sample case study community acquired pneumonia

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Article Contents

Case presentation, acknowledgments.

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Scenario 1: A Patient with Mild Community-Acquired Pneumonia—Introduction to Clinical Trial Design Issues

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David N. Gilbert, Scenario 1: A Patient with Mild Community-Acquired Pneumonia—Introduction to Clinical Trial Design Issues, Clinical Infectious Diseases , Volume 47, Issue Supplement_3, December 2008, Pages S121–S122, https://doi.org/10.1086/591391

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A prototypical patient is presented to introduce important design issues for clinical trials of antibacterials in the treatment of community-acquired pneumonia.

Of the 4 million or more patients in the United States treated annually for community-acquired pneumonia (CAP), ∼80% are cared for on an outpatient basis [ 1 , 2 ]. Admittedly, the patient population is heterogeneous. However, 2 subgroups constitute a significant percentage of the total.

The first subgroup consists of young, otherwise-healthy individuals who are nonsmokers aged <40 years. “Atypical” pathogens, such as Mycoplasma pneumoniae or Chlamydia pneumoniae , are identified frequently as the etiologic organism. Streptococcus pneumoniae may be the etiologic organism, especially during or after viral tracheobronchitis.

In contrast, individuals in the second group are older. Often, they have used tobacco products for years and meet clinical criteria for chronic bronchitis and/or emphysema.

To focus on clinical trial design issues pertinent to the population of patients with mild pneumonia, a typical clinical-trial candidate patient is described below.

Present illness. A 35-year-old male resident of Boston, Massachusetts, presents with fever and cough. He was well until 3 days earlier, when he suffered the onset of nasal stuffiness, mild sore throat, and a cough productive of small amounts of clear sputum. Today, he decided to seek physician assistance because of an increase in temperature to 38.3°C and spasms of coughing that produce purulent secretions. On one occasion, he noted a few flecks of bright-red blood in his sputum.

Other pertinent history. It is March. He lives in a home in the city with his wife and 3 children, aged 7, 9, and 11 years. The children are fully immunized. The 11-year-old child is recovering from a “nagging” cough that has persisted for 10–14 days.

The family has a pet parakeet who is 5 years old and appears to be well. The patient has not traveled outside the city in the past year. He is an office manager.

The patient smokes 1 pack/day and has done so since the age of 15 years. Several times a month, especially during the winter, on arising from sleep, he produces ∼1 tablespoon of purulent sputum.

Medical history. The patient has no history of familial illness, hospitalizations, or trauma. There are no drug allergies or intolerance. The only medication he takes is acetaminophen occasionally, for headaches. He drinks beer or wine in moderation.

Physical examination. His body temperature is 38.9°C (100°F), his pulse is 110 beats/min and regular, and his respiratory rate is 18 breaths/min. His oxygen saturation is 93% while breathing room air. There is mild erythema of the mucosa of the nose and posterior oropharynx. Inspiratory “rales” are heard at the right lung base.

Laboratory and radiographic findings. His hemoglobin level is 12.5 g/dL, with a hematocrit of 36%. His WBC count is 13,500 cells/µL, with 82% polymorphonuclear cells, 11% band forms, and 7% lymphocytes. His platelet count is 180,000 cells/µL. The results of a multichemistry screen are unremarkable.

Chest radiography documents bilateral lower lobe infiltrates that are more pronounced on the right side. There are no pleural effusions.

Management questions. A validated prediction rule forecasts that this patient's risk of death from his CAP is <1% [ 3 ]. Therefore, he is a candidate for outpatient therapy.

What is the likely microbiological diagnosis? On the basis of the cough of 2 weeks' duration in the patient's 11-year-old child, the pneumonia could be due to M. pneumoniae or another atypical pathogen. However, this illness could represent pneumococcal pneumonia superimposed on a viral upper respiratory tract infection.

Clinical trial design questions. These are the hard questions and illustrate some of the many reasons for this workshop: Is the patient of sufficient reliability to participate in an outpatient clinical trial of antibacterials for mild CAP? Is it ethical or, from a practical standpoint, feasible to conduct a placebo-controlled trial? If an active comparator drug is used, how does one generate a valid and defensible margin of noninferiority?

What are valid, reproducible, and quantifiable clinical end points (outcomes)?

It would help greatly if the etiology of the pneumonia could be determined for the majority of the enrolled patients. What are the current diagnostic tools that can be applied and thereby “enrich” the patient population?

Multiple precautions are necessary to avoid bias in the interpretation of the results of clinical trials. For example, what are acceptable methods in the “blinding” of treatment arms?

How can investigators reliably and with reasonable sensitivity detect adverse drug effects?

The articles that follow address these questions and more. Participants in this workshop uniformly agreed that the interaction of US Food and Drug Administration regulations, industry sponsors, and Infectious Diseases Society of America academics represents an opportunity to modernize future clinical trials for CAP.

Supplement sponsorship. This article was published as part of a supplement entitled “Workshop on Issues in the Design and Conduct of Clinical Trials of Antibacterial Drugs for the Treatment of Community-Acquired Pneumonia,” sponsored by the US Food and Drug Administration and the Infectious Diseases Society of America.

Potential conflicts of interest. D.N.G. serves on the speakers' bureau of Abbott Laboratories, Bayer, GlaxoSmithKline, Lilly, Merck, Pfizer, Roche, Schering-Plough, and Wyeth; and has received consulting fees from Advanced Life Sciences and Pacific Beach Bioscience.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Community-acquired pneumonia.

Hariharan Regunath ; Yuji Oba .

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Last Update: January 26, 2024 .

• Continuing Education Activity

This comprehensive course covers the diverse facets of community-acquired pneumonia, a prevalent cause of hospitalization, mortality, and substantial healthcare expenditure. The spectrum of this disease ranges from mild cases managed as outpatients to severe conditions necessitating intensive care unit intervention. Throughout this activity, participants focus on the nuances of community-acquired pneumonia evaluation and treatment. Learners gain the knowledge and skills necessary for early diagnosis and timely determination of the appropriate level of care—crucial factors in enhancing patient outcomes.

A key emphasis of this course lies in understanding the pivotal role played by the interprofessional team in evaluating and treating patients with community-acquired pneumonia. By engaging in interdisciplinary collaboration, learners gain insights into how different healthcare professionals contribute to a holistic approach to managing this condition. This collaborative model not only enhances patient care but also significantly improves the competence of individual team members.

• Identify the varied community-acquired pneumonia presentations to facilitate early and accurate diagnosis.
• Differentiate between bacterial and viral etiologies of community-aquired pneumonia through a comprehensive assessment of patient history, physical examination findings, and relevant diagnostic tests.
• Apply appropriate antibiotic stewardship principles in the management of community-acquired pneumonia, ensuring optimal antimicrobial selection, dosage, and duration to minimize resistance and adverse effects.
• Collaborate with interprofessional healthcare team memebers, including respiratory therapists, pharmacists, and infection control specialists, to optimize the comprehensive care of patients with community-acquired pneumonia.
• Introduction

Community-acquired pneumonia is a leading cause of hospitalization and mortality and incurs significant healthcare costs. As disease presentation varies from a mild illness that can be managed as an outpatient to a severe illness requiring treatment in the intensive care unit, diagnosing early and determining the appropriate level of care is important for improving outcomes. [1] [2] [3] [4] [5]

Many pathogens cause community-acquired pneumonia, including bacteria, viruses, and fungi. [6]  Common bacterial pathogens can be classified as:

• Gram-positive agents such as  Streptococcus pneumoniae ,  Staphylococcus aureus , group A streptococci, and other streptococci 
• Gram-negative agents such as  Haemophilus influenzae ,  Moraxella catarrhalis , and Enterobacteriaceae
• Atypical agents such as  Legionella, Mycoplasma, Chlamydia pneumoniae,  and  Chlamydia psittaci  [7]  

Among viruses, rhinovirus, influenza, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and other respiratory viruses (parainfluenza, respiratory syncytial virus, human metapneumovirus, etc) have become increasingly detected as pathogens based on molecular detection methods. Worldwide,  S pneumoniae  and  H influenzae  are still the leading causes of acute bacterial pneumonia (see Image. Mycobacterium Avium-Intracellulare Pneumonia). The most recent population-based active surveillance in the United States identified that human rhinovirus, influenza virus, and  S pneumoniae were the most common pathogens. [8]  

• Epidemiology

The estimated worldwide incidence of community-acquired pneumonia varies between 1.5 to 14 cases per 1000 person-years and is affected by geography, season, and population characteristics. [5]  In the US the annual incidence is 24.8 cases per 10,000 adults, with higher rates as age increases. Pneumonia is the eighth leading cause of death and first among infectious causes of death. The mortality rate is as high as 23% for patients admitted to the intensive care unit for severe pneumonia.

All patients with comorbid illness are considered at risk for pneumonia, but specific risk factors exist for particular pathogens. Drug-resistant pneumococci are more likely in:

• Those older than 65
• Children in daycare centers
• Those who have taken beta-lactam antibiotics in the previous 90 days
• Individuals with alcohol use disorder, chronic medical conditions, and immune suppression

Pseudomonas pneumonia is more likely in those with:

• Bronchiectasis
• Malnutrition
• Corticosteroid therapy
• Antibiotic intake for greater than 7 days in the preceding month

Other etiological clues from geographic regions include the following: 

• Coccidioidomycosis in the Southwestern US
• Blastomycosis or histoplasmosis in the states of the Ohio River valley bird exposures for  Chlamydia psittaci
• Contact with flea-infested or infected rodents or rabbits during outside activities such as lawn mowing in the Northeast US (Martha's Vineyard, Cape Cod, etc) for tularemia pneumonia 
• Pathophysiology

Pathogens initially colonize the pharynx, followed by micro-aspiration, which is the mechanism of entry into the lower respiratory tract. Once there, the pathogen induces the host's pulmonary defense. If there is a defect in the host's defense or it is overcome by high inoculum or virulence of the pathogen, then pneumonia will result. Pathogens may also spread through the hematogenous route and macro-aspiration.

• History and Physical

Common symptoms of pneumonia include fever, chills, cough productive of purulent sputum, dyspnea, pleuritic chest pain, and weight loss. Patients with alcohol use disorder and those who are immune-compromised may have an absence of fever and less evident or systemic symptoms such as weakness, lethargy, altered mental status, dyspepsia, or other upper gastrointestinal symptoms. The presence of some symptoms may provide etiological clues. For example, diarrhea, headache, and confusion (related to hyponatremia) can indicate  Legionella infection; otitis media, Stevens-Johnson syndrome, or anemia with jaundice (hemolytic anemia) may indicate  Mycoplasma infection .  Pneumonia can provoke acute decompensation of an underlying chronic illness, such as congestive heart failure, and can confound the initial presentation of pneumonia and result in delays in diagnosis and treatment.

Initial workup for pneumonia will include imaging and blood work (see Images. Lung Abscess, Computed Tomography Scan and Bilateral Pneumonia,   Computed Tomography Scan and Lung Pneumonia with Fibrosis). A chest x-ray will be needed to identify an infiltrate or effusion, which, if present, will improve diagnostic accuracy (see Image. Healthy Lung and Q Fever Pneumatic Lung, Chest X-ray). Bloodwork should include a complete blood count with differentials; serum electrolytes with renal and liver function tests help confirm evidence of inflammation and assess severity. Influenza testing is recommended during the winter season. Testing for respiratory viruses on nasopharyngeal swabs by molecular methods can be considered if available.

Tools such as CURB 65 (confusion, urea greater than or equal to 20 mg/dL, respiratory rate greater than or equal to 30/min, blood pressure systolic less than 90 mm Hg or diastolic less than 60 mm Hg), and Pneumonia Severity Index for severity assessment may assist in determining the treatment setting, such as outpatient versus inpatient. Still, accuracy is limited when used alone or without practical clinical judgment.

In hospitalized patients, blood and sputum cultures should be collected, preferably before the institution of antimicrobial therapy, but without delay in treatment. If cultures are negative, urine collection and testing for   legionella   and pneumococcal antigens must be considered as they aid in diagnosis. In the presence of confounding comorbidities, such as congestive heart failure, serum procalcitonin levels can be used as a biomarker to initiate and guide antimicrobial therapy. Serology for tularemia, endemic mycoses, or  C psittaci  can be evaluated in the presence of epidemiologic clues. [9] [10] [11]

• Treatment / Management

Monotherapy with a macrolide (erythromycin, azithromycin, or clarithromycin) or doxycycline is recommended in the outpatient setting. In the presence of comorbid illness (chronic heart disease excluding hypertension); chronic lung disease (chronic obstructive pulmonary disease and asthma); chronic liver disease; chronic alcohol use disorder; diabetes mellitus; smoking; splenectomy; human immunodeficiency virus (or other immunosuppression); a respiratory fluoroquinolone (high-dose levofloxacin, moxifloxacin, gemifloxacin); a combination of oral beta-lactam (high dose amoxicillin or amoxicillin-clavulanate, cefuroxime, cefpodoxime); and macrolide is recommended. [11] [12] [13] [14]

Inpatient management is recommended for patients with a CURB 65 score greater than or equal to 2. A respiratory fluoroquinolone monotherapy or combination therapy with beta-lactam (cefotaxime, ceftriaxone, ampicillin-sulbactam, or ertapenem) and macrolide are recommended options for non-intensive care settings.

Admission to the intensive care unit must be considered in patients with 3 or more signs of early deterioration. These include respiratory rate greater than 30, PaO 2 /FiO 2 less than or equal to 250, multilobar infiltrates, encephalopathy, thrombocytopenia, hypothermia, leucopenia, and hypotension. Combination therapy with a beta-lactam and either a macrolide or a respiratory fluoroquinolone is recommended. In patients with suspected aspiration, ampicillin-sulbactam or ertapenem can be used. Monotherapy is not recommended.

If risk factors for Pseudomonas are present, then antipseudomonal beta-lactam (piperacillin-tazobactam, cefepime, ceftazidime, meropenem, imipenem) along with either an antipseudomonal fluoroquinolone (ciprofloxacin or levofloxacin) or a combination of aminoglycoside and azithromycin are recommended. Vancomycin or linezolid should be added if community-acquired methicillin-resistant  S aureus  is a consideration. 

The recommended duration of therapy is 5 to 7 days in patients with a favorable clinical response, such as the absence of fever for more than 48 to 72 hours, not requiring supplemental oxygen, and resolution of tachycardia, tachypnea, or hypotension. Prolongation of therapy is indicated in patients with a delayed response, specific bacterial pathogens such as Pseudomonas (14-21 days) or  S aureus  (7-21 days), or Legionella pneumonia (14 days), and for complications such as empyema, lung abscess, or necrotizing pneumonia. Chest tube placement will be needed to drain an empyema, and in cases with multiple loculations, a surgical decortication may be needed. A 14-day therapy with macrolide or doxycycline will treat tularemia pneumonia or psittacosis, and itraconazole is the drug of choice for pneumonia caused by coccidioidomycosis or histoplasmosis.

A 5-day therapy with oseltamivir is recommended for all patients who test positive for the influenza virus and present within 48 hours of symptom onset; there is no benefit to oseltamivir if started beyond 48 hours after symptom onset. Still, any hospitalized patients with influenza must be treated with this agent regardless of the presentation time from the beginning of the illness. 

Intravenous glucocorticoids can be considered adjunctive therapy in critically ill patients with severe community-acquired pneumonia without risk factors for adverse outcomes from using steroids (eg, influenza infection). They are associated with reductions in short-term mortality and duration of intensive care days. [15] [16] [17] [18]

• Differential Diagnosis

Differential diagnoses for community-acquired pneumonia include:

• Acute bronchitis
• Acute exacerbation of chronic bronchitis
• Aspiration pneumonitis
• Congestive heart failure and pulmonary edema
• Pulmonary fibrosis
• Myocardial infarction
• Systemic lupus erythematosus pneumonitis
• Pulmonary drug hypersensitivity reactions (nitrofurantoin, daptomycin)
• Drug-induced pulmonary disease (bleomycin)
• Sarcoidosis
• Cryptogenic organizing pneumonia
• Pulmonary embolus
• Pulmonary infarction
• Bronchogenic carcinomas
• Granulomatosis with polyangiitis (Wegener granulomatosis)
• Tracheobronchitis
• Radiation pneumonitis
• Pearls and Other Issues

Vaccine recommendations evolve in parallel with changing epidemiology vaccine developments and formulation advancements. All adults 65 years and older and those younger than 65 and considered at risk for pneumonia must receive a pneumococcal vaccination (PCV). The 2 vaccines used until 2021 were the pneumococcal polysaccharide vaccine (PPSV) 23 and PCV13. In summer 2021, the US FDA approved 2 additional preparations, PCV20 and PCV15, for adult vaccinations. Since then, the Advisory Committee on Immunization Practices (ACIP) recommendations favored using these latter formulations for adult vaccinations. Current ACIP recommendations for previously unvaccinated, non-immune-compromised individuals who are at least aged 65 years, as well as those between 19 to 64 years with risk factors for pneumonia, receive either PCV20 alone or PCV15 coupled with PPSV23 one year later.

For adults who already had vaccinations with prior formulations (PCV13 or PPSV23), subsequent options are different. Those who received only PCV13 can be followed by PPSV23 vaccination a year later. If the prior vaccine was only with PPSV23, then after a year, either PCV20 alone or PCV15 followed a year later with another PPSV23 can be given. The 1-year interval between pneumococcal doses can be shortened to 8 weeks for immunocompromised individuals.

Influenza vaccination is recommended for all adult patients at risk for influenza-related complications. Inactivated flu shots (trivalent or quadrivalent, egg-based or recombinant) are usually recommended for adults. Live attenuated intranasal vaccine can be given to healthy, nonpregnant adults under 49. This is contraindicated in pregnancy, the immune-suppressed and health care workers caring for them, and in those with comorbidities.

COVID-19 vaccination is recommended for all non-immune-compromised adults with either a single dose of a 2023-24 mRNA vaccine regardless of previous vaccination and that it be given at least 2 months after the most recent prior dose of COVID-19 vaccine. Novavax (protein-based) vaccine is given in 2 doses separated by 3 to 8 weeks for unvaccinated individuals. In contrast, a single dose after 2 months of the last dose is sufficient for those previously vaccinated with any other formulation of the COVID-19 vaccine. For individuals with moderate to severe immune compromise, 3 or 4 vaccine doses are recommended, with at least one using an mRNA formulation. A vaccine against respiratory syncytial virus is recommended for adults over 60 who may be at risk for severe disease.

• Enhancing Healthcare Team Outcomes

Patients with community-acquired pneumonia may present to the clinician or the emergency department. The medical staff should be aware of the signs and symptoms associated with pneumonia. Working together, the healthcare team will improve outcomes. Members can include primary care, emergency department personnel, specialists, nurses, and pharmacists. Most patients respond to outpatient antibiotic therapy for 5 to 7 days. Patients who are short of breath, febrile, and in respiratory distress need to be admitted. An infectious disease or pulmonology consult is recommended if the diagnosis is unclear. Some patients may present with a parapneumonic effusion, which may require drainage. Typically, nurses monitor the patients and report current status and updates to the rest of the team. Pharmacists evaluate medication choices, check for allergies and drug interactions, and educate patients about possible side effects and the importance of compliance.

The providers should encourage all patients to get the annual influenza vaccine. In addition, all adults 65 and older and those considered at risk for pneumonia must receive the pneumococcal vaccination. The outcomes in most patients with community-acquired pneumonia are favorable. [19]  

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Computed Tomography of a Lung Abscess. The thick-walled cavitary lesion in the right lung is an abscess. The diffuse ground glass infiltrates seen in both lungs represent pneumonia. Yale Rosen, Public Domain, via Wikimedia Commons (CC by 4.0)  (more...)

Healthy Lung and Q Fever Pneumatic Lung, Chest X-ray. X-ray A represents a normal healthy lung; X-ray B represents a lung with Q fever pneumonia. Hehkuviini, Public Domain, via Wikimedia Commons.

Bilateral Pneumonia, Computed Tomography Scan. Bilateral pneumonia with abscesses, effusions, and cavers in an adult male. Christaras A, Public Domain, via Wikimedia Commons (CC by 2.5).

Chest X-ray of Mycobacterium Avium-Intracellulare Pneumonia. Contributed by S Bhimji, MD

Lung Pneumonia With Fibrosis. Contributed by Fabiola Farci, MD

Disclosure: Hariharan Regunath declares no relevant financial relationships with ineligible companies.

Disclosure: Yuji Oba declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Regunath H, Oba Y. Community-Acquired Pneumonia. [Updated 2024 Jan 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Community-acquired pneumonia (non Covid-19)

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Case history

A 54-year-old smoker with multiple comorbidities (diabetes, hypertension, coronary artery disease) presents with a 2-day history of a productive cough with yellow sputum, chest tightness, and fever. Physical exam reveals a temperature of 101°F (38.3°C), BP of 150/95 mmHg, heart rate of 85 bpm, and a respiratory rate of 20 breaths per minute. His oxygen saturation is 95% at rest; lung sounds are distant but clear, with crackles at the left base. Chest x-ray reveals a left lower lobe infiltrate.

Other presentations

Pneumonia can occur at any age, but the incidence increases significantly in old age, and pneumonia is a leading cause of illness and death in older patients. The clinical manifestations of pneumonia in elderly persons are often less intense than those in younger patients. [1] Simonetti AF, Viasus D, Garcia-Vidal C, et al. Management of community-acquired pneumonia in older adults. Ther Adv Infect Dis. 2014;2:3-16. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4072047 http://www.ncbi.nlm.nih.gov/pubmed/25165554?tool=bestpractice.com Atypical pathogens such as Mycoplasma pneumoniae , Chlamydophila pneumophila , and respiratory viruses can present in a subacute fashion with gradual onset of fever, nonproductive cough, constitutional symptoms, relatively normal white blood cell count, and absent or diffuse findings on lung exam. [2] Masiá M, Gutiérrez F, Padilla S, et al. Clinical characterisation of pneumonia caused by atypical pathogens combining classic and novel predictors. Clin Microbiol Infect. 2007;13:53-61. http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X%2814%2961580-9/fulltext http://www.ncbi.nlm.nih.gov/pubmed/17328727?tool=bestpractice.com Patients with severe pneumococcal or Legionella pneumophila pneumonia often progress rapidly to respiratory failure.

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Community-acquired pneumonia: a case study

Affiliation.

• 1 Long Island Jewish Medical Center, New Hyde Park, New York, USA. [email protected]
• PMID: 11858290

Community-acquired pneumonia (CAP) is an infectious disease commonly seen in the primary care environment. CAP is ranked as the sixth leading cause of death in the United States. It affects more than 10 million individuals per year and accounts for 500,000-1,000,000 hospital admissions. Precise diagnosis of CAP continues to be complex. Despite enormous advances in serologic analysis and antimicrobial development, at least 50% of causative pathogens are not identified. This article presents a case report of a white female in her seventies diagnosed with CAP and emphasizes the need for early detection, immunization, and prompt interventions to reduce morbidity and mortality rates. This case brings to light the dilemma practitioners can face when treating high-risk populations on an outpatient basis.

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A Case Study: Pneumonia

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5:  Community-Acquired Pneumonia

Sean N. Avedissian; Marc H. Scheetz

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Patient presentation.

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Chief Complaint

“I have been coughing, have chest pain, and cannot breathe for about 2 days now.”

History of Present Illness

WA is a 40-year-old Caucasian male who presents to the emergency department with a fever, cough, chest pain (worsening when breathing or coughing), and shortness of breath. Normally, he has a fairly active lifestyle as he trains for marathons. He has not traveled outside the United States recently. He states he has “been taking cough medicine at night” for the past 4 days to help him sleep, but it has not been getting better. Also, he reports that he has been waking up at night due to heavy sweating. He states all his symptoms have gotten worse in the last 2 days. After being assessed in the ED, WA is admitted to the medicine unit for further workup.

Past Medical History

Diabetes: Type 1

Surgical History

Family history.

Father has diabetes: Type 1, history of heart attack; mother has hypertension.

Social History

Married with no kids. Denies smoking and drinks alcohol occasionally (weekends, social events)

Home Medications

Insulin (bolus/basal: ~35 units total daily)

Aspirin 81 mg PO daily (cardiovascular protection)

Atorvastatin 20 mg PO daily (cardiovascular protection)

Physical Examination

Vital signs.

Temp 100.8°F, HR 110 bpm, RR 30, BP 125/75 mm Hg, p02 93%, Ht 5′9″, Wt 70 kg

Slightly lethargic, mild—moderate distress

Normocephalic, atraumatic, PERRLA, EOMI, normal mucus membranes and conjunctiva, adequate dentition

Diminished breath sounds and crackles (rales) bilaterally

Cardiovascular

NSR, no m/r/g

Soft, non-distended, non-tender, bowel sounds hyperactive

Lethargic, oriented to place and person, (–) Brudzinski’s sign, (–) Kernig’s sign

Extremities

No significant findings

States he cannot remember all of them. He says he received all his age-related vaccines when younger. Has not received his flu-shot this year as he always forgets to receive it.

Laboratory Findings

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Ep 130 Community Acquired Pneumonia: Emergency Management

While community acquired pneumonia (CAP) is ‘bread and butter’ emergency medicine, and the diagnosis is often a ‘slam dunk’, it turns out that up one third of the time, we are wrong about the diagnosis; that x-rays are not perfect; that blood work is seldom helpful; that not all antibiotics are created equal and that deciding who can go home and who needs to go to the ICU isn’t always so clear cut. With this in mind we are taking a deep dive into CAP with Dr. Leeor Sommer and Dr. Andrew Morris , from diagnosis to disposition so that we can better achieve our EM goals of stabilizing sick patients, getting the right diagnosis, initiating the best treatment with the information at hand, prognosticating/appropriately deciding on disposition of patients, and being healthcare and antimicrobial stewards…

Podcast: Play in new window | Download (Duration: 1:30:46 — 83.2MB)

Subscribe: Apple Podcasts

Podcast production, sound design & editing by Anton Helman; Script writing assistance by Andrew Cameron & Anton Helman.

Written Summary and blog post by Alexander Hartt and Anton Helman September, 2019

Cite this podcast as: Helman, A., Sommer, L., Morris, A. Episode 130 – Community Acquired Pneumonia – Emergency Management. Emergency Medicine Cases. September, 2019. https://emergencymedicinecases.com/community-acquired-pneumonia .  Accessed [date]

Sources of the high misdiagnosis rate of CAP in the ED

Some of the reasons why we misdiagnose CAP up to 1/3 of the time in the ED include pressure to make early treatment and disposition decisions (because of time-to-antibiotic “rules” in some jurisdictions), the expectation to have a definitive diagnosis when consulting services for admission, because the classic constellation of symptoms (cough, shortness of breath and fever) is often absent, there are many pneumonia mimics (CHF and PE being the most critical to identify and treat in the ED), early anchoring bias , there is overlap in clinical presentation of viral URI and pneumonia, blood tests may be misleading, CXR has poor accuracy, and there is no single historical or physical exam finding that has high enough likelihood ratio to shift pretest probability significantly.

To aid diagnostic accuracy and avoid over prescribing antibiotics, force yourself to consider the diagnosic criteria for CAP: fever, respiratory symptoms and imaging evidence of an infiltrate. Pay close attention to respiratory rate and oxygen saturation – the vast majority of patients with CAP will have an elevated respiratory rate and abnormal O2 sat, but don’t be fooled by the marathon runner – they can maintain perfectly normal vitals with their CAP.

Likelihood ratios for physical findings in CAP

The highest positive likelihood ratios of clinical findings for CAP from a 2019 meta-analysis are RR≥20 (3.47), fever (3.21) and HR>100 (2.79).

Normal vital signs combined with a normal pulmonary examination had a summary estimate -LR = 0.10 in a 2018 metaanalysis.

Normal vital signs alone have a -LR = 0.18 for CAP.

Pitfall : Using diagnosis of “acute bronchitis” in patients with viral respiratory illness, as it is a non-specific term that sets expectations by patients to be treated with antibiotics for a viral illness.

Blood tests for diagnosis and prognosis of CAP are promising statistically but usually not pragmatically useful

WBC > 10,400 per mm 3 has +LR = 3.4, -LR = 0.52 for CAP, but normal values do not rule out pneumonia and WBC is not included in any of the prognostic decision tools. WBC in the extremes (<4, >20) may be of prognostic significance.

CRP of >200mg/L hav been found to have a +LR>5, while <75mg/L have been found to have a -LR<0.2, however, most patients will have values between these extremes, in which case there is little diagnostic or prognostic utility.

Procalcitonin may be a significantly better predictor for blood culture positivity in CAP than WBC count, C-reactive protein, and other clinical parameters, may reduce antibiotic exposure, and has been used to help guide cessation of antibiotic treatment, however procalcitonin does not appear to pragmatically change antibiotic exposure, LOS or mortality in the ED setting. Our experts recommend not ordering procalcitonin in the ED.

Hypoglycemia (blood glucose < 70 mg per dL or 3.89 mmol per L) at presentation is associated with increased 30-day mortality even after adjustment for other variables, including comorbid illness and Pneumonia Severity Index (PSI) score.

Lactate has been shown to be a better predictor of 28-day mortality, hospitalization and ICU admission than CURB-65 in ED CAP patients.

Chest x-ray indications, accuracy, false negatives and false positives for community acquired pneumonia

Indications for chest x-ray in patients with acute respiratory illness for CAP :

• At least one abnormal vital sign (Fever, tachycardia, RR>20)
• Two of: decreased breath sounds, crackles, absence of asthma

Common conditions that may lead to false negative chest x-ray in CAP

• Volume depletion
• Neutropenia
• Early disease (first 12 hours)

Subtle chest x-ray findings that are often missed in CAP

• Silhouetting of heart border
• Small pleural effusion
• Retrocardiac infiltrate

Pitfall: Assuming that a non-apical lung infiltrate cannot be acute pulmonary tuberculosis

Indications for CT chest in suspected community acquired pneumonia

• Clinical course is not as expected (long duration, worsening despite appropriate CAP treatment)
• Recurrent infections
• An x-ray with atypical findings
• Neutropenic patients
• Profound immunocompromised state

While CT chest may be more accurate than chest x-ray at visualizing the upper lobes/lingula, showing interstitial edema of atypical pathogens, further characterizing necrotizing infection, multilobar disease, empyema, and pleural involvement, it is rarely indicated in the ED for suspected CAP.

POCUS perfomed by experienced operators is more accurate than chest x-ray for community acquired pneumonia, but is limited by the time it takes to perform

A 2014 meta-analysis concluded that, in the hands of experienced operators , ultrasound examination has a sensitivity and specificity as high as 94% and 96% , respectively. Ultrasound examination may offer an ideal alternative diagnostic modality in pediatric patients and critically ill patients in whom it is difficult to obtain a 2-view chest x-ray. However, for patients who are stable enough to go to the radiology department to get a 2 view chest x-ray, the time required to complete a thorough lung POCUS exam may be a limiting factor.

Indications for blood cultures in suspected community acquired pneumonia

• Severe CAP requiring ICU admission
• Evidence of sepsis
• Cirrhosis, asplenia or neutropenia
• Cavitary lesions or empyema on chest x-ray

Indications for sputum gram stain and cultures in suspected community acquired pneumonia

Patients with CAP are able to produce a valid sputum sample only 70% of the time. The sensitivity of sputum Gram stain ranges from 15% to 69% and specificity ranges from 11% to 100%. Many elderly patients with CAP are not able to produce an adequate specimen.

Consider sputum gram stain and cultures in the ED for patients with:

• Intubated patients with CAP
• History of alcohol abuse, liver disease, lung disease, leukopenia, cavitary infiltrates, asplenia, pleural effusion, and recent travel

Urine Legionella and Pneumococcus are rarely indicated in the ED

A 2009 retrospective analysis of Legionella CAP found 6 factors to be independent predictors:

• Fever (OR 1.67, p < 0.0001)
• Absence of sputum production (OR 3.67, p < 0.0001)
• Low serum Na (OR 0.89, p = 0.011)
• Elevated lactate (OR 1.003, p = 0.007)
• Elevated CRP (OR 1.006, p < 0.0001)
• Thrombocytopenia (OR 0.991, p < 0.0001)

Legionella may occur any time of year, but more illness is found in the summer and early fall.

Urine antigen testing in a 2009 meta-analysis showed a pooled sensitivity of 74% and specificity of 99% based on poor quality evidence.

In low prevalence areas, urine Legionella testing is not recommended in the ED by our experts as it is not cost effective.

Testing for Pneumococcal urine antigen in the ED is not recommended by our experts because empiric therapy will cover strep pneumococcus.

Antibiotic recommendations for community acquired pneumonia in Ontario

Consult your local biogram for recommendations in your area

• No risk factors for MRSA or pseudomonas, hemodynamically stable, non-ICU: amoxicillin or doxycycline (if penicillin allergy) or amoxicillin-clavulanic acid (if poor oral hygiene or non-ICU inpatient admission anticipated)
• No risk factors for MRSA or pseudomonas and are hemodynamically unstable, or have ICU admission planned, or are unable to tolerate oral antibiotics: IV ceftriaxone
• MRSA risk factors: add vancomycin or l inezolid
• Pseudomonas risk factors: piperacillin-tazobactam or miropenem

The vast majority of pneumonias are caused by only 2 bacteria: Streptococcus pneumonia and Haemophilus influenzae . All strep pneumonia and most H flu are susceptible to penecillin or amoxicillin. Therefore,the first line antibiotic for CAP patients without risk factors for MRSA or pseudomonas and who are hemodynamically stable, based on a Cochrane review is amoxicillin 1g po bid.

For patients with true penicillin allergy doxycycline 100mg po bid is the recommended first line antibiotic for these with CAP. It has good atypical coverage and a low risk for C. diff.

Amoxacillin-clavulinic acid (Clavulin) does not appear to confer added coverage against strep pneumo (as the mechanism for resistance is not via beta-lactamase), however it can be considered as an alternative to amoxicillin or doxycycline in patients with poor oral hygiene and for non-ICU inpatients.

There is no consensus in the literature around adding azithromycin for atypical coverage. A 2014 JAMA article suggests that time to clinical stability favours the addition of azithromycin but there is no benefit for patient oriented outcomes. Likewise, the often mentioned anti-inflammatory properties of azithromycin does not confer benefit for patient oriented outcomes. In high prevalence Legionella regions, in patients with predictors (listed above) it is not unreasonable prescribe azithromycin in the ED.

Fluoroquinolones should not be first or even second line therapy. Serious adverse reactions include:

• Tendinopathy
• Multiple drug interactions
• Partial treatment of tuberculosis leading to diagnostic delay
• Increased risk of aortic dissection

Update 2022: A meta-analysis of six randomized controlled trials involving 834 patients comparing doxycycline to macrolides and fluoroquinolones for the treatment of non-severe community acquired pneumonia in adults found similar efficacy and adverse event rates, with lower length of hospitalization and lower cost of antimicrobial agent in the doxycycline group compared to levofloxacin group. Abstract

Oral antibiotics are as effective as IV antibiotics for most community acquired pneumonia

Oral antibiotics are recommended over IV antibiotics in the vast majority of ED patients with CAP or suspected CAP. There are at least 9 RCTs that show no clinical benefit for IV antibiotics over oral antibiotics for CAP. The bioavailablility of almost all antibiotics commonly used for CAP are comparable whether IV or po. In addition, IV antibiotics have a higher rate of side effects, and take longer time to administer in the ED.

IV antibiotics such as Cefriaxone are indicated in CAP patients who:

• Are hemodynamically unstable
• Have ICU admission planned
• Are unable to tolerate PO

MRSA is on the decline but should still be considered for at risk patients

Empiric therapy with vancomycin or linezolid for MRSA was recommended in 2011 IDSA guidelines for MRSA for hospitalized patients with severe community-acquired pneumonia defined by one of the following:

• A requirement for admission to the ICU
• Necrotizing or cavitary infiltrates

However, the prevalence of MRSA since 2011 has been declining with two 2016 studies finding a prevalence of only 0.7-3%.

MRSA nasal screening is of little value considering the low prevalence of MRSA CAP and the poor positive predictive value of the test. A meta-analysis of 22 studies with 5243 patients found that nasal screening had a pooled sensitivity of 70.9%, specificity of 90.3%, positive predictive value (PPV) of 44.8%, and negative predictive value (NPV) of 96.5% for MRSA pneumonia.

Indications for extended antibiotic coverage for Pseudomonas in community acquired pneumonia

Consider broadening antibiotic coverage to cover Pseudomonas with piperacillin-tazobactam, meropenem or ciprofloxacin in the setting of:

• Bronchiectasis
• Tracheostomy
• Septic shock
• Broad spectrum antibiotics for >7 days in the last month
• Hospitalization for >1 day in last 3 months
• Immunocompromised (chemo, chronic steroids)
• Nursing home resident with poor functional status

It is unnecessary to provide antimicrobial coverage for anaerobes in patients suspected of aspiration pneumonia in the ED

Even in the setting of true aspiration pneumonia, the organisms involved are usually susceptible to beta-lactams (ceftriaxone). There is no need to add metronidazole or clindamycin.

Five-7 days duration of antibiotic treatment for uncomplicated community acquired pneumonia is sufficient

For uncomplicated CAP, 5-7 days of antibiotics is sufficient. More complex cases involving immunocompromised patients and those with structural lung disease will likely benefit from longer therapy. A metaanalysis of studies comparing treatment durations of 7 days or less with durations of 8 days or more showed no differences in outcomes and prospective studies have shown that 5 days of therapy are as effective as 10 days and 3 days are as effective as 8.

Treatment failure is defined by lack of defervenscence within 4-5 days and lack of subjective patient improvement within 72hrs

Our experts define treatment failure by a lack of defervescence within 4-5 days and lack of subjective patient improvement within 72hrs. Radiographic improvement can take weeks so is unreliable.

Adjunctive steroids may be of benefit in patients with severe community acquired pneumonia

Steroids are thought to curb the inflammatory response in CAP, reduce the frequency of acute respiratory distress syndrome, and decrease the length of illness. A systematic review and metaanalysis suggested that steroids reduce the need for mechanical ventilation and rate of acute respiratory distress syndrome by 5% with an NNT=20, however there are other high quality studies not reviewed in the metaanalysis that show no benefit. The SCCM/ESICM guidelines and expert consensus seems to favour steroids being reserved for those with severe CAP and those taking steroids chronically.

Initial steroid dosing options in the ED include:

• Dexamethasone 10mg IV
• Methylprednisolone 40mg IV
• Hydrocortisone 50mg IV

Learn more about steroid treatment in Journal Jam 17- Steroids for CAP and COVID Pneumonia

Update 2022: A meta-analysis of 16 RCTs including 3,842 hospitalized patients with community acquired pneumonia found no difference in all cause, in hospital mortality with corticosteroid therapy (RR 0.85, 95% CI 0.67 – 1.07), but was associated with a reduction in progression to mechanical ventilation (RR 0.51, 95% CI 0.33 – 0.77). Steroid use was also associated with subsequent readmission (RR 1.20, 95% CI 1.05 – 1.38). Abstract

Resuscitation of the patient with community acquired pneumonia and septic shock

Fluid choice and volume: Based on the SALT-ED and SMART trials, most experts agree that Ringer’s Lactate is the fluid of choice in septic shock patients. While massive fluid resucitation may worsen hypoxemia respiratory failure and precipitate need for intubation, under-resuscitation may worsen end-organ damage. Aiming for a MAP≥65 is a reasonable goal in addition to physical signs of end organ perfusion such as urine output and normal sensorium.

Norepinephrine indications and timing : Based on the CENSER trial it is reasonable to start peripheral norepinephrine as soon as the MAP <65 and/or there are signs of poor organ perfusion; the trial suggests that early norepinephrine in addition to fluid resuscitation results in less cardiogenic pulmonary edema, and possibly lower mortality.

The role of NIPPV in severe CAP: While NNPV theoretically theoretically prevents CAP patients from clearing secretions and mucus plugging, it may be used for limited periods of time as a bridge to intubation, and may be especially helpful in those with concurrent COPD exacerbation, where the evidence is clear for clinical benefit.

Learn more about COPD and pneumonia in Episode 24: COPD & Pneumonia

The role of High-Flow Nasal Cannula (HFNC) in severe CAP: The FLORALI trial suggested that HFNC may improve 90 day survival as well as subjective dyspnea and respiratory discomfort at 1-hr compared to non-rebreather and BiPAP in severely hypoxic CAP patients. It also showed that HFNC is non-inferior to non-rebreather facemask and BiPAP for reducing the need for intubation. HFNC is thought to reduce the work of breathing prior to respiratory exhaustion.

Pneumonia Severity Index (PSI) is the risk stratification tool of choice for community acquired pneumonia

PSI is more sensitive than SMART-COP and much more sensitive than CURB-65 for determining which patients will require ICU admission, while offering equal sensitivity for mortality for CAP overall. Despite CURB-65 having a higher specificity for CAP than PSI, our experts recommend PSI as the risk stratification tool of choice.

Problems with PSI

• PSI may underestimate the severity of pneumonia in an otherwise young healthy patients
• PSI does not include psychosocial conditions or cognitive impairments that may preclude discharge from the ED
• Any patient over 50 years of age is automatically classified as risk class 2 which may exaggerate their risk

Note that all CAP risk stratification tools rely on blood work so they do not apply to those well enough to not get lab testing.

Validated IDSA/ATS criteria for ICU admission

Patients with 3 or more criteria may benefit from ICU admission:

• Respiratory rate >29 breaths/min
• Hypotension requiring volume resuscitation
• PaO2/FiO2 < 250 (patients requiring >3 liters oxygen)
• Temperature < 36C
• Multilobar infiltrates
• BUN >20 mg/dL
• WBC <4,000/mm3
• Platelets <100,000/mm3

In addition, multilobar pneumonia is an independent risk factor for increased mortality in CAP.

Discharge criteria for outpatient care in patients with community acquired pneumonia

Some experts recommend a CURB-65 score of zero as criteria for outpatient care, however CURB-65 was validated as mortality prediction tool, and was not designed to determine disposition. Our experts recommend the following minimal criteria for outpatient care of CAP:

• Normal mental status
• Able to tolerate oral intake
• Psychosocial support

Oxygen saturations less than 92% are associated with major adverse events in outpatients with CAP.

Update Oct 2019: Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America Plus an excellent summary of the guidelines on emDocs

Take home points for emergency management of community acquired pneumonia

• We often misdiagnose CAP. To help us be better diagnosticians think about the diagnostic criteria (fever, respiratory symptoms and imaging evidence of infiltrate) and pay close attention to respiratory rate and oxygen saturation– the vast majority of patients with CAP will have an elevated respiratory rate and abnormal O2 sat, but don’t be fooled by the marathon runner – they can maintain perfectly normal vitals with their CAP.
• Not all cough is CAP. Think about the differential so that you do not overdiagnose CAP and you do not miss other important diagnoses.
• Not all patients in the ED with cough require a chest x-ray. Indications for chest x-ray include: At least one abnormal vital sign (fever, tachycardia, RR>20) and 2 of decreased breath sounds, crackles or absence of asthma. If you do get a chest x-ray remember that they can be normal or near normal early on the clinical course and in severely dehydrated or immunocompromised patients. Consider the differential diagnosis when you see an infiltrate – don’t just assume CAP.
• Procalcitonin has little, if any, role in the ED but may be useful for the inpatient team in predicting prognosis and duration of therapy. While WBC is usually unrevealing, extremes of WBC can help risk stratify your patients.
• For the septic CAP consider high flow nasal oxygen and/or NIPPV as a bridge to intubation; fluid resuscitation requires a delicate balance of considerations – don’t just slam in a few litres of crystalloid, but at the same time be sure not to under-resuscitate. Start peripheral norepinephrine early in CAP patients with septic shock – as soon as the MAP<65.
• For antibiotic choices, consult your local biogram. In Ontario, the recommended first-line outpatient therapy for CAP is currently amoxicillin 1g po bid. The recommended first-line inpatient non-ICU therapy for CAP is now amoxicillin-clavulanate 875mg/125mg po bid or ceftriaxone 1g iv q24h. Consideration for adding azithromycin empirically should only be given during the months of June through October to cover Legionella, MRSA only for those at risk (the prevalence is declining) and coverage for pseudomomas only in at risk patients. Oral antibiotics and as effective as IV antibiotics for the majority of patients with CAP.
• Recommended duration of therapy for most CAP is 5-7 days. Know the exceptions.
• PSI is the risk stratification tool of choice. Low-risk patients suitable for discharge from the ED should be defined by a PSI ≤ 70 and an oxygen saturation of at least 92% on room air. Use a PSI >130 as criteria for ICU admission.

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• Cretikos M, Bellomo R, Hillman K, Chen J, Finfer S, Flabouris A. Respiratory rate: the neglected vital sign. Med J Aust. 2008;188(11):657-659.
• Chalmers J, Taylor J, Mandal P, et al. Validation of the Infectious Diseases Society of America/American Thoratic Society minor criteria for intensive care unit admission in community-acquired pneumonia patients without major criteria or contraindications to intensive care unit care.  Clin Infect Dis . 2011;53(6):503-511.
• Williams J, Greenslade J, Chu K, Brown A, Lipman J. Utility of community-acquired pneumonia severity scores in guiding disposition from the emergency department: Intensive care or short-stay unit?  Emerg Med Australas . 2018;30(4):538-546.
• Frat JP, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. NEJM. 2015. 372(23):2185-2196.
• Pastores S, Annane D, Rochwerg B, Corticosteroid G. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part II): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017.  Intensive Care Med . 2018;44(4):474-477.
• Musher DM, Roig IL, Cazares G, Stager CE, Logan N, Safar H. Can an etiologic agent be identified in adults who are hospitalized for community-acquired pneumonia: results of a one-year study. J Infect 2013;67:11-8
• Abers MS, Musher DM. Clinical prediction rules in community-acquired pneumonia: lies, damn lies and statistics. QJM 2014;107:595-6.
• Li JZ, Winston LG, Moore DH, Bent S. Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis. Am J Med 2007;120: 783-90.
• Dunbar LM, Khashab MM, Kahn JB, Zadeikis N, Xiang JX, Tennenberg AM. Efficacy of 750-mg, 5-day levofloxacin in the treatment of community-acquired pneumonia caused by atypical pathogens. Curr Med Res Opin 2004;20:555-63. [Erratum, Curr Med Res Opin 2004;20:967.]
• el Moussaoui R, de Borgie CA, van den Broek P, et al. Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study. BMJ 2006;332:1355.
• Fine MJ. et. al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243-50.
• Shah BA, et. al. Validity of Pneumonia Severity Index and CURB-65 Severity Scoring Systems in Community Acquired Pneumonia in an Indian Setting. The Indian Journal of Chest Diseases & Allied Sciences. 2010;Vol.52.

Other FOAMEd resources on Community Acquired Pnuemonia

https://emcrit.org/ibcc/pneumonia/

Community Acquired Pneumonia – (LITFL CCC, Chris Nickson)

Evidence-based treatment for severe community-acquired pneumonia (PulmCrit)

Radiologic – Ultrasonic – Pathologic correlation for pneumonia (PulmCrit)

Antibiotics

Which patients with pneumonia need MRSA coverage? (PulmCrit)

Update in community acquired pneumonia: Macrolide resistance (Anand Swaminathan, Rebel EM)

Six reasons to avoid fluoroquinolones in the critically ill (PulmCrit)

Modes of noninvasive support

Pneumonia, BiPAP, secretions, and HFNC: Lessions learned from FLORALI trial (PulmCrit)

Mastering the dark arts of BiPAP & HFNC (PulmCrit)

Metabolic therapies

Steroid for community-acquired pneumonia (PulmCCM, Jon-Emile Kenny)

Corticosteroids for pneumonia: Ready for primetime? (emDocs, Brit Long)

Metabolic resuscitation for severe pneumonia? (PulmCrit)

POCUS for pneumonia

Pneumonia: Five minute sono (Jacob Avila)

Pneumonia US library (LITFL, James Rippey)

Drs. Helman, Sommer and Morris have no conflicts of interest to declare

About the Author: Anton Helman

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my name is Felix. I am working as an ED physician in Germany and enjoy listening to your podcast. Please keep up that fantastic work! Relating to your current episode of CAP I would like to mention two points. 1- I am very glad that you provide good evidence for treating patients orally. However in our healthcare system we are often kind of forced to go for iv antibiotics for inpatients. The health insurance declines paying the hospital bill if the patient did not receive iv medication postulating the stay was not necessary. 2- You were quite sceptic about the use of CRP/leucocyte count/pct because high values do exist in viral infections as well. However I think if someone has markedly elevated levels it still means that there is some important inflammation going on. So in an ill appearing patient with high inflammatory markers I would then treat with antibiotics because of the possible (threatening) bacteremia and take the risk of unnecessary treatment and possible adverse events of the drug in case of a viral cause.

I hope you can follow my reasoning although I am lacking some fluency in English… Thanks again for you great podcasts – I am looking forward to the next episode. Felix

In uncertainty a CAT scan of the chest is more accurate . Further PCR is developing rapidity of diagnosis eg TB and there are faster tests for drug sensitivity emerging .

Was not totally clear when, if ever, it is indicated to give fluoroquinolones (levofloxacin, moxifloxacin) PO for CAP in the outpatient setting. Is it only recommended if there are contraindications to amoxicillin or doxycycline? It appears where I work (California) that we are more apt to give Levofloxacin to elderly with CAP. Perhaps there is a belief that it’s better.than amoxicillin. Thanks.

For outpatient Amoxicillin is first line and if allergy to Penicillin then Doxycycline regardless of age. FDA has warned that fluoroquinolones are associated with Aortic Dissection, so probably best to avoid them in the elderly, especially if history of hypertension or AAA. While fluoroquinolones are in the newest guidelines as a choice for “severe” CAP, the evidence is weak that they are any better than first line agents for outpatient CAP. For severe CAP, ceftriaxone +/- azithro (for at risk patients) is a better choice.

The question :What distinguishes bronchitis from pneumonia was not answered . Looking Sick A lot of coughing with phlegm Aches and Pains Increased respiratory rate above 20 low po2 at 94 and below higher fever 39.0C and in severer cases tachcardia PR 110 or greater hypotension BP pressure systolic 90 or less respiratory rate 24 and over and Po2 on air by pulse Oximeter 92 and below Would be alerting .

Hi thanks for the excellent podcast. In the U.K. we use CURB score not only to help decide whether to admire but also use for treatment guidance. You didn’t mention Mycoplasma pneumonia – when to suspect and what treatment to add.

HI I am an Advanced Nurse Practitioner working in a Rual Access Hospital without on site supervision. I love these keeps me up to date and is fast and easy reads. Thank you so much for keeping it free. Karla

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Nursing Case Study for Pneumonia

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Charles is a 72-year-old male patient admitted via the emergency department to the medical surgical floor at 2220 with a diagnosis of community acquired pneumonia (CAP).  He arrives in the room via stretcher with oxygen (O2) via nasal cannula (NC) and is able to transfer to the bed with minimal assistance. He does get short of breath (SOB) with exertion.

What assessment findings does the nurse expect for this patient? Should there be a particular focus to the assessment?

• The great majority of patients with CAP present with fever. Other systemic symptoms such as chills, fatigue, malaise, chest pain (which may be pleuritic, nurse should ask questions about onset/radiation/provoking factors), and anorexia are also common. Tachycardia, leukocytosis with a leftward shift, or leukopenia are also findings that are mediated by the systemic inflammatory response. Focus should be respiratory in nature (auscultation, adventitious lung sounds like crackles & rhonchi) along with checking labs, CXR. Level of consciousness (LOC) on admission is important to monitor for changes.

Are there any ER results the nurse should ask about during the bedside report?

• Since the patient has a cough and fever, the nurse should check to see if a COVID test was done. It would also be beneficial to ask about chest x-rays (CXR), if blood and/or sputum cultures were taken, AND if antibiotics were already started. Most healthcare systems treat pneumonia as a core measure and must meet very strict metric guidelines (following a protocol, doing certain things within a narrow time frame window, etc)

What orders does the nurse expect the admitting provider to give?

• After admission, it is common for providers to give continuous pulse oximetry, O2 titration orders (i.e. titrate O2 to keep O2 saturation above 92%), and IV fluids. If cultures are not done already, those should be ordered. There may be a daily CXR to monitor changes. The nurse should check the med administration record for antibiotics and there may be medications for the cough/sputum (tesslon perles, guaifenesin, etc.) and fever control (acetaminophen 1000 mg q 6 hrs PRN fever greater than 101 F for example)

After screening and assessing the patient, the nurse has the following data:

Patient AA&Ox4. SOB noted with speaking and after he moves around. IV 20g noted in left arm. Productive cough with moderate sputum production occasionally. Lung sounds in all fields indicate crackles; no barrel chest noted. Skin is warm and dry. He voids per urinal no assistance needed. Verbalizes understanding of call light use.

BP 120/60 SpO2 93% on NC 2L HR 100 bpm and regular Ht 172 cm RR 18 bpm Wt 60 kg Temp 38.3°C

CXR – posteroanterior and lateral chest radiographs obtained (two view). Radiographic findings consistent with the diagnosis of CAP including minor lobar consolidations, moderate interstitial infiltrates

CBC (abnormal/significant only listed, if NOT listed then the value falls within expected limits or is not significant for this patient), for reference see nursing.com Lab Value cheat sheet: WBC 15,000 cells/mcL Bands 10% Neutrophils 60% Eosinophils 1% Basophils 1% Lymphocytes 20%

Prioritize the top nursing interventions.

• Frequent respiratory reassessments are vital for this patient along with continued LOC monitoring. The patient may need assistance with managing secretions so suction should be readily available. Positioning in the bed may alleviate symptoms and provide comfort – patient should not lie flat if there are airway concerns. The nurse should also ensure core measures are being followed. Blood cultures are needed as well as sputum so CORRECT collection and time of collection are necessary for proper monitoring. Timely administration of antibiotics helps improve outcomes.

What should the nurse be on the lookout for as the shift progresses? What warrants a call to the provider?

• Watch for airway compromise or O2 sat decline. Ensure LOC does not decline inappropriately as this may indicate worsening of condition (respiratory failure). If the provider has given parameters to call, the nurse must either hesitate nor apologize for reporting these to the provider. If there is a sepsis algorithm, this should be followed since the patient is at risk for this condition. Fever uncontrolled with antipyretics needs to be reported. Worsening chest pain or sense of impending doom may indicate a pulmonary embolism or other complication and should be reported.

Are there other orders the nurse might anticipate and/or suggest?

• A baseline lactic acid level (blood test) helps screen for sepsis. Strict I&O collection should begin since patients may have decreased appetite and/or thirst. Decreased urine output could be a sign of inadequate perfusion, so monitoring output is important. Respiratory therapy should be consulted for O2 titration, breathing treatments, O2 equipment/humidification and incentive spirometry (IS). Placing another IV may be helpful in case of patient deterioration (one in each upper extremity). Consider asking for Urinary antigen testing for S. pneumoniae

Are there past medical history concerns specific to this patient and his background that may aid in the plan of care?

• Checking pneumococcal vaccine history is important – the patient may need education if he did not receive this vaccine. If he is homeless there is a greater risk he has tuberculosis or possibly non-compliant at discharge (due to lack of resources) so should be screened. His travel history may be relevant as treatment progresses and for Infectious diseases to consider. If he has a tobacco use history, this must be documented (i.e. 20 pack history) because that puts him at higher risk of chronic lung disease. If he is unable to care adequately for himself then case management may need to be involved for short-term acute care post-hospitalization.

ABG values:

pH 7.30 PaCO2 50 mmHg HCO3- 23 mEq/L PaO2 88 mmHg

What does this ABG indicate? How do you know? What may have caused this value? What can you do?

• This is respiratory acidosis (pH < 7.35; PaCO2 > 45). It can be from hypoventilation -CNS depression -Pulmonary edema -Respiratory arrest -Airway obstruction. He may have an airway obstruction (thick sputum in throat) or his respiratory status could be worsening overall. Obtain VS, increase RR by arousing/waking him, reposition patient, maintain patent airway

The nurse gets the CNA to assist and repositions Charles in his hospital bed and he now sits straight but comfortably up in bed with pillows to bolster him. A yankauer at the bedside that he can use for a productive cough allows him to clear his airway after a brief teaching session. He had been frequently removing his NC due to ear discomfort, so RT brought padding for the tubing and Charles reports improved comfort. RT and the nurse teach him about “turn, cough, deep breath” aka TCDB.

After sleeping on and off through the shift, Charles is able to consume approximately 75% of his breakfast. He can properly demonstrate use of his IS and TCDB techniques. His NC remains in place with the padding on ears and his O2 sat is 95% on 2 L. He has two functioning IVs, one in each arm. Physician rounds and advises to continue plan of care including medication regimen based on test results after he and nurse discuss patient during rounds with the clinical pharmacist.

Describe examples of interdisciplinary team collaboration that may be useful in this patient’s care.

• The nurse should maintain open communication and good rapport with respiratory therapy and work as a team for the best outcomes. Pharmacy may be consulted for an appropriate antibiotic regimen and/or if core measures are being used. Nursing assistants can assist with repositioning and I&O adherence. A team of physicians may be on this patient’s case (i.e. Pulmonology, Infectious Diseases, etc), so being able to give appropriate updates to a variety of professionals is vital (i.e. SBAR).

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View the full transcript, nursing case studies.

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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