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Pneumonia

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Pneumonia

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  1. Pneumonia Esmaeli, A.; Francisco U.; Golpeo, K.

  2. A. G. • 75 year old • Male • Single • From Sta. Mesa, Manila • Unemployed • CC: progressive and productive cough, 3 days duration

  3. TEMPORAL PROFILE

  4. Past Medical History • PTB (2002) – sputum AFB (+); 6 months quad-tab treatment completed; Chest X-ray after treatment – resolved • S/P Cataract surgery (2002) • COPD (2011) – Symbicort 2 puffs BID  1 puff BID (2012) • Allergy to seafood and chicken • (-) HTN, (-) DM • Family History • (+) HTN (father and younger brother) • (+) stroke (father) • (+) Lung CA (brother)

  5. Social and Environmental History • Smoker (51 pack years); started 14 years old, stopped 2002, 1 pack per day • Occasional alcohol drinker (1960 -1970); Last drink was 1985, 1 small bottle of pale pilsen per week • Denies illicit drug use

  6. Review of Systems • (-) anorexia • (-) vomiting • (-) diarrhea • (-) blood in sputum • (+) exertional dyspnea • (+) sputum production • Weight loss

  7. Physical Examination Awake, weak-looking, alert, ambulatory, febrile VS: 110/60 > 72 > 32 > 39 degrees celsius AS, PPC, (-) TPC, (-) CLADS ECE, (+) crackles in L lower lung AP, NRRR, distinct S1 and S2, (-) murmur Flat abdomen, NABS FEP, (-) cyanosis, (-) edema

  8. Primary Impression Community Acquired Pneumonia, Moderate Risk (CAP, MR); Chronic Obstructive Pulmonary Disease (COPD)

  9. Laboratories Ordered • CBC • UA • Blood CS • Sputum GS/CS • Na, K, Crea, BUN • Chest Xray

  10. CBC

  11. Chest Xray Impression: • Pneumonitis/ Bronchitis Right Lower Lung • Pneumonia Left Lower Lung • Residual Fibrosis Right Upper Lung

  12. Urinalysis

  13. Blood Chemistries

  14. Cultures • Sputum GS – Gram (+) cocci in pairs with neutrophils • Sputum CS – • Blood CS, 2 sites –

  15. IV FLUID: 1 liter D5NSS to run to 10 hours (100 cc/hr) • DIET: 2100 kcal/day • TFR

  16. Antibiotic started upon admission • Ceftriaxone 2 gm IV Q24 • Levofloxacin 750mg/tab, 1 tab Q48 (Azithromycin)

  17. COPD • Symbicort 2 puffs BID

  18. Hypokalemia • KaliumDurule, 1 durule TID

  19. Pneumonia

  20. Plan • Moderate Risk 1. RR>30/min 2. PR> 125/min 3. Temp >40 or <36.00C 4. SPB <90mmHg or DBP <60mmHg 5. Altered mental status of acute onset 6. Suspected aspiration 7. Unstable comorbids 8.CXR: multilobar, pleural effusion, abscess

  21. High risk • Severe sepsis and septic shock • Need for mechanical ventilarion

  22. Outpatients Previously healthy and no antibiotics in past 3 months • A macrolide [clarithromycin (500 mg PO bid) or azithromycin (500 mg PO once, then 250 mg qd)] or • Doxycycline (100 mg PO bid) Comorbidities or antibiotics in past 3 months • A respiratory fluoroquinolone [moxifloxacin (400 mg PO qd), gemifloxacin (320 mg PO qd), levofloxacin (750 mg PO qd)] or • A B-lactam[preferred: high-dose amoxicillin (1 g tid) or amoxicillin/clavulanate (2 g bid) plus a macrolide

  23. Inpatients, Non-ICU • A respiratory fluoroquinolone [moxifloxacin (400 mg PO or IV qd), gemifloxacin (320 mg PO qd), levofloxacin (750 mg PO or IV qd)] • A B-lactam[cefotaxime (1–2 g IV q8h), ceftriaxone (1–2 g IV qd), ampicillin (1–2 g IV q4–6h), ertapenem (1 g IV qd in selected patients)] plus a macrolide[oral clarithromycin or azithromycin (as listed above for previously healthy patients) or IV azithromycin (1 g once, then 500 mg qd)]

  24. Inpatients, ICU • A B-lactam[cefotaxime (1–2 g IV q8h), ceftriaxone (2 g IV qd), ampicillin-sulbactam (2 g IV q8h)] plusAzithromycin or a fluoroquinolone (as listed above for inpatients, non-ICU)

  25. If Pseudomonas is a consideration • An antipneumococcal, antipseudomonal B-lactam[piperacillin/tazobactam (4.5 g IV q6h), cefepime (1–2 g IV q12h), imipenem (500 mg IV q6h), meropenem (1 g IV q8h)] plus either ciprofloxacin (400 mg IV q12h) or levofloxacin (750 mg IV qd) The above -lactamsplus an aminoglycoside [amikacin (15 mg/kg qd) or tobramycin (1.7 mg/kg qd) and azithromycin] The above -lactamsfplus an aminoglycosideplus an antipneumococcalfluoroquinolone

  26. If CA-MRSA is a consideration • Add linezolid (600 mg IV q12h) or vancomycin (1 g IV q12h).