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LEARNING OBJECTIVES

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

  • 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 treating 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.

PATIENT PRESENTATION

Chief Complaint

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

HPI

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 recovery without complication. The patient had no new complaints until hospital day 5 when he complained of shortness of breath, and a worsening cough with sputum production. He was noted to be in respiratory distress with an RR of 43 breaths/min, HR 147 bpm, BP 162/103 mm Hg, and O2 saturation of 87%. He was transferred to the medical ICU and underwent endotracheal intubation due to worsening respiratory status. Imaging studies along with blood and sputum cultures were obtained after transfer.

PMH

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

Colorectal carcinoma metastatic to liver (newly diagnosed)

SH

Lives with his wife; smokes one ppd × 40 years; denies alcohol or illicit drug use

Meds

Patient states that he did not take any medications at home. Hospital medications include (ICU medication list):

  • Aspirin 81 mg PO daily

  • Enoxaparin 40 mg subcutaneously every 24 hours

  • Esomeprazole 40 mg PO daily

  • Fentanyl 25 mcg/hr IV continuous infusion

  • Lorazepam 2 mg/hr IV continuous infusion

  • Metoprolol 25 mg PO every 12 hours

  • Nicotine patch 21 mg per day applied daily

All

NKDA

ROS

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

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