Pneumonia Topic Discussion Quiz!

A patient presents to the Emergency Department and is admitted to the hospital. Later that day, the patient begins developing a productive cough and is diagnosed with pneumonia. What type of pneumonia does this patient have?

• Hospital Acquired Pneumonia (HAP)

• Community Acquired Pneumonia (CAP)

• Emergency Department Associated Pneumonia (EDAP)

• Ventilation Acquired Pneumonia

Answer explanation

Community Acquired Pneumonia (CAP) is defined as pneumonia that is contracted outside of the hospital or within 48 hours of being in the hospital. Defining the type of pneumonia is important for planning treatment.

What is the treatment duration of CAP?

• At least 3 days

• At least 5 days

• At least 7 days

• At least 10 days

Answer explanation

CAP should be treated for at least 5 days. Therapy should be stopped at 5 days is the patient has shown signs of clinical improvement.

American Journal of Respiratory and Critical Care Medicine, Volume 200, Issue 7, 1 October 2019, Pages e45-e67, https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581STPublished: 01 October 2019

Which of the following patients with CAP should have a Gram Stain and Culture of Lower Respiratory Secretions ordered at the time of their diagnosis?

• 78-year-old female presenting to her ambulatory care clinic for CAP treatment

• 56-year-old male admitted for CAP. The patient received Zosyn 2 weeks ago for an unrelated intraabdominal infection.

• 34-year-old female receiving levofloxacin monotherapy for management of her inpatient CAP.

• 86-year-old male with structural lung disease, who is intubated.

Answer explanation

American Journal of Respiratory and Critical Care Medicine, Volume 200, Issue 7, October 2019. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581STPublished

Recommends not obtaining sputum Gram stain and culture routinely in adults with CAP managed in the outpatient setting.

Recommends obtaining cultures/Gram stains for severe cases of CAP that are being treated inpatient. Also, patient with suspected MRSA/pseudomonas who are receiving treatment against these bugs.

CURB-65 score for the following patient:

A 73-year-old female presents to the ED with altered mental status, fever, and a productive cough. The patient's BP is 104/70 mmHg, RR is 26, and BUN is 24.

Answer explanation

CURB-65 criteria:

Confusion +1

BUN > 20 +1

RR > 30 +1

BP <90/<60 +1

Age > 65 +1

This patient is confused, 73 years old, and has an elevated BUN which gives the patient a CURB-65 score of 3.

Based on the patient's CURB-65 score of 3, the patient should be treated ________?

Answer explanation

Ilg A, Moskowitz A, Konanki V, et al. Performance of the CURB-65 Score in Predicting Critical Care Interventions in Patients Admitted With Community-Acquired Pneumonia. Ann Emerg Med. 2019;74(1):60-68. doi:10.1016/j.annemergmed.2018.06.017

Patients with a CURB-65 score of 2 can be treated inpatient or outpatient with close follow-up. Patients with a CURB-65 score > 2 should be treated inpatient.

Which outpatient antibiotic course is the most appropriate for a patient with mild CAP who has no comorbidities?

• Ciprofloxacin 750 mg PO BID daily for 5 days

• Ceftriaxone 1-2 grams daily for 5 days

• Levofloxacin 750 mg PO daily + Augmentin 875 mg for 7 days

• Amoxicillin 1 gram PO TID x 5 days

Answer explanation

Cipro can be used for pneumonia in the setting of pseudomonal coverage with another agent, however it should not be used as monotherapy due to the lack of strep pnemo coverage.

Ceftriaxone is an IV option that would not be appropriate for outpatient treatment.

Respiratory FQ + Beta Lactam is recommended for severe inpatient treatment of CAP.

Correct answer: the patient has no comorbidities and is being treated for non-severe CAP. Monotherapy with amoxicillin, doxycycline, or a macrolide would be appropriate.

What are some risk factors that would require a patient's treatment to cover MRSA and/or Pseudomonas?

Answer explanation

Restrepo MI, Babu BL, Reyes LF, et al. Burden and risk factors for Pseudomonas aeruginosa community-acquired pneumonia: a multinational point prevalence study of hospitalized patients. Eur Respir J. Published 2018 Aug 9. doi:10.1183/13993003.01190-2017

Ex: IV antibiotics within the past 90 days, recently infected with MRSA or pseudomonas, > 5 days of hospitalization prior to VAP, septic shock, acute renal replacement therapy prior to VAP, patients with structural lung disease, >10-20% MRSA isolates, many gram negative bacilli present in gram stain indicative of pseudomonas

What is the treatment duration of HAP/VAP?

• At least 5 days

• At least 7 days

• At least 10 days

• At least 14 days

Answer explanation

Although HAP and VAP have traditionally been treated with longer durations of antimicrobial therapy, the current guidelines recommend a 7-day course of antibiotic therapy for the treatment of these types of pneumonias regardless of the pathogen(s) causing infection.

- Updated IDSA/ATS Guidelines on Management of Adults with HAP and VAP

A patient is diagnosed with aspiration pneumonia. Which pathogens are most concerning and what agent should be used to treat the patient?

• Atypical bacteria - macrolides

• Viruses - Tamiflu (oseltamivir)

• MDR bacteria (MRSA) - vancomycin

• Anaerobes - UNASYN

Answer explanation

Anaerobes are the most common pathogens in aspiration pneumonia. Ertapenem and Zosyn are other options.

Bartlett JG. How important are anaerobic bacteria in aspiration pneumonia: when should they be treated and what is optimal therapy. Infect Dis Clin North Am. 2013;27(1):149-155. doi:10.1016/j.idc.2012.11.016

A patient is diagnosed with HAP. PMH significant for recent bacteremia, for which the patient received ceftriaxone, and COPD (structural lung disease). What would you like to treat the patient with?

• Cefepime + Gentamicin + Linezolid

• Ertapenem + Daptomycin

• Ciprofloxacin + Vancomycin

• Aztreonam + Levofloxacin + Zosyn

Answer explanation

Need 2 antipseudomonal agents (prefer from different classes/avoiding 2 B-lactams) and MRSA coverage.

1) aminoglycoside and cefepime provide pseudomonal coverage and linezolid covers MRSA.

2) No pseudomonal coverage, only MRSA from daptomycin. Daptomycin should not be used for pulmonary infections because it is degraded by pulmonary surfactants.

3) Ciprofloxacin is appropriate in this setting for pneumonia treatment. However, another anti-pseudomonal agent is needed. Vanc covers MRSA

4) 3 anti-pseudomonal agents. No coverage for MRSA