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Latest IDSA PNEUMONIA Guidelines Nov(web)/Dec(print) 2003 (updates 2000 which replaced 1998)
QUIZ
A 32 yo M high school teacher is diagnosed with pneumonia in the emergency room, HIV neg history His pneumonia PORT Severity Index score (see p1426) is recorded on the chart as "Class I" by the ED resident. His temperature is 37 C, no fever at home. CXRay shows LLL infiltrate consistent with crackles on exam. He has no recent travel but one of his students just returned from Hong Kong but is not ill. Resident checks CDC website on ED computer - Hong Kong "areas with community transmission of SARS." no other students ill, no recent antibiotic tx, no allergies, no COPD, DM, renal failure, CHF or malignancy
(1) choose one A) treat as outpatient; since "Hong Kong" reference documented, document why SARS still not suspected B) outpatient but collect sputum first; any reference to SARS in the U.S. in 2004 could not be an issue C) inpatient IV antibiotics D) admit to ICU with respiratory and contact isolation - fits CDC definition of "suspected SARS" (p 1416)
(2) treatment options A) doxycycline, erythromycin, azithromycin or clarithromycin po B) azithromycin, clarithromycin, ciprofloxacin or amoxicillin-clavulanate po C) azithromycin plus cefotaxime or ceftriaxone (or other selected B-lactams) D) azithromycin, clarithromycin or levofloxacin (or other resp fluroquinolone but not Cipro)
(3) same scenario but patient has DM (or CHF or RF or COPD or malignancy) A) doxycycline, erythromycin, azithromycin or clarithromycin po B) azithromycin, clarithromycin, ciprofloxacin or amoxicillin-clavulanate po C) azithromycin plus cefotaxime or ceftriaxone (or other selected B-lactams) D) azithromycin, clarithromycin or levofloxacin (or other resp fluroquinolone but not Cipro)
(4) a 53 yo F with DM is being admitted to GMB for com acq pneumonia (CAP), no recent antibiotic therapy a) Moxifloxacin, gatifloxacin, levofloxacin or ciprofloxacin alone b) Moxifloxacin, gatifloxacin or levofloxacin alone c) Azithromycin (or clarithromycin) plus cefotaxime (or other select B-lacatam) d) Moxiflox.,gatiflox or levoflox plus B lactam (ie, cefotaxime) e) b or c f) c or d
(5) before patient leaves ED or receives antibiotics, admitting physician realizes pt should be admitted to ICU, pseudomonous is not a suspected issue a) Moxifloxacin, gatifloxacin, levofloxacin or ciprofloxacin alone b) Moxifloxacin, gatifloxacin or levofloxacin alone c) Azithromycin (or clarithromycin) plus cefotaxime (or other select B-lacatam) d) Moxiflox.,gatiflox or levoflox pus cefotaxime (or select B-lactam) e) b or c f) c or d
(6) Which would be LEAST useful test in the 53 yo patient table 4, p 1412 a) blood culture b) sputum C&S c) Legionella urinary antigen d) Legionella culture of resp secretions e) Chlamidophilia pneumoniae single IgM titer or PCR of secretions f) Influenza a/b antigen g) RSV antigen
(7) the 53 yo with DM is being discharged on December 5, the medical student has written DAILY on problem list - no hx of pneumococcal vaccine or flu shot (and no contraindications)
a) pt to receive injected influenza vaccine (preferred over FluMist since not age 5-49) upon discharge, repeat every Oct/Nov, the patient is given written documentation (ie, a pre-printed wallet card or added to med list) indicating this, this is dictated on discharge summary b) remind household contacts to receive injected influenza vaccine repeat yearly because patient has DM c) every member of house staff even if no contact with this patient, INJECTED influenza vaccine yearly in Oct/Nov ideally but now ok d) pt to receive Pneumovax and documentation before discharge since she has DM, year of vaccination is placed on patient's med list, dictated on disc summary and written on all future H&Ps e) ask patient's 66 yo husband to discuss Pneumovax with his doctor based on his age f) HIV TESTING with consent for the patient during admission since she is between 15-54 g) a through e h) a through f
ANSWERS:
1)a, PORT Class I supports outpatient tx without identification of organism 2)a, outpatient treatment without comorbidities, no recent antbx 3)d, outpatient with comorbidity, no recent antbx 4)e, inpatient medical ward 5)f, inpatient ICU, if pseudomonas not an issue 6)g, RSV testing not recommended in adults - insensitive 7)h, p1422-24 for vaccines; see table 4 p1412 lab test-general assessment for HIV testing
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