A 58-year-old man is hospitalized for a severe COPD exacerbation that requires intubation.
Which of the following will reduce the risk of developing pneumonia in this patient?
Administer oral chlorhexidine solution twice daily. Mechanical ventilation is the biggest risk factor for developing HAP, and the risk can be decreased with certain measures. (A) Patient should be placed in a semirecumbent position (head of the bed elevated 30 to 45 degrees) to prevent aspiration events. (B) Daily attempts to wean a patient from the ventilator should be performed to minimize the duration of mechanical ventilation. (D) Omeprazole and other agents that increase the pH of gastric contents have been shown to increase the rate of HAP. They should be avoided if possible. (E) Endotracheal suctioning of subglottic secretions reduces the risk of VAP. Other important preventive measures include following proper hand hygiene protocols, avoiding gastric overdistention, and using orotracheal intubation rather than nasotracheal intubation.
A 36-year-old man presents with fevers, chills, cough, and night sweats. The symptoms have developed over the past couple of weeks and have been associated with weight loss. His cough is productive of yellow sputum, and he occasionally is short of breath. The patient is originally from Botswana and currently works as a salesman. He does not smoke or use illicit drugs and has never been imprisoned. He is febrile on examination, with decreased breath sounds and rales in the upper lung field. A sputum AFB stain is positive, and his chest x-ray shows an apical infiltrate. He is started on a four-drug regimen. In addition, an HIV test is positive with a CD4 count of 290/mm3 and he is started on antiretroviral therapy. Two weeks later, the patient follows up and reports feeling worse, with increased dyspnea. A repeat chest x-ray shows radiologic worsening of the prior pneumonia. A complete workup for a new source of infection is negative.
Which of the following diagnoses should be considered?
Immune reconstitution inflammatory syndrome. The immune reconstitution inflammatory syndrome (IRIS) occurs in patients who recently started antiretrovirals and have clinical deterioration; it is a diagnosis of exclusion. Because HIV and TB coinfection is common (especially in sub-Saharan African countries), there are many reported cases of IRIS that occur with appropriate TB treatment. Unless IRIS is severe, antiretrovirals can usually be continued. NSAIDs or corticosteroids may be added temporarily to reduce the inflammation and improve symptoms. (Of note, this patient has risk factors of drug-resistant TB, and treatment failure should also be considered; however, this was not an answer choice.)
(A) IRIS is not a result of an allergic reaction to HIV medications. (C) This patient has pulmonary TB, and although a secondary bacterial pneumonia is possible, this often occurs with lower CD4 counts (PCP is a common secondary infection). (D) Rifampin does not cause pulmonary toxicity.
A 49-year-old man presents to the Emergency Department complaining of fever and a productive cough for several weeks. He also endorses night sweats and perceived weight loss. The patient is homeless and is a known alcoholic. On examination, the patient’s temperature is 38.3°C, blood pressure is 144/90 mmHg, heart rate is 94 beats per minute, and respiratory rate is 20 breaths per minute. He appears weak and disheveled with poor dentition. There are bronchial and amphoric breath sounds at the right lung base. His laboratory values are significant for a hemoglobin of 11.8 g/ dL and a leukocyte count of 13,500/mm3 . Blood and sputum cultures are collected and sent to the laboratory. His chest x-ray is shown below.
What should be done next in the management of this patient?
Start clindamycin. There are many things that can cause a cavitary pulmonary lesion; however, this patient presents with a classic history for an anaerobic lung abscess secondary to aspiration. The diagnosis should be suspected in a patient at risk for aspiration (e.g., alcoholic with poor dentition) who presents with indolent symptoms/signs of a pulmonary infection, putrid sputum, and a cavitary pulmonary lesion in a dependent lung segment. Amphoric breath sounds (resonant, blowing sounds) are sometimes heard with auscultation over a cavitary lesion, but are not a consistent physical finding. Treatment with clindamycin is cheap and effective for anaerobic lung infections.
(A) This is the treatment for aspergillosis, which can also cause pulmonary necrosis and lung cavitation. However, chronic cavitary aspergillosis presents in patients with prior lung disease and usually occurs in the upper lobes. (C) Vancomycin is a good drug for MRSA if suspected; however, it would not be a good agent for monotherapy since this presentation suggests an anaerobic infection. In addition, clindamycin has some activity against MRSA. (D) Although sputum cultures are often difficult to interpret given the high rate of contamination, bronchoscopy is an invasive procedure; it should be performed if the sputum cultures are not diagnostic and if the patient fails to respond to empiric antibiotics. (E) Surgical intervention is rarely necessary and is a last resort for treatment.
A 32-year-old woman presents to her physician complaining of a productive cough for the past 2 weeks. She has not felt well and describes frequent production of yellow or green sputum. Her temperature is 37.5°C with a heart rate of 86 beats per minute and a respiratory rate of 18 breaths per minute. There are some scattered wheezes and rhonchi on auscultation of the lungs that clear with coughing, with no rales or dullness to percussion.
Which of the following is the most appropriate next step in management?
Education and symptom management. This patient has an acute cough lasting for 2 weeks without any vital sign abnormalities or evidence of pneumonia on lung auscultation, making the likely diagnosis acute bronchitis. (Start ampicillin-sulbactam, Order sputum cultures) The vast majority of cases are caused by respiratory viruses (influenza, parainfluenza, RSV, adenovirus) and do not require sputum cultures or antibiotics. The patient should be educated about the risk of taking unnecessary antibiotics and instructed to follow-up if symptoms persist. (Order sputum cultures) If the symptoms persist for >3 weeks, or if there are any abnormal vital signs or physical examination findings suggestive of pneumonia, then a chest x-ray is warranted. (A) Oseltamivir is a neuraminidase inhibitor used for influenza A or B, but must be taken within 48 hours of symptom onset to have an appreciable effect. (C) There is no evidence that β2 agonists are beneficial in acute bronchitis, though they are often prescribed if there is significant wheezing on examination.
A 30-year-old medical student is undergoing medical screening in order to start a rotation at a new hospital. She denies any current symptoms and reports no previous medical problems. She is originally from South Africa and her vaccinations are up to date, including a Bacillus Calmette–Guérin (BCG) vaccine she received as a child. A PPD is placed and read 48 hours later, which shows an area of induration that is 11 mm wide.
What is the most appropriate next step in management?
Obtain a chest x-ray; if normal, start isoniazid and pyridoxine for 9 months. There are a couple of important teaching points in this vignette. First, screening for TB is often performed with a PPD, and it is important to know what the threshold is for a positive test result. In patients with close contact to a patient with active TB, a concerning chest x-ray, or who are immunosuppressed (via medications, HIV infection, etc.), a positive test is >5 mm. For those patients at high risk (healthcare workers, jail workers, the homeless, IV drug users, uncontrolled diabetes, chronic kidney disease, etc.), a positive test is >10 mm. And for all others without risk factors, a positive test is >15 mm. This patient has an induration of 11 mm and is a healthcare worker, therefore she warrants further workup to differentiate active from latent TB. (Note: Prior BCG vaccination rarely produces an induration of >10 mm as an adult, and the CDC recommends that BCG vaccination status should not influence the workup and treatment of TB.) If the chest x-ray is negative, then the patient has latent TB and should be treated within 9 months of isoniazid and pyridoxine (vitamin B6, which helps to prevent isoniazid-induced neuropathy).
(A) Treatment of active TB is becoming complicated with MDR-TB; however, active TB is generally treated with a four-drug regimen (rifampin, isoniazid, pyrazinamide, ethambutol) for 2 months followed up by a two-drug regimen (rifampin, isoniazid) for 4 months. (B) Because this patient is a healthcare worker, she should be treated for latent TB given the risk of reactivation and exposure to other patients. (D) A chest x-ray should be performed before starting treatment to differentiate latent from active TB. (E) Reassurance would only be appropriate if the PPD result was negative.
Click to expand