Suspected Aspiration Pneumonia vs HCAP

Patient presents to the Emergency Department from nursing home with fever, dyspnea, and altered mental status.

Presentation:

PS is a 69 y/o M who presented to the Emergency Department from nursing home with fever, dyspnea, and altered mental status. His initial lactic acid was 4.5. He was seen by the treating physician and sepsis was suspected. PS was admitted with orders for labs, blood cultures, T2Bacteria®, and broad-spectrum antibiotics.

Patient Selection Criteria:

SIRS criteria:

  • Temperature: 103.5˚F
  • Heart Rate: 130 bpm
  • Respiratory Rate: 20
  • WBC (initial): 19,920/mm3

Evaluation and Treatment Decision:

Suspected aspiration pneumonia vs HCAP

Empiric Therapy: Vancomycin, Clindamycin, Ceftazidime

T2Bacteria scheduled to result at 2030 on second shift. Result: K. pneumonia (time to result: ~5 hours), result reviewed by ID pharmacist next am

Blood Culture Result: Negative after 5-days incubation

WBC next am on Ceftazidime: 24,950/mm3 (worsening)

Decision making based on T2Bacteria Result:

  1. Reviewed internal antibiogram. Changed Ceftazidime to Meropenem based on antibiogram percent susceptibility of 88% vs 99%.
  2. Discontinue Clindamycin and vancomycin
  3. WBC next am after switch to Meropenem: 10,960/mm3

Discussion:

At the time of admission, this patient had blood cultures obtained and T2Bacteria ordered. At Piedmont Columbus Regional, patient selection for T2Bacteria testing was based on >2 SIRS criteria PLUS suspected source of infection PLUS hypotension or altered mental status. This patient was positive for 2 of 4 SIRS criteria and had a suspected source of infection and altered mental status, thus meeting criteria for testing.

Determination of the causative organism for this patient’s infection allowed optimization of the antibiotic regimen within 24 hours of presentation. The patient was not improving on empiric therapy and experienced clinical improvement after the switch from ceftazidime to meropenem. Additionally, clindamycin was discontinued on Day 2 and vancomycin was discontinued on Day 3 allowing for 5 days of therapy to be saved for clindamycin and 4 days of therapy to be saved for vancomycin. The patient continued to improve and was discharged back to the nursing home after meropenem therapy was completed.

 

 

 

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