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Charles Krasner, M.D.

University of NV, Reno School of Medicine

Sierra NV Veterans Affairs Medical Center
Kathy Peters is a 63 y.o. patient that presents to your urgent
care office today with a history of coughing and wheezing for
the past 5 days. Originally, she thought she was getting a cold;
however, her symptoms have been getting worse, and she
states she has never felt this "wiped out" from a cold. She is
here to see you today because she feels like she has become
more short of breath over the past 24 hours.
She tells you that she started feeling sick approximately 5
days ago. It started with a dry cough; however, over the past
couple days she has expectorated some clear, and more
recently, thicker rust-colored, mucous. She denies frank
blood in her sputum. She notices some wheezing after
coughing spells. This morning, Kathy woke up in a
"coughing fit" and she said she felt some sharp pain in her
chest. She rates the pain a 5/10 when it occurs. Kathy has
felt feverish over the past few days; she sometimes gets the
"chills." Her highest temperature was 102 degrees

PMH: hypertension
Habits: smoker for 30 years
 BP: 110/80, HR: 96, RR: 26, T: 101.6, SpO2:
94% on room air
 Physical exam: fatigued appearing, congested
 Wheezing and rhonchi right lower chest with
As you consider all of her presenting
symptoms and history you begin to think that
the most likely choice out of your differential
diagnosis list is:

 a. Asthma
 b. Chronic Bronchitis
 c. Nosocomial Pneumonia
 d. Community-Acquired Pneumonia (CAP)
 Candida albicans
 Staph aureus
 Strep pneumonia (pneumococcus)
 Pseudomonas aeruginosa
 Mycoplasma pneumonia
 Chest radiography
 Blood cultures
 Arterial blood gases
 Sputum cultures
a. M. pneumoniae
b. S. Pneumoniae
c. C. pneumoniae
d. A virus
e. Legionella
 The CURB-65 scale is a simple test to determine pneumonia
severity, but it is not a substitute for clinical judgment. Clinicians
should assign 1 point for each criteria met by the patient.

 •C onfusion
 •Blood U rea Nitrogen (BUN) >20 mg/dL
 •R R >/= 30
 •B P (systolic <90 mmHg or diastolic </= 60 mmHg)
 •>/= 65 y.o.

 If the individual scores 0-1 points, outpatient treatment is

 2 points indicates hospitalization and inpatient treatment.
 Greater than or equal to 3 points warrants inpatient treatment in
the ICU.

The most appropriate antimicrobial for
• A macrolide (azithromycin) OR doxycycline
• Combination therapy with a macrolide AND doxycycline
• Combination therapy with a beta-lactam (high dose amoxicillin,
Augmentin) AND doxycycline
• A respiratory fluoroquinolone (levofloxacin, moxifloxacin)

If Kathy had taken antibiotics in the last 3

months, ciprofloxacin would be an appropriate
• True
• False
Why classify pneumonia?

 Critical difference between these two types as

different organisms can be responsible
 Pneumonia treatment is almost always initially
empiric, therefore knowledge of the likely
pathogens is essential in selecting antibiotic
 Pneumonia acquired outside the hospital in
the immunocompetent host
 Often have comorbities that make them
susceptible to more severe disease and need
for hospitalization - CHF, diabetes, COPD,
renal insufficiency, stroke
 It’s Strep pneumoniae (pneumococcus) till proven otherwise-
from mild to severe cases, it’s the # 1 cause of CAP. Starts
with shaking chills and rusty sputum
 “Typical”(seen on gram  “Atypical”(not seen)-
stain) diagnosed by serology
Haemophilus influenza Mycoplasma pna
Moraxella catarrhalis Chlamydia pna
Legionella pna
 Young healthy people, mild disease-
Mycoplasma pneumoniae
 Young healthy people with severe disease-
Strep pneumoniae
 Smokers-
Strep pneumoniae, Haemophilus influenza, Moraxella
Empiric treatment must always cover possibility
of S. pneumonia:
Active against: Strep? Atypicals? Example
Penicillin Yes No Augmentin
Cephalosporin Yes No ceftriaxone
Macrolides Yes (+/-) Yes Z-pak
Quinolones Yes Yes Levoquin
Doxycycline Yes Yes Doxycycline
 Healthy outpatient, no prior antibiotic use:
azithromycin, doxycycline for mild pneumonia
 Outpatient mild-moderate infection, comorbities,
prior Z- pak: Levofloxacin (generic)
 Inpatient Med Ward – azithromycin and ceftriaxone iv,
transition to oral levofloxacin
 ICU admit – ceftriaxone and azithromycin- consider
adding Vancomycin if cavities on CXR;, but follow
cultures to quickly adjust meds to micro lab results
 Watch for empyema/exudative effusion as
complication of pneumococcus if patient remains
febrile. May need chest tube