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You are called by the emergency department and told of a 72-year-old male nonsmoker with a history of diabetes, coronary artery disease, and hypertension who presents with pneumonia and needs to be admitted to the hospital. The patient is febrile and tachypneic, has a blood pressure of 145/65, and has an oxygen saturation of 95% on room air. Physical examination is significant for rhonchi in the right lower lung fields, and a chest x-ray shows a right lower lobe infiltrate. Laboratory studies show a white blood cell count of 14,000 and no evidence of acute renal failure. Blood cultures have been obtained and an unknown antibiotic has been started in the emergency department.

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1. Should this patient be admitted to the hospital?

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2. What historical information is needed to make a treatment decision for this patient?

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3. What is the best initial treatment if this patient has no antibiotic allergies and no significant contact with the health care system?

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4. What would be the best initial treatment if this patient has no antibiotic allergies and is a resident of a long-term care facility?

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5. What additional steps need to be taken to ensure compliance with the pneumonia core measures?

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Answers

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  1. Yes, to a non-ICU setting. This patient is hemodynamically stable and has a CURB-65 score (an easy-to-use risk assessment method for community-acquired pneumonia [CAP] described below) of 2 (age, tachypnea), so it is reasonable to manage the patient out of the ICU.

  2. A history of medication allergies, particularly antibiotic allergies, is essential for the development of a safe treatment plan. Additionally, because initial antimicrobial therapy is selected primarily based on the type of pneumonia a patient has, risk factors for health care–associated pneumonia (HCAP) and other respiratory infections should be considered.

  3. Ceftriaxone and azithromycin, ampicillin/sulbactam, and azithromycin or levofloxacin are all appropriate choices for this patient for first-line therapy in a hospitalized patient with CAP.

  4. This patient likely has HCAP, and is at risk of infection with bacteria commonly seen in patients with CAP, but is also at risk of infection with MRSA and Pseudomonas. Levofloxacin will be effective against most causes of CAP, vancomycin is for potential MRSA, and piperacillin/tazobactam is useful for the treatment of Pseudomonas.

  5. Pneumonia vaccine before discharge is the last remaining quality measure. The patient has had blood cultures drawn, rapid initiation of antibiotic therapy, selection of appropriate antibiotics for an immunocompetent patient not requiring ICU admission, and evaluation of his oxygenation status with a pulse oximeter. As a nonsmoker, the patient does not need smoking cessation counseling, but documentation of the patient's smoking status is required. Note: Use of a standard order set increases the likelihood that all relevant quality measures will be met.

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