in adults who require 

            hospitalization.” Aug 29, 2019. <> (9/6/19).


Klompas, M. et al. “Epidemiology, pathogenesis, microbiology, and diagnosis of 

            hospital acquired and ventilator- associated pneumonia in adults.” Nov 1, 

2018.<> (9/6/19).

Klompas, M  et al.“ Treatement of hospital-aquired and ventilator associated 

            pneumonia in adults.” Jul 10 2019. <>, (9/6/19).


Ramirez, J, et al.“ Overview of community acquired pneumonia in adults.” Jun 25 

2019. <> (9/6/19).