aspiration pneumonia general medicine rotation 12 15 09
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TRANSCRIPT
ASPIRATION PNEUMONIATRENNETTE R. GILBERT, PHARM D. CANDIDATEUNIVERSITY OF SOUTHERN NEVADA COLLEGE OF PHARMACY
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Objectives
Discuss background, epidemiology, and pathogenesis of aspiration pneumonia
Discuss risk factors for aspiration pneumonia
Discuss diagnosis, treatment, and monitoring response to therapy
Relate above objectives to patient case
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Aspiration Pneumonia
Aspiration: inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract Relatively common event Pneumonia is a consequence of aspiration
2 factors required for pneumonia to occur:1. Compromise of inherent defense mechanisms2. Bacterial burden must be large enough to cause infection
“True” aspiration pneumonia caused by normal flora Oral cavity Nasopharynx Gastrointestinal bacteria
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Epidemiology
Incidence 2nd most frequent dx in hospitalized
Medicare patients Definition has not always been consistent
Etiology Most cases caused by anaerobes
CA: usually anaerobes alone HA: usually anaerobes + aerobes, polymicrobial
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Risk factors for aspiration
Reduced consciousness Neurologic deficits GI disorders Anesthesia Protracted vomiting Large volume tube feedings
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Signs/Symptoms
Predisposing condition for aspiration Putrid sputum Common pneumonia symptoms
Fever > 38°C Leukocytosis/leukopenia Productive cough Decline in oxygenation
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Diagnosis
Suspect pneumonia if: New or progressive infiltrate seen on chest
x-ray AND signs/symptoms of systemic infection
Lower respiratory tract sampling Bronchoalveolar lavage or protected
specimen brush Culture specimen
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Treatment
Treat hypoxemia/provide oxygen Empiric antibiotic selection depends on
setting/patient characteristics No clear guidelines on which regimen is best If nosocomial, more virulent bacteria s/b
targeted CA:
Respiratory FQ + clindamycin, metronidazole OR β-lactam/ β-lactamase inhibitor
HA: GNB coverage + clindamycin, metronidazole +/-
vancomycin
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Monitoring Response to Therapy Vitals
Tmax, HR WBC
Should be trending down CXR
Should see improvement Oxygenation
Should see O2 sat increase Should be able to ↓ supportive oxygenation
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Patient Case
AS is a 76 y/o male admitted to MOFH s/p hemicolectomy on 11/12.
Admitted to ICU for post-op observation and stabilization and subsequently transferred to SDU
On clear liquid diet → full liquid → soft diet 11/18: pt began to have episodes of emesis and
thick, discolored sputum 11/19: began to have increased work of
breathing 11/20: transferred to ICU and intubated.
S:
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Patient Case cont…
PMH Near obstructing transverse colon malignancy Atrial fibrillation on warfarin Osteoarthritis of the hip w/ prosthesis HTN Iron deficiency anemia Diverticulosis Dyslipidemia
Allergies: Lortab, percocet, carvedilol
SH: (+) Tobacco, (-) alcohol, (-) IVDA
S:
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Patient Case cont…
Outpatient meds Furosemide 40 mg PO
BID Metoprolol tartrate 25
mg 1 and ½ tablets PO QD
Oxybutynin chloride 5 mg 1 PO QHS
Potassium Chloride 10 mEq PO BID
Simvastatin 80 mg PO QHS
Coumadin 2 mg as dir by anticoag clinic
Inpatient meds Protonix 40 mg IV
QD Heparin drip Digoxin 0.125 mg
IV QD Metoprolol 5 mg
IV Q4h Cardizem drip 5-
15 mg/hr Dilaudid PCA
O:
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Patient Case cont…
VS HR: 106-158 BP: 81/42 RR: 26 O2sat: 90% on 100% FIO2 NRB
Labs 7.199/46/71
Tmax: 102.3° F
137
4.3 16
109
2.1
66
158326
9.4
8.9
30.2
O:
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Patient Case cont…
ARDS 2° to aspiration pneumonia Septic shock ARF Post-op ileus
A:
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Patient Case cont…
Provide oxygenation Provide IV fluids Panculture Begin empiric antibiotics
P:
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Patient Case cont…
Antibiotics Vancomycin 1 gm Q 12h
Start: 11/22 Stop: 12/2 Metronidazole 500 mg IV Q6h
Start: 11/21 Stop: 12/1 Meropenem 1gm IV Q8h
Start: 11/25 Stop: 12/6 Fluconazole 400 mg IV QD
Start: 11/23 Stop: 11/30 Levofloxacin 500 mg IV QD
Start: 11/23 Stop: 12/6
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Patient Case cont…
Cultures Obtained 11/20
Blood No growth
Sputum Heavy growth E. coli and Klebsiella pneumoniae
Urine No growth
Stool (-) Salmonella, Shigella, Campylobacter
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Patient Case cont…
AS vitals Afebrile from 11/27 – 12/4 HR: 90s-130s
WBC After 7 days of abx therapy, began to trend down
CXR 11/22 – diffuse bilateral airspace opacities 11/24 – extensive bilateral pulmonary parenchymal
disease 11/30 – improving aeration of the lungs
Oxygenation On vent, required high FIO2 and PEEP set @ 15 By 11/28, FIO2 was able to ↓, now weaning off vent
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Patient Case cont…
AS risk factor for aspiration pneumonia: GI disorder: post-op ileus
AS symptoms consistent w/pneumonia: Productive cough, purulent sputum Decline in oxygenation Fever Chest x-ray abnormalities
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Resolution
AS remains in ICU Still on vent, tolerating CPAP trials Awake, responsive Tolerating TF w/low residuals Developed DVTs
LUE, RLE Developed VAP and UTI
Both sputum and urine cultures grew Pseudomonas
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Conclusions
AS treatment was appropriate Provided oxygen Empiric abx selection Corrected predisposing condition
My recommendations for aspiration pneumonia abx: CA:
Metronidazole + Levofloxacin HA:
Metronidazole + Meropenem + Aztreonam
References
1. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med, 2005 171: 388-416.
2. Marik PE: Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001 Mar; 433(9): 655-71.
3. El-Solh et al: Microbiology of severe aspiration pneumonia in institutionalized elderly. Am J Respir Crit Care Med, 2003 167:1650-54.
4. Koda-kimble5. Venes D, editor. Taber’s cyclopedic medical dictionary.
20th ed. Philadelphia: FA Davis Company; 2005. 1696 p.