Transcript Community Acquired Pneumonia Practicum November 20, 2014

Community-Acquired Pneumonia
Practicum
December 8th, 2016
RACHEL MARINI, PHARMD
UNIT-BASED PHARMACIST
UPMC PRESBYTERIAN
[email protected]
SLIDES ADOPTED FROM:
BRIAN A. POTOSKI, PHARMD, BCPS
Learning Objectives
 Determine the appropriate site of treatment for
patients with Community-Acquired Pneumonia
 Recognize the appropriate diagnostic criteria for
CAP
 Design a treatment and monitoring plan for an
individual patient with CAP based on his/her
clinical presentation and specific risk factors.
Quiz
~10 MINUTES
PHOTO CREDIT:
STYLISH STREAKING
Brief Review
DEFINITION
PATHOPHYSIOLOGY
Definition CAP
 Acute infection of pulmonary parenchyma that is
associated with signs/symptoms of infection,
evidence of infiltrate on chest radiography, and
presentation from the community setting
 Community setting factors
 Do not live in long term care facility, skilled nursing facility, or
nursing home
 No recent hospitalization or antimicrobial therapy
 No risk factors for multidrug resistant pathogens
Pathophysiology
 Lung is constantly exposed to many different substances and microbes
during inhalation
 Body has a host defense system (both innate and acquired) that typically
prevents these inhaled pathogens from causing an infection.
 Infection occurs



When there is a breakdown in the host defense mechanisms
Exposure to a very virulent pathogen
Overwhelming inoculum (or concentration of bacteria)
 Routes of PNA infection:
1.
2.
3.
Inhaled as aerosolized particles (most common)
Enter the lung via bloodstream from extra pulmonary site of infection
Aspiration of oropharyngeal contents
 Adherence of these to the epithelial cell surface is the first step
Pathophysiology
Organism inhalation
Organisms pass upper
airway defense
mechanisms
(mucus-producing cells,
cilia, gag reflex, etc.)
Lower airway alveolar
macrophages release
cytokines
Widespread inflammation
and immune response
causes damage and
alveolar edema
IDSA Guidelines
COMMUNITY ACQUIRED PNEUMONIA
IN ADULTS
Areas of Focus
 Site of care decisions
 Diagnostic testing
 Antibiotic treatment
 Switch IV to PO
 Duration of antibiotic therapy
 Prevention
Site of Care Decisions
 All major decisions regarding management start with initial
assessment of severity
 After diagnosis is made, options include:
1.
Outpatient
2.
Hospitalization with admission to general medical ward
3.
Hospitalization with admission to intensive care unit (ICU)
 Reasons to avoid unnecessary hospitalizations:
 Cost (25x greater to treat inpatient)
 Resume normal activity sooner
 Patients prefer outpatient treatment
 Hospitalization increases risk of thromboembolic events and superinfection
 Mortality benefit
Site of Care Decisions
 Physicians often overestimate severity of disease and
hospitalize a significant # of patients who have a low
risk for death
 Scoring systems help to identify patients with CAP who
may be candidates for outpatient treatment

Strong recommendation; level I evidence
 Severity of illness scoring system: CURB-65
 PSI (Pneumonia Severity Index) is a prognostic model
 Scoring system should supplement clinical judgment
 Strong recommendation; level II evidence
CURB-65
Table 1: Clinical Signs and Symptoms
C
Confusion
U
Uremia (BUN ≥ 20 mg/dl)
R
Respiratory rate ≥ 30 bpm
B
SBP < 90 mmHg or DBP ≤ 60 mmHg
6
5
Age ≥ 65
Table 2:
Total Score
0
30 day mortality Risk Level
(%)
0.7%
Low
1
2.1%
Low
2
9.2%
Moderate
3
14.5%
4 or 5
40% or 57%
Steps:
1. Assign one point for
meeting each criteria in
Table 1 (0 through 5)
2. Then apply to Table 2 to
decide site-of-care
Suggested Site-ofCare
Outpatient
Outpatient
Short inpatient /
supervised outpatient
Moderate to High Inpatient/ICU
High
ICU
Direct Admission to ICU
 ~10% hospitalized CAP
patients require ICU
admission
 1 major criteria

Strong recommendation;
level II evidence
 3 minor criteria

Moderate
recommendation; level II
evidence
Areas of Focus
 Site of care decisions
 Diagnostic testing
 Antibiotic treatment
 Switch IV to PO
 Duration of antibiotic therapy
 Prevention
Diagnostic Testing
 Diagnosis: clinical features + a demonstrable infiltrate
on chest radiograph +/- microbiological data


Moderate recommendation; level III evidence
Clinical features maybe lacking/altered in elderly
 Specific pathogens should be investigated if it would
significantly alter standard empiric management




Downside of extensive testing cost
Less likely to change management in outpatients (optional)
For inpatients, may be able to narrow antibiotics
For inpatients who fail initial therapy, may indicate to broaden or
direct coverage to specific pathogen, or may identify resistance
Diagnostic Testing
Diagnostic Testing
 Outpatient point of care (POC) testing  influenza
 Respiratory tract specimen Gram-stain and culture
 Influenced by quality of specimen
 Usually low yield
 Urinary antigen tests:
 Streptococcus pneumoniae
 Legionella pneumophila
 Severe CAP diagnostic tests:
 Blood samples for culture
 Urinary antigen tests
 Expectorated sputum for culture (or endotracheal aspirate if intubated)
Respiratory Tract Specimen
 Used to identify pathogens associated with CAP

Also to broaden initial empiric coverage for less common pathogens
(S. aureus or Gram-negative bacilli)
 At least 40% of patients are unable to produce any
sputum


Higher yield with endotracheal aspirates or bronchoscopy sampling
Best specimens are collected before antibiotics are given
 Best indication for extensive respiratory tract cultures
severe CAP
Blood Cultures
 Pretreatment blood cultures yield probable pathogen
5-14% of cases
 Most common isolated pathogen: S. pneumoniae
 Strongest indication for blood cultures severe CAP
 More likely to be infected with other pathogens including
Staphylococcus aureus, Pseudomonas aeruginosa, other
Gram-negative bacilli
Antigen Tests
 Urinary antigen tests available: S. pneumoniae and
L. pneumophila serogroup 1


Higher diagnostic yield in patients with more severe illness
Questionable role empiric antibiotics will cover these
pathogens
 Rapid antigen test for influenza
 Consideration of antiviral therapy
Case #1
Case 1
 LI is a 70 y/o male who presents to the ED with SOB,
productive cough, and altered mental status. His VS include
T 38.6C, HR 106, RR 32, BP 85/45 after fluid resuscitation,
O2 sat 86% on 4L nasal cannula. His Cr is 2.1 and his BUN
is 26. He is placed on a norepinephrine drip.
1. What is LI’s CURB-65 score?
2. Where is the best site-of-care for LI?
3. Which diagnostic tests are recommended?
Case 1

LI is a 70 y/o male who presents to the ED with SOB, productive cough, and altered
mental status. His VS include T 38.6C, HR 106, RR 32, BP 85/45 after fluid resuscitation,
O2 sat 86% on 4L nasal cannula. His Cr is 2.1 and his BUN is 26. He is placed on a
norepinephrine drip.
1. What is LI’s CURB-65 score?
Answer: 5
Table 1: Clinical Signs and Symptoms
C
Confusion
1
U
Uremia (BUN ≥ 20 mg/dl)
1
R
Respiratory rate ≥ 30 bpm
1
B
SBP < 90 mmHg or DBP ≤ 60 mmHg
1
65
Age ≥ 65
1
Case 1

LI is a 70 y/o male who presents to the ED with SOB, productive cough, and altered
mental status. His VS include T 38.6C, HR 106, RR 32, BP 85/45 after fluid resuscitation,
O2 sat 86% on 4L nasal cannula. His Cr is 2.1 and his BUN is 26. He is placed on a
norepinephrine drip.
2. Where is the best site-of-care for LI?
Table 2:
Total Score
0
30 day mortality Risk Level
(%)
0.7%
Low
1
2.1%
Low
2
9.2%
Moderate
3
14.5%
4 or 5
40% or 57%
Answer: ICU
Suggested Site-ofCare
Outpatient
Outpatient
Short inpatient /
supervised outpatient
Moderate to High Inpatient/ICU
High
ICU
Case 1
 JB is a 70 y/o male who presents to the ED with SOB, productive cough, and
altered mental status. His VS include T 38.6C, HR 106, RR 32, BP 85/45 after
fluid resuscitation, O2 sat 86% on 4L nasal cannula. His Cr is 2.1 and his BUN
is 26. He is placed on a norepinephrine drip.
3. Which diagnostic tests are recommended?
Answer:
• Blood culture
• Sputum culture
• Legionella and S. pneumoniae
• UAT
• Bronchoscopy if intubated
Areas of Focus
 Site of care decisions
 Diagnostic testing
 Antibiotic treatment
 Switch IV to PO
 Duration of antibiotic therapy
 Prevention
Goals of Antibiotic Therapy
 Eradication of the infecting organism
 Resolution of clinical disease
 Avoid adverse events/ side effects from treatment
regimens utilized
Antibiotic Treatment
 Empiric antimicrobials
are the mainstay of
therapy until better
diagnostic methods are
available
 Recommendations for
empiric therapy based on:
1.
2.
3.
Cover the most common
pathogens
Knowledge of local
susceptibility patterns
Patient specific factors
 Thinking broadly, which of the following pathogens are most
QUESTION 1
common etiologies of community -acquired pneumonia?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Streptococcus pneumoniae
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Haemophilus influenzae
Legionella spp.
Oral anaerobes
Gram-negative bacilli
MRSA
Respiratory viruses
a, b, c, d, e, & i
All of the above
CAP Pathogens
 S. pneumonia
is the most
frequently
isolated
pathogen
Antibiotic Resistance Issues
 Resistance patterns vary by geography
 Hospital antibiograms should be considered in clinical
practice when formulating empiric regimens
1. Drug-resistant S. pneumoniae (DRSP)
2. Community-acquired methicillin-resistant
Staphylococcus aureus (CA-MRSA)
UPMC Presbyterian Hospital Antibiotic Susceptibility Trend Data – 2014
Percent Susceptible
Organism
#
Penicillin
Tested
S.pneumoniae
38
Vancomycin Erythromycin Ceftriaxone TMP/
SMX
88 (non100
meningitis)
60
91 (non70
meningitis)
Moxifloxacin
100
Drug Resistant S. pneumoniae
 Drug-resistant S. pneumoniae (DRSP)
1.
Penicillin and cephalosporin resistance: decreased PBP affinity
Macrolide resistance
2.


Low-level: mef(A) – macrolide efflux pump – antibiotic gets pumped out
High-level: erm(B) - methylation of ribosomal target site – antibiotic cannot
bind
 Risk factors for infection with β-lactam-resistant S. pneumo:
Age <2 or >65
β-lactams within past 3 months
Alcoholism
Medical comorbidities
Immunosuppressive illness/therapy
Exposure to a child in a day care center
CA-MRSA
 Strains are distinct from hospital-acquired MRSA
 Generally, remain susceptible to most antimicrobials
 Contains gene for Panton-Valentine leukocidin (PVL)
 Toxin associated with necrotizing pneumonia, shock, and respiratory
failure
 Can also cause abscesses or empyema
 Should be considered if:
 Cavitary infiltrates without risks for anaerobic aspiration pneumonia
 Usually sputum and blood cultures are high-yield (Gram-positive cocci
in clusters)
 Rare but emerging problem
 Risk factors: end-stage renal disease, injection drug use, prior influenza
pneumonia, prior antibiotic therapy
Context: Clinical Practice
Community-acquired pneumonia
Outpatient
Inpatient
Previously healthy and
no use of antimicrobials
in past 3 months
Comorbid conditions* OR
Use of antimicrobials in past
3 months OR DRSP risk
Macrolide
β-lactam plus macrolide
(Level I evidence)
OR
(Level I evidence)
OR
Doxycycline
Respiratory fluoroquinolone
(Level III evidence)
(Level I evidence)
Which
antimicrobials
cover the
organisms
discussed?
*Comorbid conditions: chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancy;
asplenia; immunosuppressed
Clin Infect Dis 2007;44:S27-72
Empiric Outpatient Treatment
 Divided into 2 groups:
1. Previously healthy PLUS no antibiotics within past 3 months:
1.
2.
1.
A macrolide (azithromycin, clarithromycin) OR
 Strong recommendation; level I evidence
Doxycycline
 Weak recommendation; level III evidence
Presence of comorbidities OR use of antibiotics within past 3 months
OR risks for DRSP:
1.
2.
A respiratory fluoroquinolone (moxifloxacin, levofloxacin 750mg) OR
 Strong recommendation; level I evidence
A β-lactam plus a macrolide
 Strong recommendation; level I evidence
1.
High-dose amoxicillin (1 gram TID)
2.
Amoxicillin-clavulanate (2 grams BID)
 Alternatives: ceftriaxone, cefpodoxime, cefuroxime
 Alternative to macrolide: doxycycline
If a patient has used antimicrobials within the past 3 months, an agent from
a different class should be chosen
Outpatient therapy
Comorbid Condition Considerations
 Chronic heart disease
 Chronic lung disease
 Chronic liver disease
 Chronic renal disease
 Diabetes mellitus
 Alcoholism
 Malignancies
 Asplenia
 Immunosuppressing conditions
 Use of immunosuppressing drugs
Outpatient Treatment
 In regions with a high rate (>25%) of infection with
high-level (MIC ≥ 16) macrolide-resistant S.
pneumoniae:

Consider the use of alternative agents to the macrolides for any
patient including those without comorbidities
Case #2
Case 2
 DJ is a 34 year old female who presents to her PCP’s office complaining of a
mild sore throat, a productive cough, and fevers for the past 3 days. She took
her fever this morning and said it was 38.9◦C and has noticed more purulent
secretions over the past 24 hours. DJ’s daughter, age 4, is recovering from a
“nagging” cough that lasted about 10 days. DJ states that a few other children
in her daughters day care center have had the same type of “bug”. She has no
known past medical history and no allergies. She has not needed medical care
for a couple of years.
 Her VS include T 39◦C, HR 100, RR 18, O2 sat 93% on RA. CXR: LLL infiltrate
c/w pneumonia. Her CURB-65 score is 0. She will be treated as an outpatient
for CAP.
Does DJ have any risk factors for DRSP? If so, which one(s)?
2. Which regimen(s) are acceptable choices for treatment of DJ’s CAP?
1.
Case 2

DJ is a 34 year old female who presents to her PCP’s office complaining of a mild sore
throat, a productive cough, and fevers for the past 3 days. She took her fever this
morning and said it was 38.9◦C and has noticed more purulent secretions over the past
24 hours. DJ’s daughter, age 4, is recovering from a “nagging” cough that lasted about 10
days. DJ states that a few other children in her daughters day care center have had the
same type of “bug”. She has no known past medical history and no allergies. She has not
needed medical care for a couple of years. Her VS include T 39◦C, HR 100, RR 18, O2 sat
93% on RA. CXR: LLL infiltrate c/w pneumonia. Her CURB-65 score is 0. She will be
treated as an outpatient for CAP.
Age <2 or >65
1.
Does DJ have any risk factors for DRSP?
If so, which one(s)?
β-lactams within past 3 months
Alcoholism
Medical comorbidities
Answer: Yes, DJ has a daughter in a day
care center
Immunosuppressive illness/therapy
Exposure to a child in a day care
center
Case 2

DJ is a 34 year old female who presents to her PCP’s office complaining of a mild sore
throat, a productive cough, and fevers for the past 3 days. She took her fever this
morning and said it was 38.9◦C and has noticed more purulent secretions over the past
24 hours. DJ’s daughter, age 4, is recovering from a “nagging” cough that lasted about 10
days. DJ states that a few other children in her daughters day care center have had the
same type of “bug”. She has no known past medical history and no allergies. She has not
needed medical care for a couple of years. Her VS include T 39◦C, HR 100, RR 18, O2 sat
93% on RA. CXR: LLL infiltrate c/w pneumonia. Her CURB-65 score is 0. She will be
treated as an outpatient for CAP.
2. Which regimen(s) are acceptable choices for treatment of DJ’s CAP
Outpatient
Presence of comorbid
conditions* OR use of
antimicrobials in past 3
months OR DRSP risk
β-lactam plus macrolide
(Level I evidence)
OR
Respiratory fluoroquinolone
(Level I evidence)
Case 2
β- lactam



+
Amoxicillin 1g PO TID
Amox/clav 2g PO BID
Macrolide
Azithromycin 500mg PO q24h
Doxycycline 100mg PO q12h
Ceftriaxone 2g IV daily
 Cefpodoxime 400mg PO BID
 Cefuroxime 500mg PO BID

 Respiratory fluoroquinolone
 Levofloxacin 750mg PO daily
 Moxifloxacin 400mg PO daily
Alternatives listed in black
Context: Clinical Practice
Community-acquired pneumonia
Outpatient
Which
antimicrobials
cover the
organisms
discussed?
Inpatient
Non-ICU
Intensive Care Unit (ICU)
β-lactam plus macrolide
β-lactam
(Level I evidence)
OR
PLUS (either)
Respiratory fluoroquinolone
(Level II evidence)
OR
(Level I evidence)
Macrolide
Respiratory
fluoroquinolone
(Level I evidence)
Clin Infect Dis 2007;44:S27-72
Empiric Inpatient Treatment
 Divided into 2 groups:
1.
Inpatient, non-ICU treatment
A β-lactam plus a macrolide OR
 Strong recommendation; level I evidence
 Preferred B-lactams: ampicillin/sulbactam, cefotaxime, ceftriaxone
 Alternative to macrolide: doxycycline
 A respiratory fluoroquinolone for penicillin-allergic patients
 Strong recommendation; level I evidence

2.
Inpatient, ICU-treatment
A β-lactam + azithromycin OR
 A β-lactam + a fluoroquinolone
 Preferred β -lactams: ampicillin/sulbactam, cefotaxime, ceftriaxone
 For PCN-allergic patients: fluoroquinolone PLUS aztreonam
 Strong recommendation; level I evidence

Other Inpatient Considerations
 For Pseudomonas aeruginosa infection:
 Anti-pseudomonal β-lactam


PLUS:


Piperacillin/tazobactam, cefepime, imipenem/cilastatin, or meropenem
Either ciprofloxacin or levofloxacin OR an aminoglycoside + azithromycin
OR an aminoglycoside + a respiratory fluoroquinolone
For penicillin-allergic patients, use aztreonam in place of the β-lactam

Moderate recommendation; level III evidence
Pseudomonas Risk Factors
Recent ICU stay
 For CA-MRSA:
 Add vancomycin or linezolid
Moderate recommendation;
level III evidence

Multiple admission to healthcare facilities in past 3 months
Multiple ABX courses in last 30 days
Bronchiectasis
Structural lung disease with chronic corticosteroid use within
last 3 months
Influenza
 Early treatment (ie. within 48h symptom onset) with
oseltamivir or zanamivir is recommended for
influenza type A

Strong recommendation; level I evidence
 Use of oseltamivir and zanamivir is not
recommended for patients with uncomplicated
influenza with symptoms >48h


However, these agents maybe used to reduce viral shedding in
hospitalized patients
Moderate recommendation; level III evidence
Time to First Antibiotic Dose
 For impatient therapy, the first antibiotic dose
should be administered in the emergency
department

Moderate recommendation; level III evidence
Areas of Focus
 Site of care decisions
 Diagnostic testing
 Antibiotic treatment
 Switch IV to PO
 Duration of antibiotic therapy
 Prevention
Switch From IV to Oral Therapy
 Patients should be switched when they are
hemodynamically stable AND improving clinically, can
ingest medications, and have a normally functioning GI
tract

Strong recommendation; level II evidence
 Patients should be discharged as soon as they are
clinically stable, have no other active medical problems
and have a safe environment for continued care

Moderate recommendation; level II evidence
 Inpatient care while receiving oral antibiotic therapy is
not necessary
Areas of Focus
 Site of care decisions
 Diagnostic testing
 Antibiotic treatment
 Switch IV to PO
 Duration of antibiotic therapy
 Prevention
Duration of therapy
 Before discontinuation of therapy:
1.
CAP should be treated for a minimum of 5 days
2. Patients should be afebrile for 48-72h
3. Have no more than 1 CAP-associated sign of clinical instability
1.
Moderate recommendation; level II evidence
 A longer duration may be needed if initial therapy was not active
against the identified pathogen or if it was complicated by an
extrapulmonary infection (ie. meningitis or endocarditis)

Weak recommendation; level III evidence
 Most CAP patients have been treated for 7-10 days
 Longer durations may be necessary for S. aureus and
Pseudomonas infections
Areas of Focus
 Site of care decisions
 Diagnostic testing
 Antibiotic treatment
 Switch IV to PO
 Duration of antibiotic therapy
 Prevention
Prevention
 All patients ≥50 years of age, other risk factors for influenza
complications, health care workers should receive inactivated
influenza vaccine yearly

Strong recommendation; level I evidence
 Pneumococcal polysaccharide vaccine is recommended for patients
≥65 years of age and for those with selected high-risk diseases

Strong recommendation; level II evidence
 Smoking cessation should be a goal for persons hospitalized with
CAP who smoke

Moderate recommendation; level III evidence
 Good respiratory and hand hygiene measures should be taken
 Strong recommendation; level III evidence
Case #3
Case 3 – Pre Class Case
 JB is a 67 YO white male who presents to the ED complaining of
SOB, coughing up yellow/green sputum for the past 2 or 3 days,
fevers, and decreased appetite. For the past 3 days he called off sick
to work and today he is feeling progressively weaker, so his wife
brought him into the hospital. He states that he had similar
symptoms a few weeks ago, so he took an antibiotic (could not
remember the name) which he got from his wife who had leftover
pills prescribed to her for a urinary tract infection. He took the
medication for about a week and did notice a slight improvement in
symptoms. He stopped taking the medication about a week ago and
his symptoms have since worsened.
 PMH: diabetes mellitus type II, hyperlipidemia, hypertension
 Home Medications: metformin 1000 mg PO BID, lisinopril 10 mg
PO qAM, simvastatin 40 mg PO qHS
Case 3

Allergies: ciprofloxacin (reaction: rash)

Social History: Retired but works part time as a vendor at a local stadium
Smokes ½ pack of cigarettes/day
Drinks alcohol socially
Physical Exam:

General: Overweight gentleman in mild respiratory distress

Ht/Wt: 6’1’’/223 lbs

VS: Temp 38.5oC, HR 115, RR 31, BP 132/85, O2 saturation on RA 88%

HEENT: NC/AT, PERRLA, EOMI. Normal/moist mucus membranes.

Neck: supple, no JVD, no thyromegaly or lymphadenopathy.

Lungs: slightly labored breathing with tachypnea. Diminished breath sounds and dullness to percussion in the left
middle and lower lobe. Right lung CTA

CV: RRR, no murmurs, rubs, or gallops

Abd: Soft and non-tender, normo-active bowel sounds

Neuro: A&O x 3, CN II-XII intact

Extrem: No CCE

Skin: warm, no rash




Pertinent Labs: WBC 18,000 cells/mm3, Cr 2.1 mg/dL, BUN 23 mg/dL, glucose 200 mg/dL
CXR: LLL infiltrate c/w pneumonia
Diagnosis: Community-acquired pneumonia
http://www.glowm.com/resources/glowm/graphics/figures/atlases/Chest/LLLPNEUMONIAPOSTSEGPA_250.jpg
Case 3
 Treatment: JB is going to be admitted to the hospital
(non-ICU). The primary team starts JB on azithromycin
250 mg daily for treatment of CAP.
1.
2.
3.
4.
5.
6.
Do you think it was appropriate for JB to be admitted to the
hospital for treatment of CAP? Why or why not?
Do you agree or disagree with the physician’s antibiotic choice? If
yes, why? If not, which antibiotic regimen would you have chosen
(including dose) and why?
Which pathogens are most likely the cause of JB’s CAP?
What is the recommended duration of treatment for CAP?
What parameters would you monitor for safety and efficacy of this
treatment?
What prevention strategies should be considered for this patient?
Case 3
1.
Do you think it was appropriate for JB to be admitted to
the hospital for treatment of CAP? Why or why not?
Table 1: Clinical Signs and Symptoms
C
Confusion
0
U
Uremia (BUN ≥ 20 mg/dl)
1
R
Respiratory rate ≥ 30 bpm
1
B
SBP < 90 mmHg or DBP ≤ 60 mmHg
0
65
Age ≥ 65
1
Table 2:
Total Score
0
1
2
3
4 or 5
30 day mortality (%) Risk Level
0.7%
2.1%
9.2%
14.5%
40% or 57%
Low
Low
Moderate
Moderate to High
High
Answer: Yes,
admission is
appropriate because
JB’s CURB-65 score
is 3.
Suggested Site-of-Care
Outpatient
Outpatient
Short inpatient / supervised
outpatient
Inpatient/ICU
ICU
Case 3
 Treatment: JB is going to be admitted to the hospital
(non-ICU). The primary team starts JB on azithromycin
250 mg daily for treatment of CAP.
2.Do you agree or disagree with the physician’s antibiotic
choice? If yes, why? If not, which antibiotic regimen would
you have chosen (including dose) and why?
β-lactam plus macrolide
Inpatient
Non-ICU patients
(Level I evidence)
OR
Respiratory fluoroquinolone
Answer: Disagree. JB should be given a βlactam (i.e. ceftriaxone) with the macrolide. He
cannot receive a FQ due to his allergy. The
dose of azithromycin should also be 500 mg.
(Level I evidence)
Case 3
 β- lactam
+
 Ceftriaxone 2gIV q24h
 Amp/sulbactam 3g IV q6h
 Cefotaxime 1g IV q8h

Macrolide
Azithromycin 500mg IV q24h
Doxycycline 100mg IV q12h
Ertapenem 1g IV q24h
 Respiratory fluoroquinolone
 Levofloxacin 750mg IV daily
 Moxifloxacin 400mg IV daily
Case 3
 3. Which pathogens are most likely the cause of JB’s
CAP?
Case 3
4. What is the recommended duration of treatment for
CAP?
Answer: Before discontinuation, he should be afebrile for 4872h, have no more than 1 CAP-associated sign of instability,
able to tolerate PO, and be treated for at least 5 days
Case 3
5.What should be monitored in JB to evaluate the
safety and efficacy of his treatment?
Drug
Side Effects
Ceftriaxone
Anaphylaxis, rash
Nausea/vomiting
Diarrhea (C. diff)
Liver function tests
Interstitial nephritis
Azithromycin
Nausea/vomiting/diarrhea
QTc prolongation
Efficacy
WBC trending down, temperature, improvement in dyspnea,
cough, normalizing VS (e.g., HR, BP, O2Sat%, temp.)
Case 3
6. What prevention strategies should be considered for
this patient?
 Influenza vaccine
 Pneumococcal vaccine
 Smoking cessation
 Respiratory hygiene measures
Case 4
Case 4
 RT is a 68 year old female who presents to your retail
pharmacy to fill her prescription.
 RT presented to an urgent care facility this morning
with a 2-day history of productive cough, fever,
malaise, and muscle aches. At the urgent care
facility, she was diagnosed with community-acquired
pneumonia and given the following prescriptions for
an outpatient course of antibiotics:


Azithromycin 500mg PO daily x7 days
Amoxicillin/clavulanate 2g PO BID x7days
Case 4
 PMH: hypertension and type 2 diabetes mellitus
 Home medications:
 Hydrochlorothiazide 25mg PO daily
 Ramipril 5mg PO daily
 Metformin 500mg PO daily
 Social history:
 Does not smoke
 Social drinker
 Up to date on vaccines- including annual influenza
 Allergies: penicillin
Case 4
 When you begin to process the patients prescription,
you notice that she has an allergy listed on her
profile to penicillins. You question the patient about
the reaction that occurred when she took a penicillin
in the past and she says “her throat swelled, but she
was in the hospital last year for a cellulitis infection
and was desensitized to penicillin during the
admission”
 Should you fill the prescription…
Case 4
 You should NOT fill the prescription and contact the
physician to recommend an alternative agent to treat her
CAP  fluoroquinolone
 Desensitization should be performed by an allergy
specialist in a supervised outpatient setting or in the
intensive care unit (ICU) of a hospital
 Desensitization is temporary

Once the antibiotic is stopped for ~24 hours the person is again at
risk for sudden allergic reaction and desensitization should be
repeated if the same medication is required
Questions?
Email: [email protected]