Download CPC # 2 October 12, 2004

CPC # 2
Infectious Disease
October 7, 2008
Lisa L. Maragakis, MD MPH
Important Features of the Case
• 58 yo man with a history of alcoholism, smoking,
hypertension and chronic pain
• Presents with 5 days of cough and fever with
progressive dyspnea and “weakness”
• Confusion and slurred speech is also reported
by the patient’s wife
• Other symtoms include:
– headache
– Pleuritic chest pain (R)
– Urinary incontinence (new)
Important Features of the Case
• No recent medical care and not taking antihypertensive meds
• Upon admission:
– BP=133/94, P=125, RR=24, afebrile;
– Moderate respiratory distress; 95% on 6L NC;
wheezing and rhonchi
– Alert, not oriented to date, slurred speech
• WBC=1.1,  Hct (50%), ↓Plt (55k),  ALT (141), 
Tbili (2.1) ↓TP/alb,  PT/PTT,   lactate (12.6), 
BUN (48),  Cr (4.0), ammonia=33
• Imaging shows multi-lobar dense consolidation
and cavitation of RUL, lymphadenopathy
• Head CT essentially negative
Summary of the Case
• Alcoholic man presents with an acute
illness characterized by multi-lobar
pneumonia, hepatic encephalopathy, lactic
acidosis, coagulopathy and renal failure
• Rapidly developed hypotension,
respiratory failure, and expired within 36
hours
Possible Etiologies of the
Elevated Ammonia level
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Hepatic encephalopathy
Shock
ETOH
Renal disease
GI bleeding
Salicylate intoxication
Ethylene glycol
Possible Etiologies of the
Elevated Lactate level
• Severe hypoxemia
• Shock
• Decrease in lactate utilization due to
ETOH and liver disease
Community-Acquired Pneumonia,
Sepsis and
Multi-organ Failure
• Approximately 10% of CA pneumonia requires
ICU care and mechanical ventilation
• Risk factors
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Advanced age
Comorbid disease
DM
ETOH
Community-Acquired Pneumonia,
Sepsis and
Multi-organ Failure
– Severe CAP defined by
• RR>30, PaO2/FIO2<250, need for mechanical
ventilation, multi-lobar pneumonia, increased size
of infiltrate up to 50% in 48 hrs, BP<90/60, pressor
requirement, acute renal failure
– Mortality rates 20-53% (as opposed to 2-30%
for “regular” CAP)
Community-Acquired Pneumonia,
Sepsis and
Multi-organ Failure
– S. pneumoniae and L. pneumophila are the
most common etiologies
– Gram negative bacilli, especially Klebsiella,
occur in patients with DM, COPD, and ETOH
abuse (this patient)
Community-Acquired Pneumonia,
Sepsis and
Multi-organ Failure
– Initial presentation of CAP in older adults can
present as
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Decline in functional status
Weakness
Mental status changes
Anorexia
Abdominal pain
Differential Diagnosis of
Community Acquired Pneumonia
• S. pneumoniae accounts for 20-60% of cases
• H. influenzae causes 7-11%
• Older and debilitated patients more likely to have GNB
colonizing oropharynx
• Group A and B streptococci
• M. cattarhalis
• Legionella
• Atypicals: M. pneumoniae, Clamydyia
• Viral pneumonia: RSV, influenza, parainfluenza
• Aspiration pneumonia
Differential Diagnosis of
Community Acquired Pneumonia
• Aspiration
– Silent vs witnessed
– ETOH is a risk factor
– Chemical pneumonitis
– Mixed flora + anaerobes
– Upper lobe atypical but not impossible
Differential Diagnosis of
Community Acquired Pneumonia
• Atypical pneumonia syndromes
– M. pneumoniae
– C. pneumoniae
– Legionella
– Francisella tularensis
– M. TB
– Coxiella burnetii
– Pneumocystis
Differential Diagnosis of
Community Acquired Pneumonia
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S. aureus
Not on the traditional lists of CAP etiology
Seen increasingly as causing CAP
Can cause necrotizing, cavitary
pneumonia with rapidly progressive sepsis
as seen in this case
Diagnosis
• Send sputum and blood cultures BEFORE
antimicrobials are started
• Legionella urinary antigen (only detects
serogroup 1)
• Consider NP aspirate during flu season
• Consider anthrax if widened mediastinum
• Bronchoscopy, open lung biopsy
Therapy for CAP
• Not in the ICU
– Ceftriaxone PLUS Azithromycin or
– Moxifloxacin
• In the ICU
– Same as above or
– Cover for Pseudomonas if at risk
• Cefipime PLUS Azithromycin
• Moxifloxacin PLUS Aztreonam
Risks for Pseudomonas
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Prolonged hospital or LTCF stay (>5d)
Structural lung disease
Steroid therapy
Broad-spectrum ABX in past month
AIDS
Neutropenia
Therapy for CAP
• Aspiration
– Clindamycin can be added to cover
anaerobes
• CA-MRSA
– Linezolid can be added to cover empirically
while awaiting culture data
Therapy for CAP
• If you have the luxury of tailoring therapy
– Base ABX treatment choice on organism that
grows from sputum and/or blood
In this case…
• Treated with moxifloxacin (appropriate)
• If I had to bet, I would say this patient had
CA-MRSA necrotizing pneumonia and
sepsis with multi-organ failure