Aspiration Pneumonia General Medicine Rotation 12 15 09

ASPIRATION PNEUMONIATRENNETTE R. GILBERT, PHARM D. CANDIDATEUNIVERSITY OF SOUTHERN NEVADA COLLEGE OF PHARMACY

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Objectives

Discuss background, epidemiology, and pathogenesis of aspiration pneumonia

Discuss risk factors for aspiration pneumonia

Discuss diagnosis, treatment, and monitoring response to therapy

Relate above objectives to patient case

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Aspiration Pneumonia

Aspiration: inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract Relatively common event Pneumonia is a consequence of aspiration

2 factors required for pneumonia to occur:1. Compromise of inherent defense mechanisms2. Bacterial burden must be large enough to cause infection

“True” aspiration pneumonia caused by normal flora Oral cavity Nasopharynx Gastrointestinal bacteria

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Epidemiology

Incidence 2nd most frequent dx in hospitalized

Medicare patients Definition has not always been consistent

Etiology Most cases caused by anaerobes

CA: usually anaerobes alone HA: usually anaerobes + aerobes, polymicrobial

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Risk factors for aspiration

Reduced consciousness Neurologic deficits GI disorders Anesthesia Protracted vomiting Large volume tube feedings

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Signs/Symptoms

Predisposing condition for aspiration Putrid sputum Common pneumonia symptoms

Fever > 38°C Leukocytosis/leukopenia Productive cough Decline in oxygenation

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Diagnosis

Suspect pneumonia if: New or progressive infiltrate seen on chest

x-ray AND signs/symptoms of systemic infection

Lower respiratory tract sampling Bronchoalveolar lavage or protected

specimen brush Culture specimen

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Treatment

Treat hypoxemia/provide oxygen Empiric antibiotic selection depends on

setting/patient characteristics No clear guidelines on which regimen is best If nosocomial, more virulent bacteria s/b

targeted CA:

Respiratory FQ + clindamycin, metronidazole OR β-lactam/ β-lactamase inhibitor

HA: GNB coverage + clindamycin, metronidazole +/-

vancomycin

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Monitoring Response to Therapy Vitals

Tmax, HR WBC

Should be trending down CXR

Should see improvement Oxygenation

Should see O2 sat increase Should be able to ↓ supportive oxygenation

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Patient Case

AS is a 76 y/o male admitted to MOFH s/p hemicolectomy on 11/12.

Admitted to ICU for post-op observation and stabilization and subsequently transferred to SDU

On clear liquid diet → full liquid → soft diet 11/18: pt began to have episodes of emesis and

thick, discolored sputum 11/19: began to have increased work of

breathing 11/20: transferred to ICU and intubated.

S:

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Patient Case cont…

PMH Near obstructing transverse colon malignancy Atrial fibrillation on warfarin Osteoarthritis of the hip w/ prosthesis HTN Iron deficiency anemia Diverticulosis Dyslipidemia

Allergies: Lortab, percocet, carvedilol

SH: (+) Tobacco, (-) alcohol, (-) IVDA

S:

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Patient Case cont…

Outpatient meds Furosemide 40 mg PO

BID Metoprolol tartrate 25

mg 1 and ½ tablets PO QD

Oxybutynin chloride 5 mg 1 PO QHS

Potassium Chloride 10 mEq PO BID

Simvastatin 80 mg PO QHS

Coumadin 2 mg as dir by anticoag clinic

Inpatient meds Protonix 40 mg IV

QD Heparin drip Digoxin 0.125 mg

IV QD Metoprolol 5 mg

IV Q4h Cardizem drip 5-

15 mg/hr Dilaudid PCA

O:

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Patient Case cont…

VS HR: 106-158 BP: 81/42 RR: 26 O2sat: 90% on 100% FIO2 NRB

Labs 7.199/46/71

Tmax: 102.3° F

137

4.3 16

109

2.1

66

158326

9.4

8.9

30.2

O:

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Patient Case cont…

ARDS 2° to aspiration pneumonia Septic shock ARF Post-op ileus

A:

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Patient Case cont…

Provide oxygenation Provide IV fluids Panculture Begin empiric antibiotics

P:

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Patient Case cont…

Antibiotics Vancomycin 1 gm Q 12h

Start: 11/22 Stop: 12/2 Metronidazole 500 mg IV Q6h

Start: 11/21 Stop: 12/1 Meropenem 1gm IV Q8h

Start: 11/25 Stop: 12/6 Fluconazole 400 mg IV QD

Start: 11/23 Stop: 11/30 Levofloxacin 500 mg IV QD

Start: 11/23 Stop: 12/6

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Patient Case cont…

Cultures Obtained 11/20

Blood No growth

Sputum Heavy growth E. coli and Klebsiella pneumoniae

Urine No growth

Stool (-) Salmonella, Shigella, Campylobacter

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Patient Case cont…

AS vitals Afebrile from 11/27 – 12/4 HR: 90s-130s

WBC After 7 days of abx therapy, began to trend down

CXR 11/22 – diffuse bilateral airspace opacities 11/24 – extensive bilateral pulmonary parenchymal

disease 11/30 – improving aeration of the lungs

Oxygenation On vent, required high FIO2 and PEEP set @ 15 By 11/28, FIO2 was able to ↓, now weaning off vent

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Patient Case cont…

AS risk factor for aspiration pneumonia: GI disorder: post-op ileus

AS symptoms consistent w/pneumonia: Productive cough, purulent sputum Decline in oxygenation Fever Chest x-ray abnormalities

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Resolution

AS remains in ICU Still on vent, tolerating CPAP trials Awake, responsive Tolerating TF w/low residuals Developed DVTs

LUE, RLE Developed VAP and UTI

Both sputum and urine cultures grew Pseudomonas

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Conclusions

AS treatment was appropriate Provided oxygen Empiric abx selection Corrected predisposing condition

My recommendations for aspiration pneumonia abx: CA:

Metronidazole + Levofloxacin HA:

Metronidazole + Meropenem + Aztreonam

References

1. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med, 2005 171: 388-416.

2. Marik PE: Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001 Mar; 433(9): 655-71.

3. El-Solh et al: Microbiology of severe aspiration pneumonia in institutionalized elderly. Am J Respir Crit Care Med, 2003 167:1650-54.

4. Koda-kimble5. Venes D, editor. Taber’s cyclopedic medical dictionary.

20th ed. Philadelphia: FA Davis Company; 2005. 1696 p.