Running head: PNEUMONIA CASE STUDY



Running head: COUGH & FEVER; DIFFERENTIATING PNEUMONIA

Cough & Fever: Differentiating Pneumonia

Lisa J. King

Otterbein College

Chief Complaint: “Cough and chills X 3 days”

HOPI: M.M. is a 77 year old female that presented to the office with complaints of a productive cough and chills X 3 days. She is coughing up rust colored sputum and states she becomes short of breath with minimal exertion. She complains of uncontrolled shaking chills throughout the day and night. She reports a fever of 102 last night and states she took Tylenol which lowered the fever to 100.6 briefly but then fever returned to 102.8 this am. She complains of a pleuritic chest discomfort different from angina that is worse when she coughs. She denies radiation of chest pain, nausea or vomiting. She also states she has a generalized feeling of fatigue.

Current Medications: ASA 81 mg daily; Plavix 75mg daily; Atenolol 50 mg daily; Nexium 40 mg daily; Simvastatin 40 mg q PM; Centrum plus multivitamin one tablet daily; Requip 1 mg q HS; amlodipine 5 mg daily; Albuterol MDI q 6 hours

Past Medical History: Childhood illnesses – Positive measles and mumps, date unknown. No chicken pox, whooping cough, scarlet fever, diphtheria, rheumatic fever, polio or small pox. Adult Medical – Positive CVA with left sided weakness, uterine cancer, AAA, angina, restless leg syndrome, CHF, mild cardiomegaly, hyperlipidemia, HTN, GERD, COPD, Hemorrhoids, insomnia, pneumonia, bronchitis, osteoarthritis, and urinary stress incontinence. Adult Surgical- Total hysterectomy (1972), AAA repair (2001), and cataract surgery (2008) Obstetric/Gynecologic – Menses began at age 15 with normal flow periods lasting 7 days. Last period 1965, total hysterectomy in 1972 for uterine cancer. Psychiatric – No history of psychiatric illness. Adult immunizations – Flu vaccine fall 2008, pneumococcal vaccine 2006.

Personal/Social History: M.M is a 77 year old white married female. She has three adult sons alive and well ages53, 55 and 57. She is retired and lives in a one story house with her husband of 60 years. Her husband helps her with ADL’s due to her left sided weakness from her previous CVA. She denies alcohol use. She reports drinking 3 cups of coffee everyday and eating chocolate on occasion. She quit smoking on mother’s day 2008. She had a history of 1 ppd X 40 years. She denies the use of illegal street drugs. She attends a local foursquare church in the Mansfield area. She reports wearing her seatbelt and using sunscreen when outside in the summer.

Family History: Unknown medical history of grandparents. Father deceased at age 76 from heart failure, Mother deceased at age 72 from a carotid aneurysm, sister deceased at age 66 from “cancer behind heart”, sister 79 alive with a history of heart disease and HTN, sister 75 alive with a history of HTN and DM and another sister 71 alive with a history of hyperlipidemia and COPD.

Decision Point #1: Additional history taking questions will focus on identifying the cause of the patients cough and chills. It will focus on eliminating or identifying a cardiac ideology.

How long does your chest pain last? “It is constant”

Do you have a family history of heart disease or heart attacks? “Yes, my father died of heart

failure and my sister and I have HTN”

Describe the pain in your chest. – “It is a constant aching”

Is the chest pain worse when you take a deep breath or cough? “Yes, both”

Does the pain go anywhere but your chest (Does it radiate anywhere)? “No”

Does the cough keep you awake at night? “Yes”

Are you having any heartburn? “No”

Have you fainted? “No”

Have you felt dizzy? “No”

Have you noticed any swelling in your ankles, feet or hands? “No”

Is this cough different from your chronic COPD cough? “Yes”

How is it different? “This cough hurts deep in my chest, like it is hurting in my lungs and the

pain is all the time”

Are you having any headaches? “Not really I just ache all over”

Are you able to continue with your everyday activities? “No”

What keeps you from doing your normal activities? “I get short of breath just sitting up in bed”

How are you eating? “Not well, I just don’t feel like eating anything”

Are you experiencing any night sweats? “No”

Are you coughing up any blood? “No, it is a dark yellow color, with streaks of a rust color”

Have you taken any recent trips? “No”

Have you changed any medications or started taking any herbal or over the counter products?

“No”

Have you noticed any changes in weight loss or gain? “No”

On a scale of 1-10 how bad do you feel today? “9”

Have you ever felt this way before? “Yes, when I had pneumonia”

Physical Exam:

Vital Signs – Temperature 102.7 F; BP 112/76; HR 110; Respirations 28; O2 saturation 94 %; Height 5 feet 2 Inches; Weight 157 pounds; BMI 30

General – M.M is a pleasant 77 year old woman. She is in no apparent

distress. She asks questions appropriately and makes direct eye contact. Alert and oriented times three. She has left sided weakness and requires a cane to ambulate with assistance. Her speech is clear and she does not demonstrate any difficulty with hearing.

Skin – Skin color is pale and very warm to touch, diaphoretic. Nails without clubbing or cyanosis. No rash, petechiae, or ecchymoses.

Head and face - The skull is normocephalic/atraumatic. Short gray hair is evenly distributed, thin in texture. No alopecia or balding spots noted. Facial expression appears fatigued, symmetrical.

Eye - External eyes appear symmetrical in shape and position. Peripheral vision intact. Extraocular muscle movements conjugate, without nystagmus or lid lag. Sclera white, conjuctiva pink. Pupils are 3 mm constricting to 2 mm, equally round and reactive to light and accommodations. Patient wearing eye glasses.

Ear - Acuity good to whispered voice. Bilateral ear canals pink without discharge or

foreign bodies. Bilateral tympanic membranes with good cone of light present at 5 and 7

o’clock, pearly gray in color. Bony landmarks visualized bilaterally. No perforations noted.

Small amount of cerumen noted bilaterally.

Nose - External appearance symmetrical with no deformities. Nasal mucosa pink, septum midline, no sinus tenderness.

Mouth and Throat - Lips pink and moist without cracking or ulcerations. Buccal mucosa without incidence. Tongue pink, symmetrical with no ulceration. No white or erythemic areas noted under tongue or on floor of the mouth. Hard and soft palate intact. Anterior and posterior pillars, uvula, tonsils and pharynx pink without exudates, swelling or ulcerations. Uvula vibrates but remains midline upon patient speaking Ahh. Oral mucosa pink, dentition. Patient has partial dentures.

Neck - Neck symmetrical with no masses or scars. Trachea midline. Neck supple; thyroid palpable without notches or masses. No palpable cervical, preauricular, posterior auricular, occipital, tonsillar, submental, supraclavicular lymph nodes. Bilateral submandibular lymph nodes palpated, tender. Carotid pulses palpated, no bruit auscultated. Range of motion and muscle strength against resistance without incident.

Chest, posterior/anterior - No areas of tenderness, barrel chest noted. Thorax is symmetric with symmetrical expansion. Bronchial breath sounds noted left posterior chest. Fine crackles audible in left lower lobe, diminished. Dullness noted over left posterior lower lobe. Bronchophony and Egophony present Pt. visibly short of breath.

Upper Extremities – Pt. able to perform active range of motion of hands, arms, elbows, and shoulders, weaker on left side. Patient appears visibly fatigued. No evidence of swelling or deformity. No epitrochlear nodes palpated. Radial and brachial pulses equal bilaterally.

Heart – Carotid upstrokes are brisk, without bruits. The point of maximal impulse is tapping. Good S1 and S2 auscultated with a grade II systolic murmur present. No extra heart sounds. Regular rhythm and intensity. Rate tachycardic. No peripheral edema noted.

Abdomen - Abdomen is flat with active bowel sounds in all four quadrants. It is soft, non-tender and non-distended. No palpable masses. Liver span is 8 cm in the right midclavicular line; edge of liver is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. No Costovertebral angel tenderness. No aortic or renal artery bruits. Femoral pulses equal bilaterally.

Lower Extremities - Bilateral lower extremities symmetrical. Skin smooth warm and dry. Bilateral dorsalis pedis pulses palpated. No edema or varicose veins noted. Patient able to perform active range of motion with hips, knees, ankles and feet with left sided weakness and overall fatigue.

Neurological - Alert and cooperative. Thought process coherent. Oriented to person, place, time and situation. Cranial Nerves: I – not tested; II through XII intact. Motor: Good muscle tone with left sided weakness. Strength 5/5 on right and 3/5 on left side. Vertebrae midline. Sensory: Pinprick, light touch and position intact. Stereognosis and two-point discrimination not tested. Reflexes: Biceps and patellar reflexes plus 2. Babinski response negative.

Preliminary Labs: Testing ordered on first patient visit – CBC, CMP, LFT’s, glucose level, blood cultures X 2, BNP, AMI, EKG and PA and Lateral Chest X – Ray.

Results: WBC 13.8, Hgb 11.0, Hct 32.8, RDW 14.8, MPV 6.6, Neutrophil # 11.3, BNP 89, Troponin I - 0.010, Myoglobin – 33, glucose 132, BUN 35, Creatinine 1.20, eGFR Non African American 44, Potassium 5.4, AST 11, Alkaline phosphatase 82, EKG Sinus Tachycardia, Blood Culture Negative, Chest X – Ray left lower lobe infiltration

Decision Point #2: Based on the presenting symptoms of the patient the following differential diagnoses should be considered: Pneumonia, CHF, COPD, pulmonary embolism, acute MI, systemic lupus erythematosus, asthma, acute bronchitis, postnasal discharge syndrome, bronchiectasis, tuberculosis, pharmacologic and ACE inhibitor induced cough, GERD and malignancy.

When examining these differential diagnoses many can be eliminated based on the patient history, physical exam and preliminary laboratory values. Based on the patients history pharmacologic and ACE inhibitor induced cough can be eliminated as a possible diagnosis based on the patients list of medication. None of the medications listed by the patient would cause the patients symptom of cough. The patient is not currently taking an ACE inhibitor medication.

After adding in the patient’s physical assessment another reduction in the differential list can be made. The presentation of a high grade fever removes the differential diagnosis of asthma, COPD, GERD, pulmonary embolism and postnasal discharge syndrome. None of these diagnoses would account for a fever. Additional physical exam findings remove systemic lupus erythematosus from the list of possibilities due to the fact that the classic presenting factor in lupus is a butterfly rash. No rash was present on M.M during her physical examination.

An acute MI can be eliminated based on the negative Troponin and Sinus tachycardia found on the EKG. A patient with an MI also does not typically present with a high fever. This is also true for the differential of CHF. The patient’s BNP was within normal limits and no signs of peripheral edema were present of physical exam of the patient. Therefore both an acute MI and CHF can safely be eliminated as a causing factor of the patient’s illness.

The chest X – Ray results revealed a left lower lobe infiltration, but did not identify a mass or nodule thus greatly reducing the likelihood of a malignancy. The remaining differential diagnoses of acute bronchitis, bronchiectasis, tuberculosis, and pneumonia need to be further evaluated in order to be removed as a possibility.

Bronchiectasis is an abnormal widening of the airways (WHO, 2009). It results in a permanent distortion of one of the conducting bronchi or airways caused by a weakening of the muscular components of the bronchial walls (Emmons, 2009). It is characterized by a chronic productive cough, mucopurulent sputum, hemoptysis, shortness of breath, fatigue, weight loss, pleuritic pain and wheezing (Goolsby & Grubbs, 2006). Atelectasis or pulmonary cysts are often noted on the chest X – Ray resulting in wheezing or crackles noted on auscultation of the lungs (Goolsby & Grubbs, 2006). The primary criterion for diagnosis is a high resolution CT scan (Emmons, 2009). A CBC may also be used to help distinguish bronchiectasis from other conditions. A patient with bronchiectasis will present with anemia, an elevated white blood count with an increase number of neutrophils and eosinophils as well as polycythemia due to long term hypoxia (Emmons, 2009). When examining the history and exam of M.M it is evident that a diagnosis of bronchiectasis is not likely. While M.M presented with many of the physical symptoms of this disease, her diagnostic studies as well as her presence of fever limit the likelihood of this as the correct diagnosis. The chest X-ray indicated a left lower lung infiltrate, but did not reveal any evidence of Atelectasis or pulmonary cysts. While her white blood count was elevated with an increase in the number of neutrophils her eosinophils were within normal limits at 0.1%. Lab work was also negative for any signs of polycythemia. These clinical findings remove bronchiectasis from our list of differentials.

Tuberculosis, another possible diagnosis for M.M, is a bacterial infection that primarily attacks the lungs. It is spread through the air by breathing in droplets from an infected person (Tuberculosis, 2009). Symptoms of tuberculosis include cough, fever, fatigue, weight loss, and night sweats. Patients present with signs and symptoms of weeks to months duration (Fiebach, Kern, Thomas, Ziegelstein, Barker & Zieve, 2007). Goolsby & Grubbs (2006), indicate a presence of multilobular granulomas in the upper lungs identified on a chest X –ray. When sputum cultures are collected they return positive for M. tuberculosis. Chronic cough and night sweats are the most noted symptoms associated with tuberculosis. While M.M presents with a cough, it is acute in nature, only starting 3 days ago. Her chest X-ray did not reveal any signs of a granuloma. These factors make the diagnosis of tuberculosis unlikely.

The next differential to consider is acute bronchitis. Acute bronchitis is a viral or bacterial infection that causes an inflammation in the tracheobronchial tree. Coughing is a result of the hypersensitivity that results from this inflammation (Fiebach et al, 2007). Patients commonly present with a cough, fever, malaise, chest discomfort, chills and headache (Goolsby & Grubbs, 2006). Wheezes and crackles are commonly auscultated in the lungs. There is equal fremitus and no egophony (Goolsby & Grubbs, 2006). The symptoms of bronchitis are very similar to that of a pneumonia infection. According to Fiebach et al (2007) the differentiating factor in these two conditions is the lack of dyspnea in bronchitis. Bronchitis also typically has no abnormal lung finding on chest X-ray. When looking at the history and exam of M.M, bronchitis does not appear to be her diagnosis. She complains of dyspnea on exertion and reports no headache. While she presented with crackles and a productive cough, she also demonstrated positive signs of egophony which is not characteristic of a bronchitis infection. It is also important to consider the lung infiltrate evident on her chest X-ray. Due to these considerations the diagnosis of bronchitis should be excluded.

The final differential to consider is pneumonia. Pneumonia is a lower respiratory infection and inflammation of the terminal bronchioles and alveoli causing a consolidation from the accumulation of fluid in the small airways and alveolar spaces (Dunn, 2005). There are several types of pneumonia: Hospital acquired pneumonia (HAP), ventilator associated pneumonia (VAP) and Community acquired pneumonia (CAP). The type of pneumonia present helps to differentiate between a possible viral, bacterial or fungal cause (Holcomb, 2007). Since M.M. has not been admitted to the hospital in the previous 14 days nor has she been on a ventilator we will examine the characteristics of community acquired pneumonia.

Community acquired pneumonia is classified by either a typical (bacterial) presentation or an atypical (nonbacterial) presentation. The different classifications present differently. A patient presenting with bacterial pneumonia usually will have an abrupt onset of fever, nausea and vomiting, severe shaking chills, tachypnea, tachycardia and malaise with a productive cough. Sputum is typically purulent, blood tinged or rust colored, crackles are audible on auscultation and consolidation is noted on a chest X-ray (Miskovich-Riddle & Keresztes, 2006). Signs and symptoms of atypical pneumonia are generally less severe than those of typical pneumonia (Coughlin, 2007). Fever, headache, malaise, a hacking dry cough, Myalgia, diarrhea and Pharyngitis are the classic presentation representing a viral or atypical pneumonia. Some patients with viral pneumonia develop a severe earache or cutaneous rash. The symptoms of M.M match the criteria of the bacterial pneumonia more closely than that of the presentation of the viral pneumonia hence we will focus on that classification from this point.

Individuals at highest risk for developing pneumonia include those over the age of 65, the very young, individuals with multiple medical co morbidities, immunosuppression, smokers, and those on prolonged bed rest (Buckley, 2006). The laboratory findings of the individual may include: decreased hemoglobin and hematocrit, an increase in white blood cells, an elevated ESR, decreased sodium and phosphate an increase in AST, ALT, glucose, total bilirubin, Creatinine and BUN (Buckley, 2006). An acute infiltrate or evidence of consolidation on a pulmonary exam are other typical findings in pneumonia (Miskovich-Riddle & Keresztes, 2006). These finding are commonly present but it is noted that CAP can present in the absence of an infiltrate (Kleinpell & Elpern, 2004). According to Holcomb (2007) a patient who is dehydrated or intubated may not exhibit signs of pulmonary infiltrates until 1-2 days after the onset of symptoms. A sputum culture can be obtained to identify the causative agent of the pneumonia; however the American Thoracic Society does not recommend obtaining a sputum culture for outpatient therapy (Miskovich-Riddle & Keresztes, 2006). There are several indicative reasons why sputum samples are not relied upon in an outpatient setting. First an acceptable sample is difficult for a patient to produce, interpretation of gram stains are not standardized, atypical pathogens could be missed and waiting results of a sample will delay treatment (Kleinpell & Elpern, 2004). A delay in antibiotic therapy has been associated with an increase risk of death therefore prompt and accurate diagnosis and initiation of antibiotic therapy are essential at achieving desirable outcomes (Kleinpell & Elpern, 2004). After looking at the history and physical exam findings of M.M the diagnosis of pneumonia should be the top differential diagnosis.

Decision Point #3:

At this point additional testing that could be performed would obtain the purpose of further clarifying and supporting the elimination of differential diagnoses. A chest CT could be preformed to completely rule out the diagnosis of bronchiectasis. A D-dimer and a VQ scan could be ordered to eliminate the possibility of a pulmonary embolism. And a skin PPD test could be performed to rule out the possibility of tuberculosis. To strengthen the diagnosis of pneumonia an ESR could be drawn for an indication of the presence of inflammation. A confident diagnosis of pneumonia can be made based on the existing tests completed. A sputum culture could be obtained to determine the exact type of causative organism; however it is not indicated in outpatient treatment of pneumonia. If the patient does not respond to the initial treatment initiated or the patient’s condition deteriorates sputum culture should then be considered.

Decision Point #4:

The suspected diagnosis for this patient is community acquired bacterial pneumonia. This diagnosis is based on the presenting symptoms of a productive cough, high fever and chills. It is supported by the patient’s presentation of tachycardia, tachypnea, rust colored sputum, audible crackles on auscultation, dullness to percussion, positive egophony and the presence of an infiltrate on chest X-ray. Additional supporting factors include the elevation of white blood cells, decreased hemoglobin and hematocrit, an increased BUN, Creatinine and potassium level and an elevated glucose.

The initial management of community acquired bacterial pneumonia is aimed at a rapid diagnosis and initiation of appropriate antibiotics to reduce morbidity and mortality. Kleinpell & Elpern (2004) indicated recent data showed that antibiotics should be initiated within 4 hours of presentation. In addition to starting antibiotics it is important to determine how sick your patient is and where treatment should take place. Several tools have been designed to assist the provider in determining the site of treatment. A scoring system has been developed to identify the patient’s risk for mortality. The Pneumonia Patient Outcomes Research Team (PORT) developed a Severity Index (PSI) aimed at identifying the most at risk patients (Kleinpell & Elpern, 2004). This index assesses hypoxemia, ability to maintain oral intake and adequate home care support to assign a risk class for each individual patient (Kleinpell & Elpern, 2004). Patients who score in a risk class I, II, or III are considered low risk and can obtain treatment on an outpatient basis, while those falling in class IV or V should be hospitalized for treatment (Kleinpell & Elpern, 2004). Other tools used to aid in the determination of patient severity and need for hospitalization are the CURB-65 and CRB-65. This tool uses the patient’s mental status, urea level, respiration and blood pressure as a basis for determining initial placement for management (Dunn, 2005). Providers are encouraged to incorporate their clinical judgment when deciding location of treatment.

Treatment with a broad spectrum antibiotic is recommended since the exact organism is not known (Miskovich-Riddle & Keresztes, 2006). The goal is to provide immediate treatment to reduce mortality and morbidity; waiting on results from a sputum sample to indicate the afflicting organism is therefore not indicated. If the patients condition does not improve with initial treatment of a broad spectrum antibiotic such as amoxicillin it may be necessary to order a sputum sample to find a more appropriate course of treatment. Table 1 provides a list of specific affecting organisms and the antibiotics used to treat them if a sample is obtained.

Three sets of guidelines have been developed for the treatment of CAP. The guidelines were developed by the American Thoracic Society (ATS), The IDSA and the Centers for Disease Control and Prevention (Miskovich-Riddle & Keresztes, 2006). The CDC recommends a macrolide or Doxycycline or beta-lactam for outpatient CAP. Newer fluoroquinolones can be given to those with allergies to the above (Miskovich-Riddle & Keresztes, 2006). The ATS guidelines are based on three criteria: age, co morbidity and antibiotic use within the previous three months (Miskovich-Riddle & Keresztes, 2006). Table 2 describes the recommended interventions from the American Thoracic Society. The interventions from the IDSA were based on evolving resistance to antimicrobial agents, initial empiric therapy and pathogen-specific therapy. Due to the similarities between the guidelines established by the IDSA and the ATS a combined consensus guideline from the two agencies is undergoing its final stages of development (Miskovich-Riddle & Keresztes, 2006). In order to prevent resistance to antibiotic therapy there is a recommended use of high doses of antibiotics with longer durations (Miskovich-Riddle & Keresztes, 2006). Table 3 provides a detailed list of commonly prescribed medications based on drug class and their recommended dosages. Since the exact organism of infection is not known M.M was prescribed amoxicillin 500 mg every 8 hours for 14 days. She was also told to take Tylenol for her pleuritic pain and fever.

Decision Point #5:

No additional testing was done based on the solid evidence already available to support the diagnosis of Bacterial Community Acquired Pneumonia. The patient responded well to the amoxicillin and reported improvement in cough pleuritic pain. The patient denies fever or shortness of breath. She denies any further concerns at this time.

M.M. was encouraged to increase her fluids in order to thin secretions from her lungs. She was encouraged to drink an average of 2.5 liters of fluid per day to replenish fluid lost by the skin with fever as well as through the kidneys (Dunn, 2005). M.M was also encouraged to cough and deep breathe to aid in the expectoration of mucus therefore improving ventilation (Dunn, 2005). Dunn (2005) suggested a balanced diet to aid in recovery and positioning the patient at an upright angle to ensure adequate ventilation and to prevent choking or aspiration. Buckley (2006) suggested the importance of a quiet environment with frequent rest periods as well as emotional support to aid in the healing process.

Prevention of further infection are also recommended by encouraging frequent hand washing to prevent the spread of germs to others. It is also recommended that patients at higher risk receive annual influenza vaccines as well as a singe pneumococcal vaccination to reduce their chances of a recurrent pneumonia episode. Patients are also encouraged to get plenty of rest and to stay warm during winter months wearing hats, gloves and scarves to cover their mouth when outside. Patients are also instructed to avoid areas where there is cigarette smoke and if they smoke, cessation information should be provided. She is advised to return for a follow up visit in 2 weeks to make sure she is improving. She is instructed to go to the emergency room if symptoms become worse or she is having difficulty breathing.

Case Study Summary:

M.M presented to an outpatient clinic visit complaining of cough and chills. Her physical assessment revealed tachycardia, tachypnea and productive cough with rust colored sputum. Crackles were audible in her lower left lung and percussion of the affected area revealed dullness. A chest x-ray illustrated a left lower lobe infiltrate. Many different differential diagnoses were evaluated for the presenting symptoms of cough and fever. The most promising differentials were acute bronchitis, bronchiectasis, tuberculosis and pneumonia which were evaluated in greater detail. After examining the patient history, physical exam and diagnostic testing it was concluded that the patient had the diagnosis of Bacterial Community Acquired Pneumonia. She was treated with a broad spectrum antibiotic and instructed to follow up in 2 weeks or sooner if symptoms became worse.

Table 1.

|Organism |Suggested Antimicrobial Therapy |

|Streptococcus pneumoniae |Preferred: Penicillin G, Amoxicillin |

| |Alternative: Macrolides, ceftriaxone, Doxycycline, |

| |fluoroquinolones, clindamycin, vancomycin |

|Haemophilus influenzae |Preferred: Cefotaxime, ceftriaxone, cefuroxime, Doxycycline, |

| |Azithromycin, TMP-SMZ Alternative: Fluoroquinolones, |

| |clarithromycin |

|Staphylococcus aureus |For methicillin – susceptible strains: Preferred: A penicillinase|

| |– resistant penicillin with or without rifampin or gentamicin, |

| |linezolid Alternative: cefazolin, clindamycin, TMP-SMZ, |

| |vancomycin For methicillin – resistant strains: vancomycin with |

| |or without gentamicin or rifampin |

|Klebsiella |Preferred: Third – generation cephalosporin. For severe |

| |infections add an aminoglycoside Alternative: aztreonam, |

| |imipenem, beta – lactam/beta-lactamase inhibitor, or a |

| |fluoroquinolone |

|Escherichia coli |Same as for Klebsiella pneumoniae |

|Mycoplasma pneumoniae |Preferred: Doxycycline or erythromycin Alternative: |

| |Clarithromycin; Azithromycin or a fluoroquinolone |

|Chlamydia pneumoniae |Preferred: Doxycycline Alternative: Erythromycin, clarithromycin,|

| |Azithromycin, or a fluoroquinolone |

|Legionella species |Preferred: a macrolide with or without rifampin; or a |

| |fluoroquinolone |

|Morexalla catarrhalis |Preferred: A second or third generation cephalosporin, |

| |amoxicillin-clavulanic acid or a macrolide Alternative: TMP-SMZ, |

| |A fluoroquinolone |

|Pneumocystis carinii |Preferred: TMP-SMZ or pentamidine isethionate plus prednisone |

| |Alternative: Dapsone plus trimethoprim; clindamycin plus |

| |primaquine; trimetrexate plus folinic acid, pentamidine |

|Pseudomonas aeruginosa |Preferred: an antipseudononal beta-lactam plus an aminoglycoside |

| |or an antipseudomonal beta-lactam |

(Chart as cited in Kleinpell & Elpern, 2004)

Table 2.

|ATS Recommended Interventions |

|In 2001, the American Thoracic Society (ATS) recommended interventions based on age, comorbidity, or antibiotic use within the past|

|3 months. Patients are stratified into four groups. |

|Group I |

|Outpatients with no cardiopulmonary disease and no modifying factors. Includes antibiotic-naïve patients without comorbidity or |

|factors such as older than 65 years of age, alcoholism, immunosuppressive illness, or exposure to a child in a daycare center |

|Antibiotic recommendation: Advanced-generation macrolide or Doxycycline |

|Group II |

|Outpatients with cardiopulmonary disease (chronic heart failure or chronic obstructive pulmonary disease) or modifying factors. |

|Antibiotic recommendation: Beta-lactam plus an advanced generation macrolide or Doxycycline; a fluoroquinolone may be used |

|independently for outpatients with acute exacerbations immuno-suppression, severe comorbidities, drug resistance, or antibiotic use|

|in the previous 3 months. |

|Group III |

|Non-intensive care unit (ICU) inpatients who fall into one of the following subcategories: |

|Cardiopulmonary disease, and/or other modifying factors, including being from a nursing home Antibiotic |

|Recommendation: I.V. beta-lactam (high-dose ampicillin, Cefotaxime (claforan), ceftriaxone (rocephin), ampicillin/sulbactam |

|(unasyn)) plus I.V. or oral macrolide or Doxycycline or an I.V. antipneumococcic fluoroquinolone alone |

|No cardiopulmonary disease and no other modifying factors Antibiotic recommendation: I.V. macrolide alone; Doxycycline and a |

|beta-lactam; or an antipneumococcic fluoroquinolone |

|Group IV |

|ICU-admitted patients; the ATS developed two subcategories |

|No risk for Pseudomonas aeruginosa |

|Risks for Pseudomonas aeruginosa |

(As cited in Miskovich-Riddle & Keresztes, 2004)

Table 3.

|Commonly Prescribed Antibiotics and Recommended Dosages |

|Beta-lactams |

|Amoxicillin 500 mg to 1 gram every 8 hours |

|Amoxicillin/clavulanate (Augmentin) 2 grams every 12 hours |

|Macrolides |

|Clarithromycin (Biaxin) 250 to 500 mg every 12 hours for 7 to 14 days |

|Clarithromycin (Biaxin) extended-release 1,000 mg one daily for 7 days |

|Azithromycin (Zithromax) 500 mg first day, then 250 mg/day for 4 days |

|Erythromycin 250 to 500 mg twice daily |

|Fluoroquinolones |

|Moxifloxacin (Avelox) 400 mg once daily for 7 to 14 days |

|Levofloxacin (Levaquin) 500 mg one daily for 7 to 14 days OR 750 mg once daily for |

|5 days |

|Gemifloxacin (Factive) 320 mg once daily for 7 days |

|Gatifloxacin (Tequin) 400 mg once daily for 7 to 14 days |

|Ketolide |

|Telithromycin (Ketek) 800 mg once daily for 7 to 10 days |

(As Cited in Miskovich-Riddle & Keresztes, 2004)

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