Elderly female admitted to hospital with suspected pneumonia

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Elderly female admitted to hospital with
suspected pneumonia
Case 1 Diagnosis and Treatment
2
History

• A 73-year-old female had suffered from a cold 2
  weeks ago
• Her GP prescribed ciprofloxacin 500mg 12 hourly
  for 7 days
• 1 day story of cough, raised temperature,
  weakness and pleuritic-type chest pain
• She was slightly confused
• Small volume blood-stained sputum produced
• Non-smoker

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Clinical examination

• Temperature 38.4C pulse rate 105/min blood
  pressure 145/80 mmHg
• Respiratory rate 32 breaths/min
• Flushed face orientated to person but not to
  place or time
• Reduced breath sounds and dullness to percussion
  at the right base
• Pleural rub right base

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Chest X-ray
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Laboratory results

• Haematology
• haemoglobin 13.6 g/dL
• white blood cell count (wbc) 13.8 x 109/L
  (normal range lt 11.0 x 109/L )
• Urea, electrolytes and liver function tests
• elevated urea at 7.8 mmol/L
• creatinine 158 µmol/L
• C-reactive protein (CRP)
• 175 mg/L (normal range lt8 mg/L)
• Blood gases
• PaO2 7.58 kPa
• PaCO2 6.49 kPa

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Treatment

• Patient is admitted to the medical ward
• Two MRSA patients in side rooms on 30 bedded ward
• Observations are started
• Nasal oxygen is administered
• Intravenous access is established

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What do you do now?
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Treatment

• Antibiotics are started
• amoxicillin 1 g IV every 8 hours
• erythromycin 1 g IV every 6 hours

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Hospital Days 2 to 4

• Patient slowly improves
• Sputum culture yields Streptococcus pneumoniae
• Switched to oral amoxicillin at day 3 when wbc
  CRP normal

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Hospital Day 5

• On Day 5 patient deteriorates
• Recurrence of fever and productive cough
• Confused
• CXR shows consolidation at left base
• WBC 11.0 x 109/L CRP 34 mg/L otherwise normal
• Blood gas (O2 via face mask 2 L/min), PaO2 11.8
  kPa PaCO2 9.1 kPa

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What do you do now?
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Modified Early Warning Score (MEWS)

• Tool for bedside evaluation of patients
• Identifies those at risk of deterioration/death
• Helps target critical care resource to those most
  likely to benefit
• Calculated from
• Systolic blood pressure
• Pulse rate
• Respiratory rate
• Temperature
• AVPU score

AVPU Alert reacting to Voice reacting to
Pain Unconscious
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Hospital Day 6

• Patient still in the medical ward
• Antibiotic treatment started Day 5 with
  ciprofloxacin 400mg bd IV
• Microbiological results
• Blood culture negative at 24 hours
• Upper respiratory tract flora from sputum from
  Day 5
• Patient remains confused and pyrexic
• Blood pressure is dropping
• Blood gases remain abnormal

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What do you do now?
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Hospital Day 6

• Patient remains in the medical ward
• Ciprofloxacin continued by itself
• Sputum and blood cultures taken
• Patient remains confused and pyrexic
• Blood pressure is dropping
• Blood gases remain abnormal

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Hospital Day 7

• Patient transferred to ICU and intubated
• BAL performed
• Film report phoned to ICU
• Gram stain of lavage few Gram-positive cocci
• Urine screening for Legionella spp. antigen
  negative

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Issues relating to diagnosis and patient
management

• Pros and cons of quantitative bacteriology in HAP
• Likely pathogens and resistance
• BAL report
• Indications for selective decontamination (SDD)

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BAL and ICOs
Intracellular Gram positive cocci
Extracellular Gram positive cocci
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Hospital Day 7

• Treatment changed to meropenem 1 gram tds IV and
  vancomycin 1 gram bd IV

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Hospital Day 9

• Patient improving
• Blood cultures negative
• Microbiology BAL results
• methicillin-resistant S. aureus (MRSA) isolated
  at 103 colony-forming units (cfu)/mL
• Klebsiella pneumoniae isolated at 106 cfu/mL
• Cefotaxime, ceftazidime, coamoxiclav, meropenem
  susceptible
• Ciprofloxacin, amoxicillin resistant

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How would you interpret the BAL findings and
manage the patient?
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Hospital Day 14 and follow-up

• Patient extubated and discharged ICU Day 14 when
  WBC count 7.3 x 109/L CRP 14 mg/L temperature
  37.1C
• Carbapenem and vancomycin are stopped after 8
  days of treatment
• Patient discharged home on Day 21

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Grades of Recommendation
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Grade A Recommendations relating to methods of
diagnosis of HAP

• There is a lack of evidence to indicate that any
  one method is better than the other.
• Endotracheal aspirates are not recommended for
  diagnosis of VAP.
• Quantitative microbiology should not be relied on
  for the diagnosis of HAP/VAP.
• Blind lavage is recommended as a simple and
  effective method to obtain respiratory specimens
  and to identify potential pathogens in suspected
  HAP/VAP.
• Identification of intracellular organisms in BAL
  is a rapid and specific test and is recommended
  as a guide to therapy.

http//www.bsac.org.uk/
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Grade A Recommendations for treatment of HAP

• Where mechanical ventilation will be for gt48 hrs
  SDD should be considered for ICU patients
• SDD should include topical and parenteral agents
  (with activity against Gram negative bacilli),
  where treatment choice depends on local pathogen
  profiles.
• SDD should not be withheld because of fear of
  resistance developing.
• Empirical antibiotic therapy of HAP should be
  based on the nature and susceptibilities of the
  unit pathogens and should also recognise duration
  of hospital stay (i.e., early- or late-onset
  infection), recent administration of antibiotic
  therapy and co-morbidities. Definitive therapy
  should be determined by culture and
  susceptibility test results.
• Monotherapy is equivalent to combination therapy
  in HAP.
• Patients with sepsis and pneumonia should not be
  treated with G-CSF.