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EMGuideWire's Radiology Reading Room: Pneumonia

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EMGuideWire's Radiology Reading Room: Pneumonia

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The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pneumonia and is brought to you by Elissabeth Hagler, MD and Tom Shuman, MD. Guest Editor is Michael Leonard, MD, Infectious Disease specialist.

The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pneumonia and is brought to you by Elissabeth Hagler, MD and Tom Shuman, MD. Guest Editor is Michael Leonard, MD, Infectious Disease specialist.

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EMGuideWire's Radiology Reading Room: Pneumonia

  1. 1. Pneumonia Case Studies Tom Shuman, MD & Elissabeth Hagler, MD Departments of Internal Medicine & Emergency Medicine Carolinas Medical Center Atrium Health Michael Gibbs, MD Emergency Medicine Lead Editor Michael Leonard, MD Infectious Disease Guest Editor
  2. 2. Disclosures  This ongoing chest X-ray interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center.  The goal is to promote widespread mastery of CXR interpretation.  There is no personal health information [PHI] within, and ages have been changed to protect patient confidentiality.
  3. 3. Process • Many are providing clinical cases and presentations are then shared with all contributors on our departmental educational website. • Contributors from many Carolinas Medical Center departments, and now… Brazil, Chile, and Tanzania. • We will review a series of CXR case studies and discuss an approach to the diagnoses at hand: PNEUMONIA.
  4. 4. Typical vs. Atypial Community Acquired Pneumonia Typical • Often lobar infiltrate • Classically presents with abrupt onset fever, pleuritic chest pain, productive cough • Common pathogens: Streptococcus pneumoniae (#1 cause), Haemophilus influenzae, Moraxella catarrhalis Atypical • Often patchy, diffuse interstitial infiltrates • Often more gradual presentation with non- productive cough, along with extra-pulmonary symptoms • Common pathogens: Mycoplasma pneumonia, Chlamydophila pneumonia, Legionella, and respiratory viruses
  5. 5. Before We Review Lobar Pneumonias, Let’s Review Lung Anatomy wikiradiography.netanatomynote.com
  6. 6. Before We Review Lobar Pneumonias, Let’s Review Lung Anatomy wikiradiography.net anatomynote.com
  7. 7. 43-Year-Old Presents To An Outpatient Clinic After A Syncopal Episode He Has Normal Labs, A Normal ECG And This Chest X-Ray He Is Sent Home
  8. 8. Subtle pneumonias can be easy to miss (especially with overlapping structures nearby). Make sure you are comparing each lung field with the other side. 43-Year-Old Seen Four Days Ago In The Outpatient Clinic Let’s Take Another Look At The First CXR…
  9. 9. Right Upper Lobe Pneumonia 43 Year Old Seen In The Outpatient Clinic Four Days Later He Now Presents To The ED With Cough, Fever & Rigors
  10. 10. 68-Year-Old Diabetic With Cough And Fever
  11. 11. 68-Year-Old Diabetic With Cough And Fever Right-Sided Infiltrates – Primarily RUL
  12. 12. Right-Sided Infiltrates – Primarily RUL Right Upper Lobe Pneumonias appear above the horizontal fissure. 68 -Year-Old Diabetic With Cough And Fever
  13. 13. Prior CXR Now 54-Year-Old With COPD & Diabetes Fever, Hypoxia, Altered Mental Status RUL Pneumonia
  14. 14. RUL Infiltrate
  15. 15. RML Pneumonia:  Blurred right heart border  Lateral diaphragm clear  Often seen best on the lateral
  16. 16. 73-Year-Old With Fever, Cough And Confusion Right Middle Lobe Pneumonia
  17. 17. RML Infiltrate
  18. 18. 69-Year-Old Fever And Right Upper Quadrant Abdominal Pain & No Pulmonary Symptoms
  19. 19. RLL Pneumonia 69-Year-Old Fever And Right Upper Quadrant Abdominal Pain & No Pulmonary Symptoms
  20. 20. Healthy 27-YearOld Male With Severe Right Pleuritic Chest Pain And Cough Chest X-Ray Read As “Negative” By The Radiologist. But It Is Not Normal To See Lung Markings Abutting The Diaphragm.
  21. 21. Right Lower Lobe Pneumonia Healthy 27 Year Old Male With Severe Right Pleuritic Chest Pain And Cough
  22. 22. RLL Pneumonia – The Lateral Views Helps Differentiate From RML Involvement
  23. 23. RLL Infiltrate
  24. 24. RLL Infiltrate – Superior Segment
  25. 25. 51-Year-Old With Cough, Rigors, Chills
  26. 26. 51 Year Old With Cough, Rigors, Chills Lingular Pneumonia
  27. 27. 51-Year-Old With Cough, Rigors, Chills
  28. 28. 51 Year Old With Cough, Rigors, Chills Lingular Pneumonia  Wedge Shaped  Seen Best On Lateral
  29. 29. Lingular Pneumonia
  30. 30. LLL Infiltrate
  31. 31. LLL Infiltrate
  32. 32. 55-Year-Old With Fever And Dyspnea Single AP View Portable CXR Obtained At The Bedside Sent For A Chest CT After This CXR Was Taken
  33. 33. 55-Year-Old With Fever And Dyspnea Retrocardiac LLL Pneumonia
  34. 34. 55-Year-Old With Fever And Dyspnea Let’s Take Another Look At The CXR! The Left Hemidiaphragm Is Indistinct
  35. 35. 40-Year-Old With Fever And Dyspnea Single AP View Portable CXR Obtained At The Bedside Sent For A Chest CT After This CXR Was Taken
  36. 36. 40-Year-Old With Fever And Dyspnea Retrocardiac LLL Pneumonia
  37. 37. 40-Year-Old With Fever And Dyspnea Let’s Take Another Look At The CXR! The Left Hemidiaphragm Is Indistinct
  38. 38.  In patients who are sick [i.e.: challenging for them to travel to Radiology] – we may start with a single-view AP chest X-ray.  In the last two cases the “next step” was a CT scan of the chest.  Another option would have been to obtain a higher quality two-view study that would have provided the benefit of the lateral projection.
  39. 39. CMC/LCH Technical Charges – March 2020 1 view chest X-ray $296 2 view chest X-ray $369 CT chest with contrast $2,628 CT chest with contrast - angiogram $3,398
  40. 40. 51-Year-Old-With Cough & Fever.
  41. 41. 51-Year-Old With Cough & Fever. The Lateral View can be useful in identifying retrosternal and retrocardiac disease. Retrocardiac LLL Pneumonia On The Lateral View
  42. 42. 5-Year-Old With Fever, Cough And Tachypnea
  43. 43. 5-Year-Old With Fever, Cough And Tachypnea RUL Collapse + RLL Necrotizing Pneumonia
  44. 44. 5-Year-Old With Fever, Cough And Tachypnea RUL Collapse + RLL Necrotizing Pneumonia
  45. 45. Healthy 5-Year-Old Treated With Tamiflu For Flu Symptoms, Admitted With Pneumonia
  46. 46. HD #1: LLL Pneumonia Healthy 5-Year-Old Treated With Tamiflu For Flu Symptoms, Admitted With Pneumonia
  47. 47. HD #4: LLL Pneumonia + Effusion Chest Tube Healthy 5-Year-Old Admitted With Pneumonia
  48. 48. HD #14: After Video Assisted Thoracoscopic Surgery [VATS] One Liter Of Pus Removed Pneumohydrothorax With Mediastinal Shift Pneumohydrothorax– concurrent pneumothorax and pleural effusion Healthy 5-Year-Old Admitted With Pneumonia
  49. 49. Air-Fluid Level: If It’s Flat There’s Air In There!
  50. 50. Healthy 5 Year Old Admitted With Pneumonia HD #14: Pneumohydrothorax And Severe Pulmonary Necrosis/Trapped Lung (*) Discharged The Following Day On IV Antibiotics With Planned Follow-Up *
  51. 51. 68-Year-Old Diabetic With Cough And Fever
  52. 52. 68-Year-Old Diabetic With Cough And Fever Right-Sided Infiltrates – Primarily RUL
  53. 53. 68-Year-Old Diabetic With Cough And Fever Right-Sided Infiltrates – Primarily RUL
  54. 54. Patient With A History of ESRD Presents With Fever And Cough
  55. 55. Patient With A History of ESRD Presents With Fever And Cough Patchy Multifocal Pneumonia
  56. 56. Healthy 20-Year- Old Male Seen At His PCP’s Office Where This Chest X-Ray Was Obtained.
  57. 57. Healthy 20-Year- Old Male Seen At His PCP’s Office Where This Chest X-Ray Was Obtained: Diagnosed With RLL Pneumonia. Rx: Ceftriaxone + A Prescription For Amoxicillin/Clavulanate
  58. 58. The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia.
  59. 59. The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia. Worsening Pneumonia Despite Therapy.
  60. 60. ED Rx: Azithromycin + Ceftriaxone & Admitted. The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia.
  61. 61. Serology [+] For Mycoplasma.
  62. 62. The Patient Was Initially Treated With Ceftriaxone In The Office And Prescribed Amoxicillin-Clavulanate. Is This An Appropriate Strategy For The Outpatient Management of Community Acquired Pneumonia?
  63. 63. The Patient Was Initially Treated With Ceftriaxone In The Office And Prescribed Amoxicillin-Clavulanate. Is This An Appropriate Strategy For The Outpatient Management of Community Acquired Pneumonia? According To The Most Recent IDSA/ATS Guidelines: The Answer is Yes.
  64. 64. This Represents A Change From The 2007 IDSA/ATS Guidelines.
  65. 65. “In a departure from the prior CAP guidelines, the panel did not give a strong recommendation for routine use of a macrolide antibiotic as monotherapy for outpatient community acquired pneumonia. This was based on studies of macrolide failures in patients with macrolide-resistant S. pneumonia1,2, in combination with a macrolide resistance rate of >30% among S. pneumonia isolates in the United States, of which is high-level resistance3.” 1Lonks JR. Clin Infect Dis 2002;35:556-564. 2Daneman N. Clin Infect Dis 2006; 43:432-438. 3CDC. Active Bacteria Core Surveillance (ABCs) Report - 2015. Report Accessed 2019. PUNCH LINE?  Pneumococcal resistance makes macrolide monotherapy risky.  Know your local resistance patterns.  Choose double therapy if atypical pneumonia is a possibility.
  66. 66. Diffuse Airspace Opacities. 45-Year-Old Presents With One Week Of Dyspnea and Night Sweats. The Patient Has Recently Been Diagnosed With HIV.
  67. 67. 45-Year-Old Presents With One Week Of Dyspnea and Night Sweats. The Patient Has Recently Been Diagnosed With HIV. Pneumocystis Jiroveci Pneumonia.
  68. 68. 25-Year-Old With Recently Diagnosed HIV and PCP Pneumonia Diffuse Infiltrates Consistent With PCP Pneumonia But What Is This?
  69. 69. 25-Year-Old With Recently Diagnosed HIV and PCP Pneumonia Diffuse Infiltrates Consistent With PCP Pneumonia Large Pneumatocele
  70. 70. 25-Year-Old With Recently Diagnosed HIV and PCP Pneumonia Large Pneumatocele Next Day: Pneumatocele Rupture And Pneumothorax
  71. 71. 25-Year-Old With Recently Diagnosed HIV and PCP Pneumonia Large Pneumatocele Percutaneous Chest Tube
  72. 72. Treatment Of Pneumocystis Pneumonia Trimethoprim-sulfamethoxazole First Choice Primaquine + clindamycin Alternative Atovaquone suspension Alternative Pentamidine1 Alternative Patients with suspected or documented PCP and moderate to severe disease, defined by a room air PO2 <70 mmHg should receive adjunctive corticosteroids as soon as possible and certainly within 72 hours after starting specific PCP therapy. 1IV route only; aerosolized pentamidine should not be used.
  73. 73. Clinical, Diagnostic, and Treatment Disparities between HIV-Infected and Non-HIV-Infected Immunocompromised Patientswith Pneumocystis jirovecii Pneumonia Helmut J.F. Salzera, b Guido Schäferc, d Martin Hoenigle, f Gunar Günthera, g Christian Hoffmannh,i Barbara Kalsdorfa, b Alexandre Alanioj–l Christoph Langea, b, m,n aDivision of Clinical InfectiousDiseases,Research Center Borstel,LeibnizLung Center,Borstel, Germany; bGerman Center for Infection Research,Clinical TuberculosisCenter,Borstel,Germany; cInfectiousDiseasesClinic, University Medical Center Hamburg-Eppendorf,Hamburg,Germany; dSection of Rheumatology,3rd Department of Internal Medicine,University Medical Center Hamburg-Eppendorf,Hamburg,Germany; eDivision of Infectious Diseases,University of Californiaat San Diego,San Diego,CA,USA; fSection of InfectiousDiseasesand Tropical Medicine and Division of Pulmonology,Medical University of Graz,Graz,Austria; gDepartment of Internal Medicine, School of Medicine,University of Namibia,Windhoek,Namibia; hInfektionsmedizinischesCentrum Hamburg (ICH) Study Center,Hamburg,Germany; iDepartment of Medicine II,University Hospital of Schleswig-Holstein, CampusKiel,Kiel,Germany; jParasitology-Mycology Laboratory, Lariboisière Saint-LouisFernand Widal Hospitals, Assistance Publique-Hôpitaux de Paris,Paris,France; kParis-Diderot,Sorbonne ParisCité University,Paris,France; lInstitut Pasteur,Molecular Mycology Unit,CNRSCMR2000,Paris,France; mInternational Health/InfectiousDiseases, University of Lübeck,Lübeck,Germany; nDepartment of Medicine,KarolinskaInstitutet,Stockholm,Sweden Accepted:February 13,2018 Published online:April 10,2018 DOI:10.1159/000487713 Clinical, Diagnostic, and Treatment Disparitie between HIV-Infected and Non-HIV-Infected Immunocompromised Patientswith Pneumo jirovecii Pneumonia Helmut J.F.Salzera,b Guido Schäferc,d Martin Hoenigle,f Gunar Günthera,g Christian Hoffmannh,i Barbara Kalsdorfa,b Alexandre Alanioj–l Christoph Langea,b,m,n a Division of Clinical InfectiousDiseases,Research Center Borstel,LeibnizLung Center,Borstel,Germany b German Center for Infection Research,Clinical TuberculosisCenter,Borstel,Germany; c InfectiousDisea University Medical Center Hamburg-Eppendorf,Hamburg,Germany; d Section of Rheumatology,3rd De of Internal Medicine,University Medical Center Hamburg-Eppendorf,Hamburg,Germany; e Division of I Diseases,University of Californiaat San Diego,San Diego,CA,USA; f Section of InfectiousDiseasesand T Medicineand Division of Pulmonology,Medical University of Graz,Graz,Austria; g Department of Intern School of Medicine,University of Namibia,Windhoek,Namibia; h InfektionsmedizinischesCentrum Ham i Respiration Clinical, Diagnostic, and Treatment Disparities between HIV-Infected and Non-HIV-Infected Immunocompromised Patientswith Pneumocystis jirovecii Pneumonia Helmut J.F. Salzera,b Guido Schäferc,d Martin Hoenigle,f Gunar Günthera,g Christian Hoffmannh,i Barbara Kalsdorfa,b Alexandre Alanioj–l Christoph Langea, b,m,n a Division of Clinical InfectiousDiseases,Research Center Borstel,LeibnizLung Center,Borstel,Germany; b German Center for Infection Research,Clinical TuberculosisCenter,Borstel,Germany; c InfectiousDiseasesClinic, University Medical Center Hamburg-Eppendorf,Hamburg,Germany; d Section of Rheumatology,3rd Department of Internal Medicine,University Medical Center Hamburg-Eppendorf,Hamburg,Germany; e Division of Infectious Received:February 13,2018 Accepted:February 13,2018 Published online:April 10,2018 DOI:10.1159/000487713 Review Respiration Received:February 13,2018 Accepted:February 13,2018 Published online:April 10,2018 DOI:10.1159/000487713
  74. 74. 2003; 126:859-861. • Thin walled parenchymal cysts • More common in children than in adults Causes: • Blunt chest trauma • COPD and other bullous/cystic lung diseases • Severe pneumonia [aspiration, anaerobic, TB, Pneumocystis…] • Mechanical ventilator barotrauma Complications: • Infection • Rupture and pneumothorax • Rapid expansion and tension pneumatocele
  75. 75. Cavitary TB Patient may present with chronic productive cough, anorexia, weight loss, fever, night sweats, and hemoptysis. Miliary TB
  76. 76. 65-Year-Old Diabetic With Fever, Cough, Pleuritic Chest Pain.
  77. 77. 57-Year-Old Renal Transplant Patient Presents With Two Weeks Of Cough. What do you notice?
  78. 78. 57-Year-Old Renal Transplant Patient Presents With Two Weeks Of Cough. Multifocal Infiltrates
  79. 79. 57-Year-Old Renal Transplant Patient Presents With Two Weeks Of Cough. Multifocal Infiltrates: What opportunistic infection should you consider?
  80. 80. 57-Year-Old Renal Transplant Patient Presents With Two Weeks Of Cough. Diagnosis: Cryptococcal Pneumonia
  81. 81. Cryptococcosis • Cryptococcosis is a major opportunistic pathogen worldwide. • In developed countries the widespread use of HAART for patients with HIV has lowered the incidence of cryptococcosis dramatically. • In developing countries with persistently uncontrolled HIV and limited access to HAART therapy, the incidence of cryptococcosis, and its associated mortality remain extremely high.
  82. 82. Cryptococcosis In developed countries cryptococcosis in largely seen in patients: • With newly diagnosed HIV • Receiving immunosuppressants following organ transplantation • Taking high-dose corticosteroids • On certain monoclonal antibody therapies, e.g.: • Infliximab (Remicade®) for rheumatologic conditions • Alemtuzumab (Lemtrada®) for chronic lymphocytic leukemia
  83. 83. Cryptococcosis Punch Line For The Acute Care Clinician?
  84. 84. Cryptococcosis Punch Line For The Acute Care Clinician? THINK ABOUT IT In The At-Risk Patient!
  85. 85. Treatment for Cryptococcosis
  86. 86. RLL Pulmonary Infarct Not All Infiltrates Are Pneumonia!
  87. 87. 60-Year-Old With Right Sided Pleuritic Chest Pain Chest CT [+] For PE: RLL Pulmonary Infarct
  88. 88. A Complete Summary Of The 2019 IDSA/ATS Guidelines For The Management of Community Acquired Pneumonia Are Discussed Next In The Appendix.
  89. 89. APPENDIX
  90. 90. Question #1: In adults with CAP, should gram stain and cultures of lower respiratory secretions be obtained at the time of diagnosis?  Recommend not obtaining sputum Gram stain and cultures routinely in adults with CAP managed in the outpatient setting.  Recommend obtaining Gram stain and cultures in adults with CAP who: (1) have severe CAP* [especially if intubated], or (2) are being treated empirically for MRSA or P. aeruginosa. *See next slide for IDSA/ATS definition of “severe community-acquired pneumonia.”
  91. 91. Question #2: In adults with CAP, should blood cultures be obtained at the time of diagnosis?  Recommend not obtaining blood cultures in adults with CAP managed in the outpatient setting.  Recommend obtaining blood cultures in adults with CAP managed in the hospital who: (1) are classified as severe CAP, (2) are being treated empirically for MRSA or P. aeruginosa, (3) were previously infected with MRSA or P. aeruginosa, (4) were hospitalized and received parenteral antibiotics in the last 90 days.
  92. 92. Question #3: In adults with CAP, should Legionella and Pneumococcal urinary antigen testing be performed at the time of diagnosis? Recommend not routinely testing adults with CAP, except in: (1) patients with severe CAP, and/or (2) in cases where this is indicated by epidemiological factors such as exposure to a Legionella outbreak, or recent travel.
  93. 93. Questions #4, #5, #6: In adults with CAP:  Should a respiratory sample be tested for Influenza virus at the time of diagnosis?  Should influenza treatment be initiated for adults with a [+] test?  Should influenza [+] adults being treated with an antiviral also be treated with an antibacterial regimen?  When influenza is circulating in the community, a rapid influenza molecular assay is recommended.  For [+] tests, treatment with oseltamivir is recommended.  For [+] tests, standard antibacterial treatment is recommended.
  94. 94. Question #7: In adults with CAP, should serum procalcitonin plus clinical judgment versus clinical judgment alone be used to withhold initiation of antibiotic treatment? Recommend that empiric antibiotic therapy should be initiated in adults with clinically suspected and radiographically confirmed CAP regardless of initial serum procalcitonin level.
  95. 95. Question #8, 9: Should a clinical prediction rule for prognosis plus clinical judgment versus clinical judgment alone be used to determine: (1) inpatient versus outpatient treatment location for adults with CAP, and (2) the best site of treatment [floor vs. Step-Down vs. ICU]?  In addition to clinical judgement clinicians should use a validated clinical prediction rule for prognosis, preferentially the Pneumonia Severity Index (PSI).  When compared with CURB-65, PSI identifies larger proportions of patients as low risk, and has a higher discriminative power in predicting mortality.  Compared with PSI, there is less evidence that CURB-65 is effective as a decision aid in guiding the initial site of treatment.
  96. 96. Question #10: In the outpatient setting, which antibiotics are recommended for empiric treatment of CAP in adults? For healthy outpatient adults: (1) amoxicillin 1 g TID, or (2) doxycycline 100 mg BID, or (3) azithromycin 500 mg on first day then 250 mg daily, or (4) clarithromycin 500 BID. For outpatient adults with comorbidities (heart failure, liver or renal disease, diabetes, alcoholism, malignancy or asplenia):  Amoxicillin/clavulanate 500mg/125 mg TID, or a cephalosporin, AND a macrolide (azithromycin, clarithromycin, or  Monotherapy with a respiratory fluoroquinolone: levofloxacin 750 mg QD, or moxifloxacin 400 mg QD, or gemifloxacin 320 mg QD.
  97. 97. Question #11: In the inpatient setting, which antibiotics are recommended for empiric treatment of CAP in adults without risk factors for MRSA and P. aeruginosa? In inpatients with non-severe CAP:  A 𝛽-lactam + a macrolide, or  Monotherapy with a respiratory fluoroquinolone, or  A 𝛽-lactam + doxycycline [if macrolides & fluoroquinolones are not tolerated] In patients with severe CAP:  A 𝛽-lactam + a macrolide, or  A 𝛽-lactam + a respiratory fluoroquinolone
  98. 98. Question #12: In the inpatient setting, should patients with suspected aspiration pneumonia receive additional anaerobic coverage beyond standard empiric treatment? Recommend not routinely adding anaerobic coverage for suspected aspiration pneumonia unless lung abscess or empyema is suspected.
  99. 99. Question #13: In the inpatient setting, should adults with CAP and risk factors for MRSA or P. aeruginosa be treated with extended-spectrum antibiotic therapy instead of standard CAP regimens? Recommend that clinicians only cover empirically for MRSA or P. aeruginosa in adults with CAP if locally validated risk factors for either pathogen are present. MRSA Vancomycin (15 mg/kg), or linezolid (600 mg BID) P. aeruginosa Piperacillin-tazobactam (4.5 grams Qº6), or cefepime (2 grams Qº8), or aztreonam (2 grams Qº8), or imipenem 500 mg Qº6)
  100. 100. Question #14: In outpatient and inpatient adults with CAP who are improving, what is the appropriate duration of antibiotic therapy? Recommend that the duration of antibiotic therapy should be guided by a validated measure of clinical stability (resolution of vital sign abnormalities, ability to eat, and normal mentation), and antibiotic therapy should be continued until the patient achieves stability for no less than 5 days.
  101. 101. Question #15: In the inpatient setting, should adults with CAP be treated with corticosteroids?  Recommend not routinely using corticosteroids in adults with non-severe CAP.  Recommend not routinely using corticosteroids in adults with severe CAP.  Recommend not routinely using corticosteroids in adults with severe influenza CAP.  Endorse the Surviving Sepsis Campaign recommendations on the use of corticosteroids in patients with CAP and refractory septic shock.

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