Bacterial Pneumonia Case File

https://medical-phd.blogspot.com/2021/05/bacterial-pneumonia-case-file.html

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD,
Adam J. Rosh, MD, MS

Case 36
A 70-year-old woman is transferred from a nursing home to the emergency department (ED) due to
fever and shortness of breath. Per her daughter, the patient has had a productive cough for 2 days
and became more short of breath and less responsive earlier today. The patient’s past medical
history is significant for diabetes mellitus, hypertension, and high cholesterol. Her vital signs
include temperature 38.9°C (102.1°F), heart rate 104 beats per minute, blood pressure 130/85 mm
Hg, respiratory rate 28 breaths per minute, and room air oxygen saturation 91% (96% with 3-L
oxygen by nasal cannula). On examination, she is awake but slow to answer questions. The
daughter states that her mother is usually more alert than this. Her skin is dry and warm to touch.
Her heart sounds are regular and mildly tachycardic without any S 3 or S4. On auscultation, she has
rhonchi at the right lung base. She does not have any jugular venous distention, lower extremity
edema, or calf tenderness.

⯈ What is the most likely diagnosis?

⯈ How should this patient be managed?

ANSWER TO CASE: 36
Bacterial Pneumonia

Summary: A 70-year-old woman is sent from a nursing home due to fever, productive cough, and
shortness of breath. On examination, she is febrile, mildly tachycardic, tachypneic, and hypoxic on
room air. She has rhonchi in the right lung base but does not have any signs of congestive heart
failure or a peripheral deep venous thrombosis.

 Most likely diagnosis: Healthcare-associated pneumonia

 Management: Supplemental oxygen, intravenous antibiotics, blood and sputum cultures,
and admission

ANALYSIS
Objectives

1. Define community-acquired versus hospital-acquired versus healthcare-associated

pneumonia.
2. Describe the various clinical presentations of pneumonia.
3. Learn the management of pneumonia including the best choices for empiric antibiotic
administration.
Considerations
This 70-year-old woman presents with history and physical examination findings consistent with
pneumonia. Pneumonia is the most common cause of death from infectious disease and the
seventh leading cause of death overall in the United States. Clinical presentations and common
etiologic organisms vary among different patient populations. Because this patient is a nursing
home resident, she is at risk for infection with multidrug-resistant bacteria. Pneumonia may be
associated with significant morbidity and mortality, especially among immunocompromised and
elderly patients. However, prompt initiation of therapy can result in improved patient outcomes.
Treatment includes appropriate empiric antibiotics, disease assessment, and respiratory support.

Approach To:
Bacterial Pneumonia

DEFINITIONS
COMMUNITY-ACQUIRED PNEUMONIA (CAP): Pneumonia that occurs in a patient living in
the general population or community.

HOSPITAL-ACQUIRED PNEUMONIA (HAP): Pneumonia that arises 48 hours or more after

hospital admission. HAP includes ventilator-associated pneumonia (VAP; infection which develops
more than 48 to 72 hours after intubation).

HEALTHCARE-ASSOCIATED PNEUMONIA (HCAP): Pneumonia that occurs in a patient

with substantial healthcare contact (intravenous antibiotics, chemotherapy, or wound care within
the past 30 days; nursing home or long-term care facility resident; hospitalization for 2 or more
days within the past 90 days; hemodialysis).

CLINICAL APPROACH
Pneumonia is caused by aspiration or inhalation of pathogenic organisms into the lungs or less
commonly by hematogenous spread. Thus patients with impaired host defenses (mucociliary
clearance or overall immune system) and those with an increased risk of bacteremia or aspiration
are at higher risk for developing pneumonia. These higher-risk patients include the elderly,
smokers, those with an impaired gag reflex, and HIV-positive patients. Viral respiratory infections
can also lead to the development of a superimposed bacterial pneumonia.

The most common causes of CAP are Streptococcus pneumoniae, Haemophilus influenzae,

Legionella, Mycoplasma, and Chlamydia. HAP and HCAP are most commonly due to aerobic
gram-negative bacilli such as Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae,
and Acinetobacter. Aspiration pneumonias are often polymicrobial, including anaerobic organisms
such as Peptostreptococcus, Bacteroides, and Fusobacterium. Immunocompromised patients are at
risk for infection with uncommon bacterial, fungal, and viral pathogens (eg, Aspergillus,
cytomegalovirus, tuberculosis, Pneumocystis jiroveci). Although the specific etiologic organism
cannot be identified with certainty without serologic or microbiologic confirmation, historical
information may help narrow the list of likely pathogens based on clinical symptomatology and risk
factors for specific infections (Table 36–1).

The typical presentation of bacterial pneumonia includes fever, productive cough with purulent
sputum, dyspnea, and pleuritic chest pain. However, patients at the extremes of age may have
minimal or no respiratory symptoms. Infants may be brought to the ED for fever, irritability, or
respiratory distress. The elderly may present with altered mental status, a decline in baseline
function, or sepsis. Patients with impaired immune systems may also present atypically.

The physical examination may reveal fever, tachypnea, tachycardia, or hypoxia. Severe illness may
be heralded by severe respiratory distress, marked hypoxia, cyanosis, altered mental status, or
hypotension. On auscultation, wheezes, rhonchi, rales,
or bronchial breath sounds may be appreciated. Decreased breath sounds and dullness to percussion
suggest the presence of a pleural effusion. Patients at the extremes of age and those who are
immunosuppressed may have atypical examination findings. For example, the elderly are often
afebrile (or even hypothermic). In these patients, tachypnea may be the most sensitive sign of
pneumonia

A chest x-ray is an important diagnostic tool in patients with suspected pneumonia as pulmonary
infiltrates will confirm the diagnosis. In some cases, a patient with an initial negative chest
radiograph may have infiltrates that “blossom” after rehydration or that are visualized using other
types of imaging (eg, computed tomography is more sensitive than plain x-ray). The radiographic
appearance of the infiltrates may suggest (but not definitively identify) a possible etiologic
organism.

For example, lobar consolidation is typical of Streptococcus

pneumoniae or Klebsiella. Staphylococcus aureus, Pseudomonas, and Haemophilus
influenzae typically cause multilobar disease. Patchy infiltrates are consistent with Legionella,
Mycoplasma, and chlamydial infection. Aspiration pneumonias usually result in infiltrates in
dependent areas of the lungs (posterior segment of upper lobe or superior segment of lower lobe).
Cavitary lesions, pleural effusions, and pneumatoceles may also be seen with bacterial pneumonias.
Immunocompromised patients are especially likely to have atypical radiographic findings (eg, more
diffuse or multilobar infiltrates).

Treatment
The initial management of patients with pneumonia includes assessment and, if needed,
cardiopulmonary stabilization which may require supplemental oxygen or intubation for patients
with severe respiratory distress or respiratory failure.

Antibiotics should be initiated promptly in order to decrease mortality and improve patient
outcome. Antibiotics are usually chosen based on the most likely pathogens as determined by
assessment of risk factors, clinical presentation (including severity of symptoms and presence of
sepsis), and radiographic findings. Healthy patients without any use of antimicrobials in the past 3
months with presumed CAP are best treated with a macrolide (azithromycin). Patients with
comorbid diseases or recent antimicrobial use should receive a respiratory fluoroquinolone
(levofloxacin) or a β-lactam (cefpodoxime) plus a macrolide as a reasonable alternative. Patients
admitted to the ICU require antibiotics that cover a broader range of organisms. A β-lactam
(ceftazidime) plus either azithromycin or a fluoroquinolone may be used. If Pseudomonas or
community-acquired methicillin- resistant Staphylococcus aureus (MRSA) infection is suspected,
additional antimicrobial coverage is required. If concern for aspiration pneumonia consider
anaerobic coverage such as clindamycin.

Patients with concern for HAP or HCAP who are at a risk for multidrugresistant pathogens should
receive a 3-drug combination therapy: (1) antipseudomonal cephalosporin (cefepime, ceftazidime),
antipseudomonal carbapenem (imipenem or meropenem), or piperacillin-tazobactam; (2)
antipseudomonal fluoroquinolone (ciprofloxacin or levofloxacin); and (3) anti-MRSA coverage
(linezolid or vancomycin).
Those without risk factors for multi-drug–resistant (MDR) organisms may be treated with a single
agent: ceftriaxone, ampicillin/sulbactam, ciprofloxacin, moxifloxacin, levofloxacin, or ertapenem.

Disposition
Factors to be considered include patient’s age and comorbidities, physical examination and
diagnostic findings, ability to tolerate oral medications, social situation, and ability to obtain close
follow-up. Obviously, any patient with unstable vital signs, respiratory distress, hypoxia, severe
infection, or intractable vomiting requires a hospital stay.