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Pharmacotherapy Casebook: A Patient-Focused Approach, 11e

Chapter 119: Community-Acquired Pneumonia: The Coughing Conundrum Level II

Trent G. Towne; Sharon M. Erdman

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LEARNING OBJECTIVES
After completing this case study, the reader should be able to:

Recognize the common signs, symptoms, physical examination, laboratory, and radiographic findings in a patient with community-acquired
pneumonia (CAP).

Describe the most common causative pathogens of CAP, including their frequency of occurrence and susceptibility to frequently used
antimicrobials.

Discuss the risk stratification strategies that can be employed to determine whether a patient with CAP should be treated as an inpatient or
outpatient.

Provide recommendations for initial empiric antibiotic therapy for an inpatient or outpatient with CAP based on clinical presentation, severity of
infection, age, allergies, and comorbidities.

Define the goals of antimicrobial therapy for a patient with CAP, as well as the monitoring parameters that should be used to assess the response
to therapy, conversion from IV to PO therapy (where warranted), and the occurrence of adverse effects.

PATIENT PRESENTATION
Chief Complaint

“I have been short of breath and have been coughing up rust-colored phlegm for the past 3 days.”

HPI

James Thompson is a 55-year-old African-American man with a 3-day history of worsening shortness of breath, subjective fevers, chills, right-sided
chest pain, and a productive cough. The patient states that his initial symptom of shortness of breath began approximately 1 week ago after delivering
mail on an extremely cold winter day. He has been taking ibuprofen and an over-the-counter cough and cold preparation but feels that his symptoms
are getting “much worse.” The patient began experiencing right-sided pleuritic chest pain and a productive cough with rust-colored sputum over the
past 3 days and feels that he has been feverish with chills, although he did not take his temperature. On presentation to the ED, he is febrile and visibly
short of breath.

PMH

Hypertension × 15 years

Dyslipidemia × 15 years

Type 2 diabetes mellitus × 10 years

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Adopted; unknown birth parents
Hypertension × 15 years Butler University
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Dyslipidemia × 15 years

Type 2 diabetes mellitus × 10 years

FH

Adopted; unknown birth parents

SH

Lives with wife and four children

Employed as a mail carrier for the US Postal Service

Denies alcohol, tobacco, or intravenous drug use

Medications

Prescription

Lisinopril 10 mg orally once daily

Hydrochlorothiazide 25 mg orally once daily

Atorvastatin 20 mg orally once daily

Metformin 1000 mg orally twice daily

Over-the-Counter

Ibuprofen 200 mg PO Q 6 H as needed for pain and fever

Guaifenesin/dextromethorphan (100 mg/10 mg/5 mL) two teaspoonfuls every 4 hours as needed for cough

All

NKDA

ROS

Patient is a good historian. He has been experiencing shortness of breath, a productive cough with rust-colored sputum, subjective fevers, chills, and
pleuritic chest pain that is “on the right side of my chest.” He denies any nausea, vomiting, constipation, or problems urinating.

Physical Examination

Gen

Patient is a well-developed, well-nourished, African-American man in moderate respiratory distress appearing somewhat anxious and uncomfortable.

VS

BP 155/85, P 127, RR 30, T 39.5°C; Wt 110 kg, Ht 5′11″

Skin

Warm to the touch; poor skin turgor

HEENT

PERRLA; EOMI; dry mucous membranes

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Neck/Lymph Nodes
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No JVD; full range of motion; no neck stiffness; no masses or thyromegaly; no cervical lymphadenopathy
Skin
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Warm to the touch; poor skin turgor
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HEENT

PERRLA; EOMI; dry mucous membranes

Neck/Lymph Nodes

No JVD; full range of motion; no neck stiffness; no masses or thyromegaly; no cervical lymphadenopathy

Lungs/Thorax

Tachypneic, labored breathing; coarse rhonchi throughout right lung fields; decreased breath sounds in right middle and right lower lung fields

CV

Audible S1 and S2; tachycardic with regular rate and rhythm; no MRG

Abd

NTND; (+) bowel sounds

Genit/Rect

Deferred

Extremities

No CCE; 5/5 grip strength; 2+ pulses bilaterally

Neuro

A&O × 3; CN II–XII intact

Labs on Admission

Na 140 mEq/L Hgb 12.1 g/dL WBC 23.1 × 103/mm3

K 4.3 mEq/L Hct 35%  Neutrophils 67%

Cl 102 mEq/L RBC 3.8 × 106/mm3  Bands 15%

CO2 22 mEq/L Plt 220 × 103/mm3  Lymphs 12%

BUN 42 mg/dL MCV 91 μm3  Monos 6%

SCr 1.4 mg/dL MCHC 35 g/dL Procalcitonin 1.9 ng/mL

Glu 295 mg/dL Lactic Acid 2.3 mmol/L

ABG

pH 7.38; PaCO2 29; PaO2 70 with 87% O2 saturation on room air

Chest X-Ray
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Right middle and right lower lobe consolidative airspace disease, likely pneumonia. Left lung is clear. Heart size is normal.
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Chest CT Scan Without Contrast

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ABG
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pH 7.38; PaCO2 29; PaO2 70 with 87% O2 saturation on room air

Chest X-Ray

Right middle and right lower lobe consolidative airspace disease, likely pneumonia. Left lung is clear. Heart size is normal.

Chest CT Scan Without Contrast

No axillary, mediastinal, or hilar lymphadenopathy. The heart size is normal. There is consolidation of the right lower lobe and lateral segment of the
middle lobe, with air bronchograms. No significant pleural effusions. The left lung is clear.

Sputum Gram Stain

>25 WBCs/hpf, <10 epithelial cells/hpf, many gram (+) cocci in pairs

Sputum Culture

Pending

Blood Cultures × Two Sets

Pending

Other Lab Tests

Streptococcus pneumoniae urine antigen—Pending

Legionella pneumophila urine antigen—Pending

Assessment

Probable multilobar CAP involving the RML and RLL

QUESTIONS
Collect Information

1.a. What subjective and objective information indicates the presence of CAP in this patient?

1.b. What additional information is needed to fully assess this patient’s CAP?

Assess the Information

2.a. Assess the severity of this patient’s CAP based on subjective and objective information available and use this information to decide on the site of
care (inpatient or outpatient).

2.b. Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety,
and patient adherence.

Develop a Care Plan

3.a. What are the goals of pharmacotherapy in this case?

3.b. What nondrug therapies might be useful for this patient?

3.c. What feasible pharmacotherapeutic alternatives are available for treating CAP?

3.d. Create an individualized, patient-centered, team-based care plan to optimize medication therapy for this patient including specific drugs, dosage
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forms, doses, schedules, and durations of therapy.
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Implement the Care Plan
3.a. What are the goals of pharmacotherapy in this case?
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3.c. What feasible pharmacotherapeutic alternatives are available for treating CAP?

3.d. Create an individualized, patient-centered, team-based care plan to optimize medication therapy for this patient including specific drugs, dosage
forms, doses, schedules, and durations of therapy.

Implement the Care Plan

4.a. What information should be provided to the patient to enhance compliance, ensure successful therapy, and minimize adverse effects?

4.b. Describe how care should be coordinated with other healthcare providers.

Follow-up: Monitor and Evaluate

5.a. What clinical and laboratory parameters should be used to evaluate the therapy for achievement of the desired therapeutic outcome and to detect
or prevent adverse effects?

5.b. Develop a plan for follow-up that includes appropriate time frames to assess progress toward achievement of the goals of therapy.

CLINICAL COURSE

While in the ED, the patient was placed on 4 L NC of O2, and his oxygen saturation improved to 98%. The patient was initiated on ceftriaxone 1 g IV daily
and azithromycin 500 mg IV daily and admitted to the hospital. Over the next 48 hours, the patient’s clinical status improved with decreasing fever,
tachypnea, tachycardia, and shortness of breath. On hospital day 2, the S. pneumoniae urine antigen was positive, and the sputum culture
demonstrated the growth of S. pneumoniae, resistant to erythromycin (MIC ≥1 mcg/mL), but susceptible to penicillin (MIC ≤2 mcg/mL), ceftriaxone
(MIC ≤1 mcg/mL), levofloxacin (MIC ≤0.5 mcg/mL), and vancomycin (MIC ≤1 mcg/mL).

FOLLOW-UP QUESTIONS

1 . Given this new information, what changes in the antimicrobial therapy would you recommend?

2 . What oral antibiotic would be suitable to complete the course of therapy for CAP in this patient? When is it appropriate to convert a patient from IV to
oral therapy for the treatment of CAP?

3 . By hospital day 4, the patient’s clinical symptoms of pneumonia had almost completely resolved, and the patient was discharged home on oral
antibiotics to complete a 7-day course of treatment. What information should be provided to the patient about his oral outpatient antibiotic therapy to
enhance adherence, ensure successful therapy, and minimize adverse effects?

SELF-STUDY ASSIGNMENTS

1 . Describe the role of molecular diagnostic testing and microbiology in the diagnosis and treatment of patient’s with CAP?

2 . Describe the role of procalcitonin testing in the decision to initiate and de-escalation of antibiotics in patients with CAP.

2 . Review national, regional, and local patterns of S. pneumoniae susceptibility and compare the data with what is seen at your institution or clinic.

3 . Describe the role of short-course (5-day) antibiotic therapy in the management of CAP.

CLINICAL PEARL
Influenza and pneumococcal vaccines for appropriate patient types are important components for preventing CAP as well as for reducing the
morbidity and mortality associated with CAP.

REFERENCES

1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the
management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S27–S72. [PubMed: 17278083]
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2. Prina E, Ranzani OT, Torres A. Community-acquired pneumonia. Lancet 2015;386:1097–1108. [PubMed: 26277247]
©2021 McGraw Hill. All Rights Reserved.   Terms of Use • Privacy Policy • Notice • Accessibility

3. Infections of the lower respiratory tract. In: Tile PM, ed. Bailey and Scott’s Diagnostic Microbiology. 13th ed. St Louis, MO: Mosby; 2014:878–891.
morbidity and mortality associated with CAP.
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REFERENCES Access Provided by:

1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the
management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S27–S72. [PubMed: 17278083]

2. Prina E, Ranzani OT, Torres A. Community-acquired pneumonia. Lancet 2015;386:1097–1108. [PubMed: 26277247]

3. Infections of the lower respiratory tract. In: Tile PM, ed. Bailey and Scott’s Diagnostic Microbiology. 13th ed. St Louis, MO: Mosby; 2014:878–891.

4. Segreti J, House HR, Siegel RE. Principles of antibiotic treatment of community-acquired pneumonia in the outpatient setting. Am J Med
2005;118(7A):21S–28S. [PubMed: 15993674]

5. Bochud PY, Moser F, Erard P, et al. Community-acquired pneumonia: a prospective outpatient study. Medicine 2001;80(2):75–87. [PubMed:
11307590]

6. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243–
250. [PubMed: 8995086]

7. Lim WS, van der Eerden MM, Laing R, et al. Defining community-acquired pneumonia severity on presentation to hospital: an international
derivation and validation study. Thorax 2003;58:377–382. [PubMed: 12728155]

8. File TM. Community-acquired pneumonia. Lancet 2003;362:1991–2001. [PubMed: 14683661]

9. Pfaller MA, Farrell DL, Sader HS, Jones RN. AWARE-Ceftaroline Surveillance Program (2008–2010): trends in resistance patterns among
Streptococcus pneumoniae , Haemophilus influenzae , and Moraxella catarrhalis in the United States. Clin Infect Dis 2012;55(Suppl 3):S187–S193.
[PubMed: 22903951]

10. Fine MJ, Stone RA, Singer DE, et al. Process and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia
Patients Outcomes Research Team (PORT) cohort study. Arch Intern Med 1999;159:970–980. [PubMed: 10326939]

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