Critical Care Medicine-Pulmonary Disorders>>>>>Pulmonary Infections
Question 3#

A 65-year-old man with congestive heart failure is intubated and mechanically ventilated in the ICU for acute decompensated heart failure complicated by pulmonary edema. His extubation is delayed by ongoing delirium. On day 5 of his ICU stay, he is noted to have a new fever, with a temperature of 38.5°C. He is on pressure support ventilation, with an inspiratory pressure of 5 cm H2O, positive endexpiratory pressure (PEEP) of 5 cm H2O, and FiO2 0.4. The remainder of his vital signs are:

His examination reveals clear lung fields with auscultation and no other notable findings. A diagnostic workup, including blood cultures, urinalysis, and chest radiograph, are performed. Chest radiograph reveals clear lung fields. His urinalysis and blood cultures are unrevealing. Over the next 48 hours, he has one additional fever, and the respiratory therapist notes increased thick secretions suctioned from his endotracheal tube that are sent for sputum culture. His vent settings, chest radiograph, and vital signs remain unchanged.

Which of the following is the MOST appropriate management at this time?

A. Initiate treatment with vancomycin and cefepime
B. Perform flexible bronchoscopy with bronchoalveolar lavage
C. Initiate treatment with vancomycin, cefepime, and azithromycin
D. Close observation
E. Initiate treatment with cefepime

Correct Answer is D


Correct Answer: D

The patient is presenting with fevers and increased sputum production without evidence of infiltrate on examination, chest imaging, and with a stable and/or improved respiratory status. The clinical presentation suggests tracheobronchitis. Current guidelines recommend observation without empiric antibiotic treatment for tracheobronchitis, given lack of evidence suggesting a clinical benefit to treatment (answer D is correct). Vancomycin and cefepime may be an appropriate regimen for a ventilator- associated pneumonia (VAP) depending on local resistance patterns, but this patient does not have evidence of pneumonia (answer A is incorrect). Further workup for pneumonia including bronchoscopy is also not indicated (answer B is incorrect). Routine coverage for atypical organisms with a macrolide is not recommended for hospital-acquired or VAP or tracheobronchitis (answer C is incorrect). Monotherapy with cefepime is not indicated either for tracheobronchitis or VAP (answer E is incorrect).


  1. Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the infectious diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63(5):e61-e111.