CPC

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CPC 2Infectious DiseaseOctober 7, 2008

• Lisa L. Maragakis, MD MPH

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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 patients wife
• Other symtoms include
• headache
• Pleuritic chest pain (R)
• Urinary incontinence (new)

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Important Features of the Case

• No recent medical care and not taking
  anti-hypertensive meds
• Upon admission
• BP133/94, P125, RR24, afebrile
• Moderate respiratory distress 95 on 6L NC
  wheezing and rhonchi
• Alert, not oriented to date, slurred speech
• WBC1.1, ? Hct (50), ?Plt (55k), ? ALT (141), ?
  Tbili (2.1) ?TP/alb, ? PT/PTT, ? ? lactate
  (12.6), ? BUN (48), ? Cr (4.0), ammonia33
• Imaging shows multi-lobar dense consolidation and
  cavitation of RUL, lymphadenopathy
• Head CT essentially negative

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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

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Possible Etiologies of the Elevated Ammonia level

• Hepatic encephalopathy
• Shock
• ETOH
• Renal disease
• GI bleeding
• Salicylate intoxication
• Ethylene glycol

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Possible Etiologies of the Elevated Lactate level

• Severe hypoxemia
• Shock
• Decrease in lactate utilization due to ETOH and
  liver disease

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Community-Acquired Pneumonia, Sepsis and
Multi-organ Failure

• Approximately 10 of CA pneumonia requires ICU
  care and mechanical ventilation
• Risk factors
• Advanced age
• Comorbid disease
• DM
• ETOH

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Community-Acquired Pneumonia, Sepsis and
Multi-organ Failure

• Severe CAP defined by
• RRgt30, PaO2/FIO2lt250, need for mechanical
  ventilation, multi-lobar pneumonia, increased
  size of infiltrate up to 50 in 48 hrs, BPlt90/60,
  pressor requirement, acute renal failure
• Mortality rates 20-53 (as opposed to 2-30 for
  regular CAP)

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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)

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Community-Acquired Pneumonia, Sepsis and
Multi-organ Failure

• Initial presentation of CAP in older adults can
  present as
• Decline in functional status
• Weakness
• Mental status changes
• Anorexia
• Abdominal pain

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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

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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

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Differential Diagnosis of Community Acquired
Pneumonia

• Atypical pneumonia syndromes
• M. pneumoniae
• C. pneumoniae
• Legionella
• Francisella tularensis
• M. TB
• Coxiella burnetii
• Pneumocystis

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Differential Diagnosis of Community Acquired
Pneumonia

• 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

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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

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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

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Risks for Pseudomonas

• Prolonged hospital or LTCF stay (gt5d)
• Structural lung disease
• Steroid therapy
• Broad-spectrum ABX in past month
• AIDS
• Neutropenia

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Therapy for CAP

• Aspiration
• Clindamycin can be added to cover anaerobes
• CA-MRSA
• Linezolid can be added to cover empirically while
  awaiting culture data

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Therapy for CAP

• If you have the luxury of tailoring therapy
• Base ABX treatment choice on organism that grows
  from sputum and/or blood

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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