A 68-year-old woman with a history of hypertension and poorly controlled diabetes mellitus presents to the emergency department (ED) with fevers and 5 days of progressive shortness of breath and cough. She presented to her primary care physician 3 days ago and was prescribed amoxicillin. Despite this treatment, her symptoms worsened; she has no other associated symptoms. On arrival to the ED, her vital signs are notable for :
She is placed on high-flow nasal cannula at 60 L/min and FiO2 0.6 in the ED, and vancomycin and cefepime administered. She is subsequently admitted to the intensive care unit (ICU) for severe community-acquired pneumonia (CAP).
Which of the following is the BEST next step in her management?
Correct Answer: B
The patient presents with severe CAP. Common pathogens explaining this presentation include S. pneumoniae, H. influenzae, Legionella, Enterobacteriaceae species, S. aureus, and Pseudomonas. The narrowest recommended antibiotic regimen for patients admitted to the ICU with CAP must include:
For patients with risk factors for S. aureus and Pseudomonas infection (which include outpatient antibiotic failure, past healthcare exposure, structural lung disease, and recent IV antibiotic exposure), empiric coverage is recommended. Given this patient’s recent antibiotic exposure and failure of outpatient antibiotic therapy, empiric treatment for methicillin-resistant S. aureus and Pseudomonas species is appropriate (answer D is incorrect). However, addition of a macrolide or fluoroquinolone is recommended to cover atypical pathogens including Legionella—at least 20% of severe pneumonia is thought to be because of atypical bacterial pathogens (answer B is correct). There are no data to support the use of bronchioalveolar lavage over routine respiratory gram stain and culture for CAP (answer A is incorrect). Additionally, although blood cultures are recommended for patients who are hospitalized with CAP, there is no additional value of quantitative respiratory cultures over routine respiratory gram stain and cultures. There is no indication for empiric treatment of vancomycin-resistant species such as Enterococcus (answer E is incorrect).
A 45-year-old man was diagnosed 1 month ago with a squamous cell lung cancer involving his left hilum and has been receiving chemotherapy. He is now admitted to the ICU with hypoxemia and fever. He reports about 10 days of low-grade fevers and loss of appetite, which has progressed to worsening shortness of breath and a cough productive of foul-smelling, purulent sputum. His chest radiograph demonstrates dense consolidation of his left lower lobe with evidence of an abscess. A computed tomography (CT) scan is ordered and he is started on vancomycin, cefepime, and metronidazole. Sputum cultures are pending.
Which of the following is the most accurate regarding his diagnosis?
Correct Answer: A
The patient’s presentation is concerning for postobstructive pneumonia and abscess in the setting of bronchial obstruction and immunosuppression. Given the severity of his illness and his recent chemotherapy, his antibiotic regimens should include empiric treatment of methicillin-resistant S. aureus, gram-negative organisms including Pseudomonas species, and anaerobic organisms (answer A is correct). Obligate anaerobic organisms will not grow in routine sputum microbiologic cultures but are considered important pathogens in postobstructive pneumonia and should be treated empirically (answer D is incorrect). Antibiotic regimens for anaerobic coverage may include betalactam/beta lactamase inhibitor combination, metronidazole, clindamycin, or carbapenem antibiotics. Lung abscesses often require prolonged treatment that is guided by repeat imaging (answer B is incorrect). Unfortunately, unless his cancer is successfully treated, he will be at ongoing risk for postobstructive pneumonia (answer C is incorrect).
A 65-year-old man with congestive heart failure is intubated and mechanically ventilated in the ICU for acute decompensated heart failure complicated by pulmonary edema. His extubation is delayed by ongoing delirium. On day 5 of his ICU stay, he is noted to have a new fever, with a temperature of 38.5°C. He is on pressure support ventilation, with an inspiratory pressure of 5 cm H2O, positive endexpiratory pressure (PEEP) of 5 cm H2O, and FiO2 0.4. The remainder of his vital signs are:
His examination reveals clear lung fields with auscultation and no other notable findings. A diagnostic workup, including blood cultures, urinalysis, and chest radiograph, are performed. Chest radiograph reveals clear lung fields. His urinalysis and blood cultures are unrevealing. Over the next 48 hours, he has one additional fever, and the respiratory therapist notes increased thick secretions suctioned from his endotracheal tube that are sent for sputum culture. His vent settings, chest radiograph, and vital signs remain unchanged.
Which of the following is the MOST appropriate management at this time?
Correct Answer: D
The patient is presenting with fevers and increased sputum production without evidence of infiltrate on examination, chest imaging, and with a stable and/or improved respiratory status. The clinical presentation suggests tracheobronchitis. Current guidelines recommend observation without empiric antibiotic treatment for tracheobronchitis, given lack of evidence suggesting a clinical benefit to treatment (answer D is correct). Vancomycin and cefepime may be an appropriate regimen for a ventilator- associated pneumonia (VAP) depending on local resistance patterns, but this patient does not have evidence of pneumonia (answer A is incorrect). Further workup for pneumonia including bronchoscopy is also not indicated (answer B is incorrect). Routine coverage for atypical organisms with a macrolide is not recommended for hospital-acquired or VAP or tracheobronchitis (answer C is incorrect). Monotherapy with cefepime is not indicated either for tracheobronchitis or VAP (answer E is incorrect).
A 25-year-old man with a history of mild intermittent asthma is admitted to the ICU with rapidly progressive hypoxemic respiratory failure following 4 days of fevers, myalgias, and cough at home. He is intubated and mechanically ventilated on volume assist-control with a tidal volume of 6 mL/kg, respiratory rate 14 breaths per minute, FiO2 0.8, and PEEP of 10 cm H2O. His arterial blood gas on these settings is:
His chest radiograph demonstrates diffuse bilateral patchy opacities, and his rapid influenza testing is positive for influenza A.
Which of the following statements is MOST accurate regarding diagnosis and treatment for this patient?
This patient is presenting with respiratory failure secondary to influenza A infection. He meets clinical criteria for ARDS, which include acute onset of bilateral infiltrates with associated hypoxemia in the absence of evidence of explanatory cardiogenic pulmonary edema (answer E is incorrect). Mainstays of treatment for severe influenza pneumonia include antiviral therapy with oseltamivir (answer C is incorrect) and empiric treatment of possible secondary bacterial infection (answer B is incorrect). Common bacterial pathogens that coinfect with influenza include S. pneumoniae, Staphylococcus aureus, and Haemophilus influenzae, and coverage should be targeted to these organisms. Treatment with steroids in patients with influenza infection is associated with an increased risk of mortality, and although these data are observational, the consensus is that steroids should be avoided if possible (answer A is incorrect).
A 65-year-old man with acute myeloid leukemia is admitted to the ICU with worsening hypoxemia while receiving induction chemotherapy on the oncology ward. His chest radiograph reveals bibasilar opacities, and he is started on treatment with vancomycin and cefepime. His hypoxemia improves by day 3 of treatment, however his fevers continue. On day 5 of treatment, chest radiograph reveals opacification of the right lower lung fields with loss of visualization of the right hemidiaphragm and costophrenic angle. A thoracic ultrasound demonstrates a pleural effusion, and diagnostic thoracentesis is performed with removal of 60 mL of fluid. Pleural fluid analysis demonstrates:
cloudy tan fluid
Gram stain and cultures are pending.
What is the next best step in management?
This patient presents with continued fevers while being treated of pneumonia and is found to have a pleural effusion with diagnostic tests highly suggestive of an empyema—these include frankly purulent pleural fluid, an LDH greater than 1000, low pH, and low glucose. The first step in management of empyema is the placement of the tube thoracostomy to completely drain the pleural space (answer B is correct). Delay in drainage may lead to increased morbidity and mortality (answer A and answer C are incorrect). Drainage with thoracentesis alone is not recommended because of the likelihood of fluid reaccumulating, making ongoing drainage necessary (answer D is incorrect). When drainage cannot be achieved through thoracostomy, thoracic surgical intervention may be necessary but is not usually the initial management strategy (answer E is incorrect).
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