Pneumonia mksap 18

1. Pneumonia MKSAP 18
THROWN TOGETHER AT THE LAST MINUTE BY DAVID LISKEY

2. Question 4
A 44 year old man is evaluated in the ED in January for 3 days of dyspnea, cough, and fever. History is
unremarkable, he takes no meds. On exam, T 38.5, BP 118/80, P 113, RR 33. O2 89% on 6L nasal cannula. He
appears uncomfortable and is oriented only to person. Breath sounds are bilaterally decreased with crackles. No
rash is noted.
Labs: WBC 19, Plt 274, BUN 36, Cr 1.45
Sputum gram stain shows 2+ PMN, 1+ epithelial cells. No organisms. Resp viral panel is RSV +. CXR shows
multilobular infiltrates.
The patient will be transferred to the ICU.
Which of the following is the most appropriate treatment?
A. Azithromycin
B. Ceftazidime + azithromycin
C. Ceftriaxone + levofloxacin
D. Piperacillin-tazobactam + ciprofloxacin

3. Answer 4
C. Ceftriaxone + levofloxacin
This patient presents with severe CAP, with
respiratory failure, uremia, AMS, and
multilobular infiltrates. IDSA guidelines
recommend that patients with at least 3 minor
criteria for severe disease should be managed
in the ICU. Guidelines recommend empiric
coverage for CAP requiring ICU level of care
including:
- A 3rd generation cephalosporin or ampicillin-
sulbactam to treat Streptococcus pneumoniae,
gram-negative bacilli, or Haemophilus influenza
- A macrolide or quinolone to cover Legionella

4. Answer 4
The other answers:
A. Azithromycin monotherapy would be appropriate for uncomplicated outpatient management
of CAP in an otherwise healthy patient.
B. Ceftazidime provides coverage for Pseudomonas but not gram-positives such as S.
pneumoniae.
D. Piperacillin-tazobactam + levofloxacin would be appropriate for double coverage of
Pseudomonal pneumonia. In this previously healthy patient without many medical contacts,
Pseudomonas is not very likely.

5. Question 18
A 45 year old man is evaluated for a 3 day history of fever, myalgia, headache, and nonproductive
cough. He works as a large animal veterinarian. Medical history is unremarkable and he takes no
medications.
On exam, T 38.2, O2 94% on room air. Exam is otherwise unremarkable.
A CXR shows patchy right lower lobe interstitial infiltrate.
Which of the following is the most likely cause of his illness?
A. Bacillus anthracis
B. Coxiella burnetii
C. Chlamydia psittaci
D. Francisella tularensis
E. Yersinia pestis

6. Answer 18
B. Coxiella burnetii
This patient presents with CAP not requiring hospitalization, which is most commonly cause by
atypical organisisms, S. pneumoniae, or a virus. His occupation puts him at risk for zoonotic
pneumonia. C. burnetii is the most likely caused based on the severity of his symptoms.
Q fever is most commonly associated with exposure to farm animals so farmers, vets, and
abattoirs are at increased risk.
Treatment with _________ is indicated to reduce symptoms and prevent progression to chronic
Q fever.

7. Answer 18
B. Coxiella burnetii
This patient presents with CAP not requiring hospitalization, which is most commonly cause by
atypical organisisms, S. pneumoniae, or a virus. His occupation puts him at risk for zoonotic
pneumonia. C. burnetii is the most likely caused based on the severity of his symptoms.
Q fever is most commonly associated with exposure to farm animals so farmers, vets, and
abattoirs are at increased risk.
Treatment with doxycycline is indicated to reduce symptoms and prevent progression to chronic
Q fever.

8. Question 26
Which of the following is the most
appropriate management at this
time?
A. Add methylprednisolone
B. Add piperacillin-tazobactam
C. Perform thoracentesis
D. Procalcitonin measurement
E. Switch to daptomycin
A 45 year old man is evaluated in the ICU for continued daily fevers. He
was hospitalized 6 days ago after 4 days of L sided pleuritic chest pain,
fever, and cough productive of yellow sputum with occasional blood
streaks. He has a history of IVDU with heroin used 7 days ago. CXR at
admission showed a LLL infiltrate. Sputum Gram stain showed GPC in
clusters. Empiric antibiotic therapy including vancomycin was started.
Sputum and 2 sets of blood cultures at admission grew MRSA and
antibiotics were deescalated to vancomycin monotherapy on hospital
day 3.
On exam, T 38.5, BP 94/68, P 118, RR 28. O2 92% on 6L O2. Decreased
breath sounds at the left base.
A vancomycin trough is therapeutic at 15 ug/mL. Repeat blood cultures
from hospital day 3 were negative. Repeat sputum Gram stain shows 3+
leukocytes and 1+ GPC. A TTE is negative for valvular vegetations. A
repeat CXR shows a L pleural effusion.

9. Answer 26
C. Perform thoracentesis
This patient has nonresponsive pneumonia demonstrated by continued fevers at hospital day 3
despite appropriate antibiotic therapy. This patient’s CXR showing a pleural effusion is consistent
with a parapneumonic effusion. To determine the need for drainage of this effusion, a
thoracentesis must be performed. Findings consistent with empyema include purulent or foul-
smelling fluid, positive fluid Gram stain, fluid pH < 7.2 or glucose level < 60. Chest tube
placement is required to treat an empyema.

10. Answer 26
The other answers:
A. The role of steroids in CAP is controversial. They may be beneficial early in the course but the
evidence is not clear on this and generally steroids are not used for CAP.
B. Adding Zosyn would be beneficial if there was evidence of a secondary infection, but the
blood and sputum cultures show no new organisms.
D. There is no doubt this patient has a bacterial infection, so checking procalcitonin would be of
little benefit at this time.
E. Daptomycin is not effective for pulmonary infections because it binds to surfactant,
preventing therapeutic levels from being reached in alveoli.

11. Question 73
An 82 year old man is admitted to the ICU with a 7 day history of fever and cough productive of green sputum. He
is unable to climb the stairs to his bedroom without becoming short of breath. Medical history is remarkable for
bronchiectasis and polymyalgia rheumatica. His only medication is prednisone 10 mg/day.
On exam, T 38.8, BP normal, P 115, RR 25. O2 88% on room air. Crackles are in the right lung base.
A sputum Gram stain shows 3+ PMN and 2+ gram-negative organisms.
A CXR shows a RLL consolidation.
Which of the following is the most appropriate treatment?
A. Ampicillin-sulbactam and levofloxacin
B. Aztreonam and ciprofloxacin
C. Cefepime and ciprofloxacin
D. Ceftriaxone and azithromycin
E. Ceftriaxone and levofloxacin

12. Answer 73
C. Cefepime and ciprofloxacin
This patient is at risk for Psuedomonas infection given his history of structural lung disease and
chronic steroid use. The presence of gram-negative bacilli on sputum is consistent with Pseudomonas.
Pseudomonas should be treated with 2 anti-Pseudomonal agents. Of the options listed, only cefepime
and ciprofloxacin both have activity against Pseudomonas.
Appropriate antibiotics include:
Cefepime or ceftazadime
Piperacillin-tazobactam
Imipenem or meropenem
Ciprofloxacin or levofloxacin
Aztreonam

13. Answer 73
The other answers:
A. Levofloxacin provides Pseudomonal coverage but single-agent coverage is not appropriate.
B. Aztreonam and ciprofloxacin both provide Pseudomonal coverage but do not provide
coverage against other common causes of CAP including S. pneumoniae.
D. Neither ceftriaxone or azithromycin are effective against Pseudomonas.
E. Levofloxacin provides Pseudomonal coverage but single-agent coverage is not appropriate.

14. Flashback to July…

15. Question 89
A 42 year old man is admitted to the ICU for nonresponsive pneumonia with a 7 day history of shortness of breath and
cough. He was diagnosed with pneumonia and prescribed levofloxacin 3 days ago and has been adherent to his
medication however, his shortness of breath has worsened to the point he is unable to climb one flight of stairs. Medical
history is remarkable for hospitalization 5 years ago with alcohol withdrawal and delirium tremens. He drinks a 6-pack of
beer on weekdays and a case of beer on weekends. His only medication is levofloxacin.
On exam, T 38.7, BP normal, P 122, RR 24, O2 89% on room air. He is in mild respiratory distress and he has decreased
breath sounds at the right lung base.
WBC 18.7, Cr 2.3. CXR shows a RLL infiltrate. Levofloxacin is discontinued.
Which of the following is the most appropriate antibiotic treatment?
A. Azithromycin + ceftriaxone
B. Clindamycin
C. Metronidazole
D. Piperacillin-tazobactam
E. Piperacillin-tazobactam + azithromycin

16. Answer 89
E. Piperacillin-tazobactam + azithromycin
This patient requires ICU admission for progressive, severe CAP after failure of levofloxacin.
This patient’s history is concerning for aspiration pneumonia, as is the location of his infiltrate.
In community-dwelling patients with aspiration pneumonia, the most common bacteria are
anaerobic bacteria but Enterobacteriaceae may also be present. Therefore, coverage for both
anaerobic bacteria and gram-negatives is indicated so piperacillin-tazobactam is an appropriate
choice.
Azithromycin should still be used to cover atypical bacteria.