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Chapter 35. Management of Pneumonias

A 65-year-old man with a past medical history of severe chronic obstructive pulmonary disease (COPD) presents with a 3-day history of fever, decreased appetite, progressive shortness of breath, cough productive of purulent sputum, and pleuritic chest pain. On physical examination, the patient is awake but confused and in moderate respiratory distress with a respiratory frequency of 32 breaths/min. His vital signs include a blood pressure of 120/70 mm Hg, pulse rate of 102/min, and an axillary temperature of 38.7°C (101.5°F). Chest examination shows increased tactile fremitus over the posterior right lung base, as well as dullness to percussion and bronchial breath sounds over this area; inspiratory crackles are evident over the left upper anterior chest. Laboratory findings are significant for a PaO2/FIO2 ratio of 225, an elevated circulating leukocyte count of 17,000/μL, and a blood urea nitrogen level of 30 mg/dL. A chest x-ray today reveals consolidation in the right lower lung as well as infiltrates in the left upper lobe. Blood and sputum samples for Gram stain and cultures are obtained but results are pending. The most appropriate management of this patient now includes which of the following actions?

a. Admission to the medical floor of the hospital and treatment with a macrolide antibiotic

b. Admission to the intensive care unit (ICU) and observation

c. Admission to the medical floor of the hospital and treatment with a respiratory fluoroquinolone

d. Admission to the ICU and treatment with a β-lactam antibiotic

e. Admission to the ICU and treatment with a β-lactam antibiotic plus a macrolide

The most correct answer is e, admission to the ICU and treatment with a β-lactam antibiotic plus a macrolide.

This patient is elderly, confused, has multilobar pulmonary infiltrates of presumed infectious origin, and is already manifesting signs of acute hypoxemic respiratory failure as well as renal dysfunction. Moreover, he has a CURB-65 score of 4, placing him at increased risk of death from complications of community-acquired pneumonia. For all of these reasons, it is important that the patient be admitted to an ICU rather to the inpatient medical floors (answers a, c). Considering this case presentation, observation in the ICU without antibiotic treatment within 4 hours greatly increases the likelihood of a poor outcome and is never appropriate management for severe CAP (answer b). Although treatment with a β-lactam antibiotic is an important aspect of the management of severe CAP (answer d), it represents incomplete coverage, particularly for Legionella spp. that are not sensitive to this antibiotic class. Thereafter co-treatment with a macrolide antibiotic is indicated for patients requiring ICU treatment.

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