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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Recognize the signs and symptoms of hospital-acquired pneumonia (HAP).

  • Identify the most common causative organisms associated with HAP, and recognize the impact of bacterial resistance on the etiology and treatment of HAP.

  • Design an appropriate empiric antimicrobial therapy regimen for a patient with suspected HAP.

  • Formulate a list of alternative antimicrobial therapy options for the treatment of HAP based on the most common causative organisms.

  • Recommend a directed/targeted antimicrobial therapy regimen for a patient with HAP based on patient-specific data and final microbiology culture and susceptibility results.

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PATIENT PRESENTATION

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Chief Complaint

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“My chest hurts, I can’t catch my breath, and this cough is getting worse.”

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HPI

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Justin Case is a 60-year-old man with a past medical history significant for MI who was admitted to the hospital 5 days ago to undergo a scheduled surgical procedure following a recent diagnosis of colorectal adenocarcinoma with metastatic lesions to the liver. The patient was taken to the OR on hospital day 2 and underwent an exploratory laparotomy, diverting ileostomy, and Hickman catheter placement in preparation for chemotherapy. Postoperatively, the patient was transferred to the progressive ICU for his recovery without complication. The patient had no new complaints until hospital day 5 when he complained of retrosternal crushing chest pain radiating to the left shoulder and left jaw, shortness of breath, and a worsening cough with sputum production. The patient was noted to be in respiratory distress with a RR of 43 breaths/min, HR 153 bpm, BP 162/103 mm Hg, and O2 saturation of 87%. He was then transferred to the medical ICU and underwent endotracheal intubation due to worsening respiratory status. Cardiac markers were obtained, given the patient’s symptoms and history of MI. Imaging and blood & sputum cultures were obtained after patient transfer.

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PMH

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CAD, S/P MI 3 years ago for which he did not undergo any surgical intervention

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SH

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  • Lives with his wife

  • Smokes one ppd × 40 years

  • Denies alcohol or illicit drug use

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Meds

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  • Patient states that he did not take any medications at home.

  • Hospital medications include (ICU medication list):

  • Aspirin 325 mg PO × 1 dose, then 81 mg PO daily

  • Enoxaparin 70 mg subcutaneously every 12 hours

  • Esomeprazole 40 mg PO daily

  • Fentanyl 25 mcg/hour IV continuous infusion

  • Lorazepam 2 mg/hour IV continuous infusion

  • Metoprolol 25 mg PO every 12 hours

  • Nicotine patch 21 mg per day applied daily

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All

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NKDA

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ROS

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Patient is experiencing significant chest pain, shortness of breath, and a cough with sputum production. He denies nausea, vomiting, or difficulty urinating. He complains of mild abdominal pain near his ...

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