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Emergency Medicine

Answer 1
  1.  Obtain blood cultures, administer IV ceftriaxone and a respiratory fluoroquinolone, and admit to the ICU. The 2007 Joint Infectious Diseases Society of America/American Thoracic Society guidelines on management of adult CAP recommend the use of severity of illness scores, such as CURB-65 (confusion, uremia, respiratory rate, low blood pressure, age ≥ 65 yr) or prognostic scoring systems (eg, Pneumonia Severity Index), to assist in determining candidates for outpatient therapy.¹ Patients with 1 or more major criteria (septic shock requiring vasopressors or respiratory failure requiring mechanical ventilation) or 3 or more minor criteria (respiratory rate > 30 breaths/min; Pao2/Fio2 ratio < 250; multilobar infiltrates; confusion; blood urea nitrogen > 20 mg/dL; leukopenia resulting from infection; thrombocytopenia; hypothermia; or hypotension requiring aggressive fluid resuscitation) should be admitted to the ICU.¹ Pre-antibiotic blood cultures should be obtained for all CAP patients requiring ICU admission. Patients admitted to an ICU should receive ß-lactam and either azithromycin or a respiratory fluoroquinolone. If Pseudomonas or CA-MRSA is suspected, antibiotic choice should be altered accordingly. Rather than supporting a specific time frame in which to initiate therapy, the guidelines recommend that the first dose of antibiotics be administered in the ED;¹ however, the Joint Commission and the Centers for Medicare and Medicaid Services core measures require hospitals to publicly report time to first dose of antibiotics, with a goal of 4 hours from hospital arrival. This patient’ CURB-65 and Pneumonia Severity Index scores exclude outpatient treatment. Although this patient does not meet any major criteria, he does have 3 minor criteria suggesting that admission to the ICU is appropriate. Piperacillin-tazobactam or vancomycin alone are inappropriate antibiotic choices for managing CAP.

    1. Mandell LA, Wunderink RG, Anzueto A, et al; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44 Suppl 2:S2772.

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