Case Presentation by Devina Mohan, MD
Chief Complaint: “I’ve been feeling bad for one week”
HPI: 56-year-old female with PMH of diabetes and hypertension comes to the ED complaining of feeling bad for the past week. She states that it all started after she was cleaning her basement after the flood last week. Initially she just feeling sick and in the past 2-3 days she has had cough with productive white sputum and subjective fevers. She states that she has not taken anything for her symptoms. She states her children were concerned about her today and sent her in. Patient denies sore throat, congestion, numbness or weakness in extremities, dysuria, hematuria, blood in stool, diarrhea, constipation.
PMH: hypertension, diabetes
PSH: cholecystectomy, small bowel resection, umbilical hernia repair
MEDS: Humulin 70/30, Quinapril 40 mg, Chlorthalidone 25 mg
SH: Denies tobacco, alcohol, or drug use
EXAMINATION OF ORGAN SYSTEMS/BODY AREAS:
Vitals: BP 82/54, HR 137, RR 18, temp 39.8, O2 sat 100% on RA
Cardiovascular: Tachycardic rate with normal rhythm, no murmurs
Respiratory: Diminished breath sounds on left lower lobe, no wheezing, no crackles
Gastrointestinal: Soft, +BS, non-distended, mildly tender to palpation diffusely, no rebound, no guarding
Musculoskeletal: No obvious deformities, 2+ bilateral radial and DP pulses, good capillary refill
Skin: Skin is cool to the touch but good capillary refill, no rashes
Neurological: AOx3, moving all 4 extremities, gait not observed as patient is feeling too weak to stand
WBC – 14.6
Hgb – 13.7
Platelets – 116
Na – 127
K – 3.9
Cl – 90
CO2 – 18
BUN – 31
Cr – 3.41
Glucose – 454
Troponin – 0.272
1. Given the above data, which would be the best diagnosis and disposition for this patient?
a) Community acquired pneumonia – oral levofloxacin, discharge home
b) Community acquired pneumonia – ceftriaxone and azithromycin, admit to medicine
c) Community acquired pneumonia – cefepime and azithromycin, admit to ICU
d) Healthcare associated pneumonia – vancomycin and levofloxacin, admit to ICU
2. What is the patient’s CURB65 score?
3. What additional test is indicated to best treat this patient?
a) CT Chest
c) RSV swab
d) Urine legionella antigen
Answers & Discussion
The patient has a community acquired pneumonia. Based on the fact that she is hypotensive and seems to have acute end-organ dysfunction with elevated creatinine and troponin, the patient does require admission. The antibiotic guidelines in the DMC system at this time for a CAP requiring admission to the floors are ceftriaxone 1g IV q12 and doxycycline PO 100mg q12. Azithromycin 500mg PO q24h can be substituted for doxycycline if not tolerated.
Given her hypotension & tachycardia, patient would require ICU admission if she did not improve with treatment. Based upon and ICU admission she should be given cefepime and azithromycin.
Community acquired pneumonias (CAP) are acute infections obtained in the community and distinguished from the HCAP and HAP as below. Most common pathogens are S. pneumoniae, Mycoplasma pneumoniae, Chlamydophila pneumoniae and respiratory viruses. Treatment guidelines usually based on resistance to S. pneumoniae. Coverage of atypical pathogens in the outpatient setting is usually unnecessary as they are usually self-limiting and affect younger persons.
- Widespread use of fluoroquinolone in outpatient setting is discouraged due to concern for development of resistance and colonization. Recommendations based on IDSA and BTS:
- Outpatient (patient with no comorbidities, recent abx use, or high rates of resistance): Doxycycline
- Outpatient (patient with comorbidities, use of abx within prior 3 months): Levofloxacin OR combination of beta-lactam (amoxicillin, amoxicillin and clavulanate potassium, ceftriaxone, cefuroxime) and azithromycin
- Hospitalized patient (medicine): Levofloxacin OR combination of beta-lactam (cefotaxime, ceftriaxone, amoxicillin and clavulanate potassium) plus azithromycin
- Hospitalized patient (ICU): combination of beta-lactam (cefotaxime, ceftriaxone, amoxicillin and clavulanate potassium) plus azithromycin OR combination of beta-lactam (cefotaxime, ceftriaxone, amoxicillin and clavulanate potassium) plus fluoroquinolone
Healthcare-associated pneumonia (HCAP) is pneumonia occurring in a non-hospitalized patient with extensive healthcare contract. This includes IV therapy, wound care, chemotherapy within 30 days of illness. Also, residence in a nursing home or other long-term care facility, admission in a hospital for 2 or more days within the prior 90 days, and attendance at a hospital or dialysis center within prior 30 days.
Hospital-acquired pneumonia (HAP) is pneumonia occurring 48 hours or more after admission and did not appear to be incubating at the time of admission.
Ventilator-associated pneumonia is a type of HAP that develops more than 48-72 hours after intubation.
- Treatment for HCAP, HAP, and VAP all tend to be based on the institutions resistance patterns and risk factors for multidrug resistance in the patients. These include recent antibiotic use.
- Important to culture and target therapy once susceptibilities are identified
- Add anti-pseudomonal coverage if it is a concern (piperacillin and tazobactam, cefepime, meropenem)
- Add MRSA coverage if that is a concern (vancomycin, linezolid)
- DMC pharmacy guidelines
- HCAP (medicine admit): cefepime plus doxycycline plus vancomycin
- HCAP (ICU admit): cefepime plus vancomycin plus azithromycin plus tobramycin
- HAP/VAP: cefepime plus vancomycin plus tobramycin
- HAP/VAP (with exposure to piperacillin and tazobactam or cefepime within prior 90 days): meropenem plus vancomycin plus tobramycin
The patient in the question had a CURB65 score of 2, with recommendation to hospitalize.
CURB 65 is a clinical prediction rule based on five factors to predict 30-day mortality. The five factors are presence of confusion, BUN>7 mmol/L, respiratory rate>30 breaths/min, BP (systolic <90mmHg, diastolic <60mmHg), age >65.
- 0 points: 0.7%, recommend treat as outpatient
- 1 point: 2.1%, recommend treat as outpatient
- 2 points: 9.2%, recommend admission to hospital
- 3 points: 14.5%, recommend admission, consider ICU
- 4 or 5 points: 40%, recommend ICU admission
The Pneumonia Severity Index (PSI) is another clinical prediction rule that has been validated and is widely endorsed. However, it involves a multistep process and classifies patients into risk classes II-V based on a point system from under 70 to over 130. Factors included are comorbidities such as neoplastic disease, heart disease, renal disease, etc; age, vital signs and mental status, and various lab findings. It is a lot more complex and maybe not as fast and efficient. The limitations of the PSI are that it underestimates severity, especially in young patients without comorbidities.
Limitations of the CURB 65 are that it may underestimate risk in elderly patients with co-morbidities.
Legionella pneumophila habituate in aquatic bodies, such as lakes and streams. Water distribution systems amplify the proliferation of the organism. The presence of algae, amebae and other bacteria also promote growth. There has been a link to aspiration of contaminated water and rainfall. The patient in the question was exposed to a lot of stagnant water while cleaning her flooded basement. A urine legionella antigen was obtained and turned out to be positive.
A CT chest could be useful if the patient had recurrent pneumonias in the same spot to identify any anatomic abnormalities or malignant lesions causing obstruction and proliferation of bacteria in one particular lobe. In this situation, we have no history of a recurrent pneumonia to necessitate a CT scan.
An ABG would be useful to evaluate hypoxemia and acidosis. The patient does have a level of acidosis based on her BMP and will likely need an ABG. However, in the initial phases of treatment, it would not change management drastically. The patient will still need resuscitation and antibiotics.
The patient would additionally require further follow up of the elevated troponins, cardiac surveillance, blood cultures and tailoring of therapy based on findings.