9 Relem. [Patient loformation Leaflet) Research Triangle Pat, NC: {GaxasmithKlin, NC; 2007 10, HuMist [Package losers] Gaithersburg, MD: Medimmune Vaccines, Inc; 207, COMMUNITY-ACQUIRED PNEUMONIA Fever with a Cough Trent G. Toune, Pham Sharon M. Erdman, PharmD Level i LEARNING OBJECTIVES ‘ter completing this case study, the reader should be able to ‘+ Recognize the typical signs, symptoms, physical examination, ‘and laboratory/tadiogrephic findings in a patient with commu. rity-acquited preumenia (CAP), ++ Descibe the most common causative pathogens of CAP, in- ‘duding ther frequency of occurrence and susceptibility 10 ‘commonly used antimicrobials. ‘+ Discuss the risk stratification strategies that can be employed: to determine whether a patient with CAP should be treated as ‘an inpatient or outpatient. ‘+ Provide recommendations for inal empitic antibiotic therapy fran inpatient or outpatient with CAP based on cinical presen- tation, age, presence of comorbidities, and presence of alrges. ++ Define the goals of antimicbial therapy for a patent with CAP, in ‘ducing mantoang parameters that should be used to assess the response to therapy as well as the occurrence of adverse effects ‘+ Descibe the clinical parameters that should be considered when changing a patient from IV to oral antimicrobial therapy in the weatment of CAP. (eNO) 1 Chief Complaint ‘have been short of breath and have been coughing up brown smucus fr the past 3 days.” me, James Thompson is a 55-year-old man with a 3-day history of worsening shortness of breath, subjective fevers, chill, right-sided chest pain, and a productive cough. The patient states that his initial symptom of shortness of breath began approximately 1 week ago afer delivering mail onan extremely cold winter day. After several days of not feling well, he went to an immediate cate clinic and received a prescription for levofloxacin 750 mg po for 5 days, which he never fled de to financial reasons, He has been taking ace minophen and an over-the-counter cough and cold preparation, but feels that hie symptoms are getting “much worse.” The patent began experiencing pleuritic chest pain and a productive cough over the past 3 days, and feels that he has been feverish with chil, although he didnot take his temperature. Upon presentation to the ED, hes febrile and appears to be visibly short of breath mPa HIN 15 years COPD % 10 years msi Lives with wife and four children Employed asa mail carrier forthe U.S. Postal Service Smokes 2 ppd for the past 30 years Denies alcohol use or IV drug use mMeds Patient states that he has only been sporadically taking his medica tions due to financial sss, Lisinopril 10 mg po once daily Hydrochlorothiazide 12.5 mg po once daily Ipratropium/albuterol MDI two inhalations four times dally Albuterol MDI twa inhalation PRN shortness of breath Acetaminophen 650 mg po Q 6 h PRN pain GGuaifenesin/destromethorphan (100 mg/10 mS ml.) 2teaspoon- fils Qh PRN cough mal NKDA R05 Patient isa good historian Patent hasbeen experiencing shortness ofbreath, a productive cough, subjective fevers, chills, and pleurtic chest pain that is “right i the mile of my ches.” He denies any ‘nauses, vomiting, constipation, or problems uri 1m Physical Examination Gen Patient is a well-developed, well-nourished, African-American man in moderste respiratory distress appearing somewhat anxious and ‘uncomfortable s [BP 156/90, P127, RR 31, 739.1°C; We 88 kg, Ht 61" skin ‘Warm to the touch; poor skin turgor ‘HEENT PERRLA; EOMI; moist mucous membranes ‘Nedk/Lymph Nodes No JVD; fall range of motion; no neck stiffness; no masses or thyromegaly; no cervical lymphadenopathy ‘Lungs/Thorax Tachypacic; labored breathing: coarse shonchi diffusely throughout right lung fields; decreased breath sounds in right middle and lower ang fields v Audible S, and $; tachycardic with regular shyt; no MRG Abd IND; (+) bowel sounds 279 fal £ FS 5 a Ey e}uownoug paunbay-hyunusiio>aq =| 91 NC ‘sase9siq snonD9ju) GoniyRect Deferred Extremities No ce 5 grip strength; 2+ pulses bilaterally Neuro A&0 x3; CN INI intact 1 Labs on Admission Na omit. ig 123 a Wc 172510) Kes ers ‘eure Gieretyt ROCAS.i0%emm? Rane (0,22. 20% 10mm? ym es BUNS gil MCV jo Monee 2% Seria mpl CHES eerie wang ‘pH 7.410; pCO, 29; pO, 65 with 859% O, saturation on room ait Wi Chest ay Right middle and lower lobe airspace disease likely pneumonia. Left lung is clear, Heart size is normal, 1 Chest CT Scan without Contrast No axillary, mediastinal, or hilar lymphadenopathy. The heart size is normal, There is consolidation ofthe right lower lobe and lateral segment of the middle lobe, wth air bronchograms. No significant pleural effusions. The let lung is clea 1m Sputum Gram Stain 525 WBC/pf,<10 epithelial cllsthpf, many Gram (+) cocein pairs Sputum Culture Pending Blood Cultures x Two Sets Pending Assessment Probable multilobar community-acquired pneumonia involving the RML and RLL Hypoxemia ESTIONS Problem Identification La, Create a ist ofthe patient's drug therapy problems. Lb, What clinical, laboratory, and radiographic findings are consis- tent with the diagnosis of CAP in this patient? Le, Whatare the common causative bacteria of CAP? 1d. What clinical, laboratory, and physical examination findings should be considered when deciding on the site of care for a patient with CAP (inpatient or outpatient)? Desired Outcome 2. What are the goals of pharmacotherapy inthe treatment of CAP? Therapeutic Alternatives | What feasible pharmacotherapeutic alternatives are available for ‘eatment of CAP? Optimal Plan 4a, What drug, dose, route of therapy, dosing schedule, and uration of treatment should be used in this patient? CLINICAL COURSE While in the ED, the patient was placed on 4LNC of Os, and his ‘oxygen saturation improved t0 98%. The patent was initiated on ‘eftiaxone 1 g IV daily and azithromycin 500 mg IV daily and admitted to the hospital. Over the next 48 hours, the patient's L); right TM non-bulging and rmobile with copious cerumen and questionable purulent fluid bbchind TMS both TMs landmarks appear normal including the pars Aaccida, the malleus, and the light reflex below the umbo. However, the let TM landmarks are more clear than the right landmarks, Throat is erythematous; nares patent. Neck Supple chest Clear, no crackles, wheeze, or chonchi v RRR Abd Soft, nontender