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Question 10#

A 40-year-old man without a significant past medical history comes to the emergency room with a 3-day history of fever and shaking chills, and a 15-minute episode of rigor. He also reports a cough productive of yellow-green sputum, anorexia, and the development of right-sided pleuritic chest pain. Shortness of breath has been present for the past 12 hours. Chest x-ray reveals a consolidated right middle lobe infiltrate, and CBC shows an elevated neutrophil count with many band forms present. Which feature would most strongly support inpatient admission and IV antibiotic treatment for this patient?

A) Recent exposure to a family member with influenza
B) Respiratory rate of 36/minute
C) Recent sexual exposure to an HIV-positive patient
D) Purulent sputum with gram positive diplococci on Gram stain
E) Signs of consolidation (bronchial breath sounds, egophony) on physical examination

Correct Answer is B

Comment:

Because of the development of effective oral antibiotics (respiratory fluoroquinolones, extended spectrum macrolides), most patients with community-acquired pneumonia (CAP) can be managed as an outpatient as long as compliance and close followup are assured. The CURB-65 score is the most strongly validated instrument for determining if inpatient admission (either observation or full admission) is indicated. Factors predicting increased severity of infection include confusion, urea above 19mg/dL, respiratory rate above 30, BP below 90 systolic (or 60 diastolic), and age above 65. If more than one of these factors is present, hospitalization should be considered. This patient’s presentation (lobar pneumonia, pleuritic pain, purulent sputum) suggests pneumococcal pneumonia. Pneumococci are the commonest organisms isolated from patients with CAP. Fortunately, S pneumoniae is sensitive to oral antibiotics such as clarithromycin/azithromycin and the respiratory quinolones. A Gram stain suggestive of pneumococci would therefore only confirm the clinical diagnosis. Exposure to influenza is an important historical finding. However, without a prodrome of influenzalike illness (upper respiratory symptoms, myalgias, prostrating weakness), this is still garden variety CAP. In the setting of an influenza-like illness, H influenzae (easily treated with standard antibiotics) and S aureus pneumonia (more problematic to treat) must be considered. Acute lobar pneumonia, even in an HIV-positive patient, is due to the pneumococcus and can be treated as an outpatient. Pneumocystis jirovecii pneumonia is usually insidious in onset, causes diffuse parenchymal infiltrates, and does not cause pleurisy or pleural effusion. Physical examination signs of consolidation confirm the CXR finding of a lobar pneumonia (as opposed to a patchy bronchopneumonia) and would simply affirm the importance of coverage for classic bacterial pathogens (ie, pneumococci, H flu). Atypical pneumonias (still often pneumococcal, but sometimes due to Mycoplasma or Chlamydia) are usually patchy and also do not affect the pleura. Currently recommended treatment regimens cover both typical and atypical pathogens.