Board Review: Bugs and Drugs

Sat, 09/07/2019 - 5:00am

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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. <www.uptodate.com> (9/6/19).

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

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

2018.<www.uptodate.com> (9/6/19).

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

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

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

2019. <www.uptodate.com> (9/6/19).