Pneumonia Cases Flashcards
Moo is a 37yo female who presented to hospital with cough, chest pain, fever and confusion. To be admitted to general medication ward for treatment. She is able to eat normally.
Vitals: T 38.7ºC, BP 117/79, HR 74, RR 23, WBC 12 x 10^9/L, Urea 6.0 mmol/L
Med Hx: NIL
Allergies: NKDA
Previous Hospitalisation: 10 months ago for MRSA Cellulitis
Chest XR: Dense consolidation in left lower lobe with abscesses
Dx: Pneumonia
Recommend Treatment for this patient
Case: Inpatient, non-severe CAP
Treatment:
- IV Augmentin 1.2g q8h OR IV Ceftriaxone 1-2g IV q24h
AND
- Macrolide: PO Azithromycin 500mg OD/ PO Clarithromycin 500mg BD/ PO Doxycycline 100mg BD
Anaerobe coverage: Required, but covered by Augmentin
MRSA Coverage: Not needed
Pseudomonas: Not needed
Burkholderia: Not needed
SU is a 63yo Male who presented to Hospital with cough, chest pain and fever. However, he is still alert and will be treated outpatient. He is able to eat.
Vitals: T 37.8ºC, BP 131/82, HR 67, RR 22, WBC 10x10^9/L, Urea 5.0 mmol/L
Med Hx: HTN, DM Allergies: NIL Previous Hospitalisation: NIL Chest XR: Dense consolidation in lower right lobe Dx: Pneumonia
Recommend a suitable treatment plan for this patient
Case: Outpatient CAP
Treatment:
- PO Augmentin 625mg TDS/ PO Cefuroxime 500mg BD AND
- Macrolide: PO Azithromycin 500mg OD/ PO Azithromycin 500mg BD/ PO Doxycycline 100mg BD
Duration: at least 5 days
(Patient has co-morbidities (DM) which puts them at higher risk for CAP complication, hence treat with broader spectrum)
Anaerobes, MSSA, Pseudomonas coverage: N.A. in outpatient treatment
GG is a 54yo male who was hospitalised for Pneumonia. He has NKDA and is otherwise healthy. Empiric therapy: - IV Augmentin 1.2g q8h - IV Azithromycin 500mg q24h - IV Ceftazidime 2g q8h
72 hours later, sputum culture results are available. GG is afebrile, able to ingest food and is generally well.
Culture Results: Positive for S.pneumoniae and B-lactamse producing H.influenza.
Recommend therapy modification for this patient
Modified therapy:
- Remove Azithromycin
- Remove Ceftazidime
- Change to PO Augmentin 625mg TDS
Treat for another 5 more days.
HT is a 48yo female is to be warded for cough, chest pain, fever and confusion.
Vitals: T 38.5ºC, RR26, BP111/79, HR 80, Urea 6.2mmol/L, WBC 11.9x10^9/L
Med Hx: NIL
Allergies: Penicillin (Anaphylaxis)
Previous Hospitalisation: Bronchitis, tested positive for P.aeruginosa 10 months ago
Chest XR: Dense consolidation in lower left lobe
Dx: Pneumonia
Recommend drug for this patient
Treatment: IV Levofloxacin 750mg q24h
Patient has penicillin allergy but requires P.aeruginosa coverage. Hence levofloxacin is the only FQ option which cover it.
LZ is a 69yo male who was hospitalised for Pneumonia. He has NKDA and has DM. Empiric therapy: - IV Augmentin 1.2g q8h - IV Azithromycin 500mg q24h - IV Ceftazidime 2g q8h - IV Vancomycin 15mg/kg q12h
72 hours later, sputum culture failed to produce any useful results. However, LZ is feeling much better since the start of hospitalisation. His vitals have returned to normal and he is able to ingest food.
Recommend therapy modification for this patient
Modifications:
- Stop Vancomycin and Ceftazidime
- Change Augmentin to PO Augmentin 625mg TDS
- Change Azithromycin to PO Azithromycin 500mg OD
- Continue treatment for another 5 days
NI is a patient who is transferred into the ICU 24h after hospitalisation due to sudden onset of severe breathing difficulty, delirium and high fever of 40.1ºC. Chest XR shows consolidation at the lower left lobe with no abscesses or empyema. He has no significant infection in the past year. Assume that the reason for his hospitalisation is unrelated to infections. He has NKDA Diagnosis is pneumonia. He is unable to ingest orally.
The doctor recommended the following regimen:
- IV Pip/Tazo 4.5g q6h
- IV Vancomycin 900mg q8h
- IV Gentamicin 450mg q24h
Do you agree with the doctor? If not, suggest a regimen for this patient
Disagree with the doctor as the suggested regimen is used in case of Nosocomial Pneumonia. Patient has only been in hospital for 24h, hence we assume CAP.
Empiric coverage for severe inpatient CAP:
- IV Augmentin 1.2g q8h
- IV Ceftazidime 2g q8h
- IV Azithromycin 500mg q24h
No need to cover PAM (Pseudomonas, Anaerobic, MRSA)
60yo F admitted to ICU for monitoring after surgery. Developed fever and worsening oxygenation on mechanical ventilation 4 days later
Vitals: T 39.7ºC, BP 101/63, HR92, WBC 18, sCr 80 Allergies: NIL Wt: 65kg MRSA Prevalence: 11% P.aeruginosa S to pip/tazo: 90%
Dx: Pneumonia
Suggest a treatment plan for this patient and state the duration of treatment
Case: VAP
MDRO risk factor: NIL
- MRSA coverage: required as prevalence >10%
- Additional Gram-negative coverage: Not required as single anti-pseudomonal agent has activity ≥90%
Treatment plan:
- IV Pip/Tazo 4.5g q8h
- IV Vancomycin 975mg q8h
Duration: 7 days
72yo M admitted to ICU for monitoring after a surgery and received mechanical ventilation. Developed fever, SoB and confusion 5 days later. He did not receive any IV abx in the past 90 days
Vitals: T 38.6ºC, BP 102/68, HR93, WBC 19, sCr 77 Allergies: NIL Wt: 70kg MRSA Prevalence: 9% P.aeruginosa S to pip/tazo: 94%
Dx: Pneumonia
Suggest a treatment plan for this patient and state the duration of treatment
Case: VAP
- MDRO risk factor: Hospitalisation ≥ 5d
- Hence both MRSA and additional gram-negative coverage required
Treatment plan: - IV Pip/Tazo 4.5g q8h - IV Vancomycin 1050mg q8h - AG or FQ for additional gram-neg coverage such as: IV Gentamicin 450mg q24h/ IV Amikacin 1050mg q24h/ IV Cipro 400mg q8h/ IV Levofloxacin 750mg q24h
Duration of treatment: 7d
61yo M admitted to ICU for monitoring after a surgery. Developed fever confusion and SoB requiring mechanical ventilation one week after. He did not receive any IV abx in the past 90 days
Vitals: T 39.6ºC, BP 99/67, HR99, WBC 17, sCr 69 Allergies: Penicillin (Anaphylaxis) Wt: 55kg MRSA Prevalence: 7% P.aeruginosa S to Levofloxacin: 92%
Dx: Pneumonia
Suggest a treatment plan for this patient and state the duration of treatment
Case: HAP requiring ventilation
- Mortality risk factor present: Yes (ventilation), hence require MRSA + more gram-neg coverage
Treatment: - IV Levofloxacin 750mg q24h - IV Vancomycin 750mg q8h - IV Gentamicin 275mg q24h (or any other AG)
Treatment duration: 7d
67yo M admitted to ICU for monitoring after a surgery. Developed fever confusion and SoB 3 days after. He received IV Augmentin 10 weeks ago for diabetic foot infection
Vitals: T 38.6ºC, BP 111/67, HR90, WBC 15, sCr 72 Allergies: NIL Wt: 71kg MRSA Prevalence: 17% P.aeruginosa S to Pip/Tazo: 81%
Dx: Pneumonia
Suggest a treatment plan for this patient and state the duration of treatment
Case: HAP
- MDRO risk factor: Yes (received Abx within 90 days)
Hence cover MRSA and more gram-negs
Treatment:
- IV Pip/tazo 4.5g q8h
- IV Vancomycin 1065mg-1420mg q8h
- IV Amikacin 1065mg q24h (or other AG, or FQ)
Treatment duration: 7d
37yo M admitted to ICU for monitoring after a surgery. Developed fever and SoB 72h later. No recent Abx
Vitals: T 38.8ºC, BP 108/77, HR91, WBC 19, sCr 73 Allergies: NIL Wt: 85kg MRSA Prevalence: 20% P.aeruginosa S to Pip/Tazo: 83%
Dx: Pneumonia
Suggest a treatment plan for this patient and state the duration of treatment
Case: HAP
- MDRO and Mortality risk factors: NIL
- MRSA prevalence: 20% hence no need cover MRSA (to cover, must be >20%)
- P.aeruginosa S: N.A. in HAP
Treatment: IV Pip/Tazo 4.5g q8h for 7d
QU is a 39yo male who was recently discharged after splenectomy. One week after his discharge, he presented to the hospital with chest pain, SoB and fever. However, his symptoms are mild and he will be treated as outpatient
Vitals: T 38.1ºC, BP 118/78, HR76, WBC 5, sCr 60
Allergies: NIL
Wt: 57kg
Dx: Pneumonia
Suggest a treatment plan for this patient. State the treatment duration
Case: CAP, outpatient but with complication risk (asplenia)
Treatment:
- PO Augmentin 625mg TDS
- PO Azithromycin 500mg OD
(or cefuroxime + other macrolide or doxycycline)
Duration: at least 5 days
