Critical Care Medicine-Pulmonary Disorders>>>>>Pulmonary Infections
Question 9#

A 75-year-old man with hypertension, mild Alzheimer disease marked by occasional short-term memory difficulties, and a past history of squamous cell carcinoma of the tongue with prior surgical resection and radiation to the neck presents from his assisted living facility with productive cough and shortness of breath. The assisted living facility staff reports that he is routinely noted to be coughing while eating meals, and his dyspnea and cough began while eating yesterday. His medications include hydrochlorothiazide and amlodipine. In the ED, his vital signs are:

A CT scan of his chest reveals patchy bibasilar ground glass opacities and tree-in-bud opacities. Supplemental oxygen is provided via a venturi mask at FiO2 0.5 and admitted to the ICU.

Which of the following is most accurate concerning this patient’s pneumonia?

A. This patient has a healthcare-associated pneumonia (HCAP) and should receive appropriate broad spectrum antibiotics
B. Placement of a gastrostomy tube for future nutrition will reduce his risk of recurrent pneumonia
C. The patient’s Alzheimer disease is a significant risk factor for future pneumonia
D. Empiric antibiotics do not have to include anaerobic coverage

Correct Answer is D

Comment:

Correct Answer: D

This patient presents with dyspnea, hypoxemia, and cough, with a reported history of coughing while eating, suggestive of aspiration. His chest imaging is notable for inflammatory changes in a gravity-dependent distribution, along with tree-in-bud opacities, all supportive of aspiration pneumonitis versus pneumonia. He also has a prior history of surgery and radiation to his tongue and neck, which likely resulted in oropharyngeal dysphagia. HCAP is no longer a distinct category of pneumonia, and he should therefore be treated as a CAP, given the absence of specific risk factors for resistant organisms (answer A is incorrect). Additionally, his presentation is not characteristic of an anaerobic pneumonia, which is often more indolent and occurs in patients with specific risk factors, and so he does not require anaerobic coverage as part of his initial empiric regimen (answer D is incorrect). Although advanced dementia may be a risk factor for aspiration, this patient has very mild symptoms of dementia (answer C is incorrect). Although feeding tubes allow for more effective nutrition in patients with dysphagia, they do not reduce the risk of aspiration pneumonia (answer B is incorrect).

References :

  1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S27-S72.
  2. Taylor JK, Fleming GB, Singanayagam A, Hill AT, Chalmers JD. Risk factors for aspiration in community-acquired pneumonia: analysis of a hospitalized UK cohort. Am J Med. 2013;126(11):995-1001.
  3. Fox KA, Mularski RA, Sarfati MR, et al. Aspiration pneumonia following surgically placed feeding tubes. Am J Surg. 1995;170(6):564.