Clinical Case Discussion: Community Acquired Pneumonia

CLINICAL
CASE
DISCUSSIO
N Presenter-
Dr Nikita Ingale
Jr3
Pharmacology
PG Guide-
Dr Vijay Motghare
Professor and head
Pharmacology

• Name – XYZ
• Age – XX yrs
• Sex- Male
• Registration no – ------
• Ward – ward—
• Date of admission –------ at 10:00 am
Patients profile -
CCD- Community acquired pneumonia 25/09/19

Admission notes by Jr2 on 3/09/19-
- Patient came to medicine OPD with
Chief complaints  Fever, chills - 5 days
 Cough - 5 days
 Breathlessness - 3 days
 Pain in Right Hip - 20 days

CCD- Community acquired pneumonia
Admission notes by jr2 on 3/09/19-
No History of - Chest pain
- Hemoptysis
- Conscious & oriented
- Febrile with chills
- Temp - 1020F
- Tachypneic , RR- 62/min
- BP 120/70 mm Hg
- RBS 110mg/dl
- SPO2 - 82% on Room and 95% on O2
On examination-
25/09/19

- Pulse 140/min, regular
- No pallor/ icterus/ cyanosis/ Lymphadenopathy/ edema
- Jugular Venous Pressure Normal
- Hypopigmented patch with islands of hyperpigmentation
over B/L medial malleolus
- Tenderness over right hip & inguinal region with restricted
motility .
Admission notes by jr2-
25/09/19

- Respiratory System: B/L Coarse Crepitations
- Decreased air entry on both sides
- Cardiovacular system: Tachycardia
- Per abdomen examination: Soft , No Hepatosplenomegaly
- Central nervous system – within normal limits
Admission notes on 3/09/19-
Systemic
examination
25/09/19

Arterial blood gas findings-
- pO2 80mmHg
- pCO2 28.9mmHg
- PaCO2 4 kPa
- pH 7.59
- HCO3
- 28.6mEq/L
- SpO2- 96.8%
Respiratory alkalosis
25/09/19

Blood investigations
Complete blood count –
- TLC 11000/mm3
- P- 73% L- 25% E-% M-%
- Hb 8 gm%
- Platlets - 213000/mm3
Advised-
- Sputum routine microscopy
- AFB
- CBNAAT
- H1N1 PCR
- HIV
25/09/19
- MCV 90 fl
- RDW 18.5%
- KFT – normal and LFT – normal
- CRP : 103 IU/ ml

Reports for advised investigations-
Sputum:
Routine & Microscopy
- Gram Positive Cocci in Clusters & Chains
- >25 leucocyte/HPF
- AFB – NEGATIVE
- CBNAAT – NEGATIVE
- H1N1 PCR – NEGATIVE
- HIV - NEGATIVE
Advised-
- Chest xray
- HRCT
25/09/19

Chest Xray
Findings –
Chest xray was s/o B/L heterogenous
opacities diffusely spread across the lung
fields.
Radiological findings-
DIAGNOSIS
Community Acquired Pneumonia
3/09/19

Radiological findings-
HRCT thorax
- B/L mosaic attenuation with ground glass opacities.
- Peripherally distributed patchy areas of consolidation with central cavitation
- S/O Infective Etiology
- B/L moderate pleural effusion.
3/09/19
25/09/19

Treatment notes on 3/09/19-
- Supplemental Oxygen
- Inj. Piperacillin-tazobactam 4.5 gm I.V. TDS
- Inj. Azithromycin 500 mg I.V. OD
- Tab Oseltamivir 75 mg BD
- Nebulization with bronchodilator 6 hrly
- With supportive treatment
- General condition = moderate
- BP = 128/70 mm Hg
- RBS = 110
- Temp = 102 degree C
- SP02 = 82%
- Resp rate = 62/ min
- Pulse = 140/ min
25/09/19

- BP = 120/70 mm Hg
- RBS = 106
- Temp = 100.2 degree C
- SP02 = 80%
- Pulse = 136/ min
25/09/19

- Pt did not respond to the
given treatment
- which was evident from
persistent tachypnea
(over next 48 hours) even
though pt. was maintaining
O2 saturation
25/09/19

- pt. was started on AKT
.
[ all first line anti tubercular drugs ]
25/09/19
- BP = 110/70 mm Hg
- RBS = 110
- SP02 = 86%
- Pulse = 128/ min

Treatment notes on 6/09/19 to 8/09/19-
- AKT [ all first line anti tubercular drugs ]
.
Patients tachypnea was still persistant, with the treatment for 6 days
Advised-
- CT Pelvis
- repeat HRCT
- Chest Xray
25/09/19

Repeat HRCT thorax + CT Pelvis
• Peripherally distributed patchy areas of
consolidation with central cavitation &
mediastinal lymphadenopathy
• B/L pleural effusion
• B/L Hip effusion with collection in Right
Thigh
• DVT in RT external iliac vein
• Repeat Chest xray-
• Increased heterogenous opacities with
• Multiple Cavitations
• within consolidation
08/09/19

Can be it something else….??
• Cavitatory Lung Disease
• Joint Involvement
• Venous Thrombosis
• Skin Involvement
??Autoimmune/
Connective Tissue
Disorder??
ANA by IFA: Negative
RA Factor: Negative
p-ANCA : Negative
c-ANCA: Negative
Sr. ACE Level: Normal
No connective tissue / autoimmune disorder
25/09/19

- Inj. Linezolid 600mg I.V. BD added
CXR & HRCT were
s/o Staphylococcal
Pneumonia
25/09/19

Treatment notes on 10/09/19 to 12/09/19-
- Inj. Linezolid 600mg I.V. BD added
Patients tachypnea was still persistant, with the treatment for 4 days
- BP = 118/70 mm Hg
- RBS = 118
- SP02 = 82%
- Pulse = 118/ min

Pt. was subsequently started on -
- Inj. Meropenem 1 gm I.V. TDS
- Inj. Clindamycin 600 mg I.V. BD
- Inj. Colistin 3mIU stat f/b 2mIU I.V TDS
- Inj. Ulinastatin 2lac Units BD for 5 days
- Cap Oseltamivir was cntd
- AKT was cntd [ all first line anti tubercular drugs ]
The entire treatment
regimen was changed as
the pts conditioned showed
no improvement
25/09/19

- AKT was cntd
Same treatment given
25/09/19

- AKT was cntd
25/09/19

- AKT was cntd
Advised-
- Repeat HRCT thorax
- Repeat Chest Xray
25/09/19No improvement , with the treatment for 6 days

• HRCT THORAX-
• Cavitatory consolidation &
pneumatocoele formation.
• Rupture & coalition of cavities to
form large septated B/L
hydropneumothorax.
• Interstitial septate thickening noted in
B/L lung most marked in upper lobe.
Pneumatocele
• Chest Xray-
• Pneumatocele formation
16/09/19

Seen by lecturer on 17/09/19--
- Pt’s dyspnea increased & SPO2 fell < 90% even on high flow O2
- Pt had extreme tachycardia with a HR of 160/min.
- On examination pt. had hyper-resonant note all over rt lung field & trachea was
shifted to left & absent A/ E bilaterally.
- Urgent CXR was done which was s/o
Rt sided tension pneumothorax probably d/t spontaneous
rupture of pneumatocele.
25/09/19

Lecturer notes on 17/09/19-
• Pt was taken for urgent inter Costal Drainage insertion under Local anesthesia
• Which resulted in dramatic improvement in pt’s clinical condition, ICD fluid sent for culture
sensitivity
B/L ICD
IN-SITU
25/09/19

Lecturer notes on 20/09/19-
- As patient was symptomatically better
- And breath sounds were now present in B/L lung fields
- ICD removal was planned
- His Right ICD was removed
- Pt was shifted on Inj. Amoxiclav.
- Inj. Amikacin (as ICD fluid sent for culture was positive for Acinetobacter sp,
sensitive to Amikacin).
25/09/19
Treatment given for 3 days

Current status of the patient-
- Patient was vitally stable
- Dyspnea had resolved completely.
- Patient was finally discharged on oral antibiotics like amoxiclav 625 mg TDS for 7
days and AKT.
- Chest xray was done, which was normal
25/09/19

Community acquired pneumonia-
Community Acquired Pneumonia (CAP) can be defined as:
(a) symptoms of an acute lower respiratory tract illness (cough with or without expectoration,
shortness of breath, pleuritic chest pain) for <1 week
(b) at least one systemic feature (temperature >37.7°C, chills, and rigors, and/or severe malaise)
(c) new focal chest signs on examination (bronchial breath sounds and/or crackles)
(d) no other explanation for the illness
[National College of Chest Physicians India, Indian chest society and PGI Chandigarh

Streptococcus pneumonia-
 Most common cause of CAP
 About 2/3rd of CAP are due to S.pneumoniae
 Typical symptoms (e.g. malaise, shaking chills, fever, rusty sputum, pleuritic chest pain, cough etc)
 Lobar infiltrate on Chest Xray
 Common in Immuno suppressed host
 25% will have bacteremia – serious effects
25/09/19

Clinical features -
• Fever, cough with or without sputum production, dyspnea, myalgia, malaise, fatigue, GI
symptoms and pleuritic chest pain.
• Physical examination may reveal focal areas of bronchial breathing, wheeze/ crepitations.
Strong predictors of CAP:
• Temperature >100.4°F,
• heart rate >110 beats/min, and
• pulse oximetric saturation <96%
25/09/19

Etiology -
- Global data-
- Streptococcus pneumoniae is the most
common etiological agent
- Viruses are responsible for CAP in as
much as 10–36% of the cases.
- Legionella pneumophila
- Mycoplasma
- Staphylococcus aureus
- Indian data-
- Strepto. pneumoniae (35.3%)
- Mycoplasma pneumoniae(23.5%)
- Klebsiella pneumoniae (20.5%)
- Haemophilus influenzae (8.8%).
- Staphylococcus aureus 15%
25/09/19
- Staphylococcus aureus, Klebsiella pneumoniae and Pseudomonas aeruginosa are not
typical causes of CAP in otherwise healthy hosts.

Are there any Guidelines for management of CAP-
• A joint exercise by the Department of Pulmonary Medicine, PGI Chandigarh
• with sponsorship from two National Pulmonary Associations (Indian Chest Society and National
College of Chest Physicians)
• Representation and experts: Departments of Internal Medicine, Microbiology, Pharmacology and
Radiodiagnosis, PGI Chandigarh
 American Thoracic Society
 Infectious Diseases Society of America
 British Thoracic Society
 European Respiratory Society
25/09/19

Empirical treatment -
Initial empiric antibiotic treatment based on-
-the most likely pathogen in the locality and knowledge of local susceptibility patterns
• The empiric antibiotic treatment is primarily aimed at Str. pneumoniae as it is the most prevalent
organism in CAP.
• The commonly used antibiotics are either b-lactams or macrolides
Indications for empiric combination therapy in CAP:
• Chronic heart, lung, liver, or renal disease
• Diabetes mellitus
• Alcoholism
• Malignancies
• Severe CAP with or without co-morbidities
- In non-severe CAP, a diagnosis
should be established before
starting antibiotics
- In severe CAP, antibiotics should
be administered as soon as possible
preferably within 1hr

Recommendations for outpatient setting-
- Therapy should be targeted toward coverage of the most common organism, namely Strepto
pneumoniae
- Recommended antibiotics [are oral macrolides (e.g. azithromycin and others) or oral β-lactams
(e.g. amoxicillin 500–1000 mg thrice daily) for outpatient without comorbidities
- For outpatients with comorbidities , oral combination therapy is recommended (β-lactams plus m
acrolides)
- There is insufficient evidence to recommend tetracyclines
and Fluoroquinolones for empiric treatment
- Antibiotics should be given in appropriate doses to prevent
emergence of resistance
25/09/19

Recommendations for inpatient non-ICU settings-
- The recommended regimen is combination of a β-lactam plus a macrolide (preferred β-lactams
include cefotaxime, ceftriaxone, and amoxicillin–clavulanic acid)
- In the uncommon scenario of hypersensitivity to β-lactams, respiratory fluoroquinolones
levofloxacin 750 mg daily) may be used if tuberculosis is not a diagnostic consideration at admission
- Patients should also undergo sputum testing for acidfast bacilli simultaneously if fluoroquinolones
are being used in place of β-lactams.
25/09/19

Recommendations for inpatient ICU settings-
- The recommended regimen is a β-lactam (cefotaxime, ceftriaxone, or amoxicillin–clavulanic acid)
plus a macrolide for patients without risk factors for P aeruginosa
- If P. aeruginosa is an etiological consideration, an antipneumococcal, antipseudomonal antibiotic
(e.g. cefepime, ceftazidime, cefoperazone, piperacillin– tazobactam, cefoperazone–sulbactam,
imipenem, or meropenem) should be used
- Combination therapy may be considered with addition of aminoglycosides/ antipseudomonal
fluoroquinolones (e.g. ciprofloxacin)
- Fluoroquinolones may be used if tuberculosis is not a diagnostic consideration at admission
- If a patient does not respond to treatment within 48–72 h, he/she should be evaluated for the cause
of non-response, including development of complications, presence of atypical pathogens, drug
resistance
25/09/19

Any role of immunization?
- Routine use of pneumococcal vaccine among healthy immunocompetent adults for
prevention of CAP is not recommended
- Pneumococcal vaccine may be considered for prevention of CAP in special
populations who are at high risk for invasive pneumococcal disease
- Influenza vaccination should be considered in adults for prevention of CAP
25/09/19

Rationality-
- Inj. Piperacillin-tazobactam  empirical treatment of community acquired pneumonia
[ ceftazidime could be a better option]
- Inj. Linezolid  staphylococcal pneumonia
- Inj. Meropenem  active against both gram-positive and gram- negative bacteria, aerobes , anaerobes
- Inj. Clindamycin  for anaerobic coverage
25/09/19

Rationality-
- - Inj Amoxiclav  prescribed after ICD fluid culture sensitivity
- Inj Amikacin prescribed after ICD fluid culture sensitivity
- Supplemental oxygen  to maintain saturation
25/09/19

Irrationality -
- Tab Oseltamivir  prophylactically to prevent H1N1 as the patient was admitted in the ward with H1N1 cases
on the nearby beds [Isolation of the patient was a better option]
- Inj Azithromycin  not needed empirically in nonsevere CAP when piperacillin tazobactum was already
prescribed
- Inj. Colistin  basic polypeptide active against gram-negative bacteria, more potent on Pseudomonas
- Inj. Ulinastatin urinary trypsin inhibitor [glycoprotein] clinically used for the treatment of acute pancreatitis
, chronic pancreatitis, burns, septic shock, and toxic epidermal necrolysis
- None of the antibiotics given as a full course treatment

Irrationality -
- No culture sensitivity for pleural fluid done
- AKT- Started when no tuberculosis symptoms
- Sputum AFB, CBNAAT –ve
- No mantaux test done
- should have been discontinued at discharge as chest xray was normal
- No temperature charting done to correlate tubercular symptoms to continue AKT
- Repeated Chest Xrays and HRCTs done- diagnostic modalities [ overburdening govt setups with already high
patient load]
- Brand names and short forms used
25/09/19

Clinical Case Discussion: Community Acquired Pneumonia

Clinical Case Discussion: Community Acquired Pneumonia

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