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Pharmacotherapy Review and Recertification Course:
Complex Pneumonia Case
Marc H. Scheetz, Pharm.D., BCPS (AQ-ID), FCCP, M.Sc.
Professor of Pharmacy Practice and Pharmacology
Director of Pharmacometrics Center for Excellence
Midwestern University, Downers Grove, Illinois
Chicago College of Pharmacy and Graduate Studies
Infectious Diseases Pharmacist, Northwestern Medicine
Chicago, Illinois
Learning Objectives:
At the conclusion of this session, given a patient case, the participant should be able to
• Select the appropriate treatment and monitoring for a complex patient-case with multiple
conditions, including pneumonia, acute renal insufficiency, sepsis, chronic obstructive
pulmonary disease (COPD) and dehydration.
• Interpret clinical data, including lab, physical examination and vital signs.
• Determine and prioritize pneumonia-related treatment goals.
• Determine approaches to manage drug allergies and select next best drug therapy when
primary drugs are precluded
• Discuss approaches to limiting antimicrobial over use by stewarding antibiotic usage
appropriately
• Discuss safety issues in patients receiving treatment for pneumonia.
Format: Today’s session will be a highly interactive discussion of the attached case studies.
Premise: Participants in this course are pharmacists who practice in clinical acute care settings. You are
responsible for evaluating and monitoring the patient’s therapy. You are responsible for providing
comprehensive patient management and education.
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©2018 American Society of Health-System Pharmacists, Inc. All rights reserved. 1
CASE Date: Dec 2018
Initials DOB/Age Sex Race/Ethnicity Source
AB 74 yo F African Patient and medical
American records
CC/HPI (including symptom analysis for CC):
“I can’t breathe!”
AB with a PMH of COPD presented worsening shortness of breath and has been on your general medicine
floor for 2.5 days. Two weeks prior to today’s admission, she presented to your emergency department (ED)
with hypoxia and dehydration. She was initially started on intravenous levofloxacin, although she was later
found to have H3N2 influenza A and treated with oseltamivir 75 mg orally every 12 hours. She returned to
her baseline state of health and was discharged home 3 days ago with a prescription for an additional 3 days
of oseltamivir. On the day of discharge the patient displayed the following vital signs.
BP= 137/97 mm Hg Pulse= 64 bpm, regular R=16/min T=98.2°F (oral)
Because she noticed increased production of thick, yellow sputum and used her albuterol inhaler five times in
rapid succession, she presented to the ED again. Vitals signs on presentation were: BP= 135/85 mm Hg, T=
99.9°F. Her O saturation was 88% on room air, so she was placed on 4 L/min of O via nasal cannula Her O
2 2 . 2
saturation improved to 92% with this intervention. The ED physician admitted her to the general medicine
floor for a COPD exacerbation. AB’s breathing gets progressively worse 2.5 days after admission.
Past Medical History (major illnesses and surgeries)
HTN x 30 years
Dyslipidemia x 23 years
Chronic Obstructive Pulmonary Disease (x 5 years)
Osteoarthritis (knees, uses walker)
2
Obesity (BMI = 30 kg/m )
Osteopenia
Current Prescription/OTC Medications
Start Date Drug Name/Strength/Regimen Indication
3/2015 Hydrochlorothiazide 50 mg orally daily HTN
1/2017 Lisinopril 20 mg orally daily HTN
2/2010 Pravastatin 20 mg orally daily Dyslipidemia
2/2014 Tiotropium 18 mcg/cap, 1 cap inhaled daily COPD
2/2014 Albuterol 90 mcg per puff, 1-2 puffs every 4- Shortness of breath
6 hours prn
4/2016 Acetaminophen 500 mg po three times daily Pain
prn
10/2016 Calcium 600 mg + Vitamin D 400 units po Osteopenia
twice daily
Vaccinations: Influenza vaccine fall 2017 (missed Preventative medicine
vaccination this year)
Pneumococcal polysaccharide vaccine (age 67) Preventative medicine
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©2018 American Society of Health-System Pharmacists, Inc. All rights reserved. 2
Objective Data (observations/vital signs/physical examination/labs)
Physical Exam (on general medicine floor).
General: Obese, moderate respiratory distress
HEENT: Pursed lips with exhalation. Normocephalic. Pupils equally reactive to light and accommodation. No
lymphadenopathy. Neck supple.
Lungs: Tachypneic, increased respiratory effort, prolonged expirations with end-expiratory wheezing,
decreased air movement, inspiratory crackles at the left lower lung base.
CV: Tachycardia, regular rhythm, no murmurs/rubs/gallops, no jugular venous distension > 10 cm, warm
extremities with < 2 second capillary refill.
Abd: normal active bowel sounds, no abdominal tenderness to palpation, no distension
Ext: No lower extremity edema.
Neuro/Psych: A + O x 3, lethargic but arousable
Vital Signs
BP= 105/65 mm Hg Pulse= 95 bpm R=28 T=101.4°F (oral)
Height = 5’ 5” Weight = 180 lb BMI = 30 kg/m2
ECG = sinus tachycardia
Laboratory Tests (measured today)
ABG (room air): pH=7.32 / PaCO =60 / PaO = 67 / O sat=87%
2 2 2
9
CBC with Differential: WBC = 16 X 10 /L (85% neutrophils), Hgb = 13.1 g/dL, Platelets = 365K
Na = 139 mEq/L K = 4.5 mEq/L Cl = 99 mEq/L CO = 27 mmol/L BUN = 37 mg/dL Cr = 1.2
mg/dL 3
Glucose = 107 mg/dL
AST = 22 units/L ALT = 44 units/L
Blood culture: pending
Respiratory culture: pending
Urinary Legionella antigen: negative
Radiology:
CXR: Hyperexpanded lungs, mild cardiomegaly. Consolidation in left lower lobe concerning for pneumonia.
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©2018 American Society of Health-System Pharmacists, Inc. All rights reserved. 3
Presentation Questions
Dehydration
1. AB progressively deteriorates and is transferred to the medical intensive care unit for
maintenance of hemodynamic stability and intubation. Which of the following is an appropriate
initial fluid regimen?
a. Lactated Ringers at 125 mL/hr over 24 hours
b. Lactated Ringers 1000 mL infused over 30 minutes
c. D5W 1000 mL infused over 30 minutes
d. Albumin 25 g (100 mL of 25% solution) infused over 24 hours
Healthcare-Associated Pneumonia and Sepsis
2. If AB is ventilated while transferring from the general medicine floor to the intensive care unit,
which of the following would represent her pneumonia diagnosis?
a. Community Acquired Pneumonia (CAP)
b. Health Care Associated Pneumonia (HCAP)
c. Ventilator Associated Pneumonia (VAP)
d. Hospital acquired Pneumonia (HAP)
COPD
3. Which of the following risk factors predisposes AB to pneumonia with Gram-positive and Gram-
negative multidrug-resistant pathogens?
a. Five-year history of COPD
b. Status as a retired nurse
c. Post influenza infection
d. Recent intravenous antibiotics
Hospital Acquired Pneumonia and Sepsis
4. In addition to fluid status correction and vasopressor initiation, which of the following is the
next most important intervention to help AB regain hemodynamic stability?
a. Early Ambulation
b. Broad-spectrum antibacterial coverage
c. Hydrocortisone
d. Intravenous immune globulin
5. Which of the following is a guideline-approved, empiric drug regimen to provide coverage for
Gram-negative organisms in AB?
e. Doripenem 1 g intravenously every 8 hours
f. Moxifloxacin 400 mg intravenously once daily + Gentamicin 500 mg intravenously once
daily
g. Piperacillin-tazobactam 4.5 g intravenously every 6 hours + Gentamicin 500 mg
intravenously once daily
h. Tigecycline 100 mg intravenously as a loading dose followed by 50 mg intravenously
every 12 hours + Moxifloxacin 400 mg intravenously once daily
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©2018 American Society of Health-System Pharmacists, Inc. All rights reserved. 4
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