PP-AVE-ID-0073-1

Case study: An elderly lady

hospitalised with pneumonia

The cases and outcomes depicted do not represent actual patients.

These cases studies are fictitious and are intended for educational purposes only.
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 Case history

This 72-year-old woman was admitted to hospital for management of

pneumonia
She had been well until one week prior to admission, when she
developed fever and flu-like symptoms
She is having cough, sputum production, haemoptysis, chest pain or
dyspnoea
She presented at the ED because of the persistence of the flu-like
symptoms

ED, emergency department.

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 Case presentation

Temperature 38.4oC
BP 147/82 mmHg
Pulse 147 bpm and irregular
Respiratory rate 35 breaths/min
Mildly confused
Crackles audible in the anterior left chest
No evidence of CHF
Normal abdominal examination

BP, blood pressure; bpm, beats per minute; CHF, congestive heart failure.
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 Test results and initial care

CBC:
• Hb 155 g/L
• WBC 10.5 x 109/L with a left shift
• Platelets 80,000/µL
Na 129 mmol/L
Creatinine 180 µmol/L, urea 14.5 mmol/L
Liver function normal
Chest radiograph and CT scan are shown on the following slides
The patient was admitted to the ICU for further management

BP, blood pressure; bpm, beats per minute; CBC, complete blood count; CHF, congestive heart failure; CT, computed
tomography; Hb, haemoglobin; ICU, intensive care unit; WBC, white blood cell.
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 Radiograph

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 CT scan

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 What is your diagnosis?

Based on the case history, presentation and the results of the clinical
and laboratory investigations, which of the following diagnoses would
you suggest?

Unilateral atelectasis
Diagnosis
Pneumonia

Pleural effusion

Click on choice to make a diagnosis

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 What is your diagnosis?

Based on the case history, presentation and the results of the clinical
and laboratory investigations, which of the following diagnoses would
you suggest?

Unilateral atelectasis
Diagnosis
Pneumonia
Unilateral atelectasis
Pleural effusion Correct answer: Pneumonia

Click here to continue

with the case

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 What is your diagnosis?

Based on the case history, presentation and the results of the clinical
and laboratory investigations, which of the following diagnoses would
you suggest?

Unilateral atelectasis
Diagnosis
Pneumonia
Pneumonia
Pleural effusion

Click here to continue

with the case

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 What is your diagnosis?

Based on the case history, presentation and the results of the clinical
and laboratory investigations, which of the following diagnoses would
you suggest?

Unilateral atelectasis
Diagnosis
Pneumonia
Pleural effusion
Pleural effusion Correct answer: Pneumonia

Click here to continue

with the case

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 Assessment of severity

Initial assessment of severity is key to most major decisions

regarding the management of community-acquired pneumonia (CAP)

Mandell LA, et al. Clin Infect Dis 2007;44:S27–S72.

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 CAP or severe CAP?

The ATS-IDSA validated definition for severe CAP includes either

one major criterion or ≥3 minor criteria

ATS, American Thoracic Society; CAP, community-acquired pneumonia; IDSA, Infectious Diseases Society of America.
Metlay JP, et al. Am J Respir Crit Care Med 2019;200:e45–e67.
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 Modified ATS-IDSA criteria for severe pneumonia: major
clinical parameters

One of:
• requirement of mechanical ventilation
• septic shock

ATS, American Thoracic Society; IDSA, Infectious Diseases Society of America.

Mandell LA, et al. Clin Infect Dis 2007;44:S27–S72.
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 Modified ATS-IDSA criteria for severe pneumonia: minor
clinical parameters
Any three of:
• RR 30 breaths/min
• Confusion/disorientation
• Uraemia (BUN 20 mg/dL)
• Leucopenia (WBC <4000 cells/mm3)
• Multilobar infiltrates
• PaO2/FiO2 ratio ≤250
• Thrombocytopenia (platelets <100,000 cells/mm3)
• Hypothermia (core temp <36oC)
• Hypotension requiring aggressive fluid resuscitation

ATS, American Thoracic Society; BUN, blood urea nitrogen; IDSA, Infectious Diseases Society of America; PaO 2/FiO2 ratio, ratio of arterial oxygen partial
pressure (PaO2 in mmHg) to fractional inspired oxygen (FiO2 expressed as a fraction, not a percentage); RR, respiratory rate; WBC, white blood cell.
Mandell LA, et al. Clin Infect Dis 2007;44:S27–S72. 14
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 Clinical features of this case

Choose one of the ATS-IDSA minor criteria for pneumonia severity

which is a clinical features of this case:
RR 30 breaths/min

Confusion or disorientation
Clinical features of this case
Uraemia (BUN 20 mg/dL)

Leucopenia (WBC <4000 cells/mm3)

Multilobar infiltrates

PaO2/FiO2 ratio ≤250

Thrombocytopenia (platelets <100,000 cells/mm3)

Hypothermia (core temp <36oC)

Hypotension requiring aggressive fluid resuscitation

ATS, American Thoracic Society; BUN, blood urea nitrogen; IDSA, Infectious Diseases Society of America; PaO 2/FiO2 ratio, ratio of arterial oxygen partial
pressure (PaO2 in mmHg) to fractional inspired oxygen (FiO2 expressed as a fraction, not a percentage); RR, respiratory rate; WBC, white blood cell.
Mandell LA, et al. Clin Infect Dis 2007;44:S27–S72.
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 Clinical features of this case

Choose one of the ATS-IDSA minor criteria for pneumonia severity

which is a clinical features of this case:
RR 30 breaths/min

Confusion or disorientation
Clinical features of this case
Uraemia (BUN 20 mg/dL)
RR 30 breaths/min
Leucopenia (WBC <4000 cells/mm3)
Confusion or disorientation
Multilobar infiltrates
Uraemia (BUN 20 mg/dL)
PaO2/FiO2 ratio ≤250
Multilobar infiltrates
Thrombocytopenia (platelets <100,000 cells/mm3)

Hypothermia (core temp <36oC)

Hypotension requiring aggressive fluid resuscitation Click here to continue

with the case
ATS, American Thoracic Society; BUN, blood urea nitrogen; IDSA, Infectious Diseases Society of America; PaO 2/FiO2 ratio, ratio of arterial oxygen partial
pressure (PaO2 in mmHg) to fractional inspired oxygen (FiO2 expressed as a fraction, not a percentage); RR, respiratory rate; WBC, white blood cell.
Mandell LA, et al. Clin Infect Dis 2007;44:S27–S72.
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 Clinical features of this case

Choose one of the ATS-IDSA minor criteria for pneumonia severity

which is a clinical features of this case:
RR 30 breaths/min

Confusion or disorientation
Clinical features of this case
Uraemia (BUN 20 mg/dL)
Leucopenia (WBC <4000 cells/mm3)
Leucopenia (WBC <4000 cells/mm3)
Correct answers:
Multilobar infiltrates
RR 30 breaths/min
PaO2/FiO2 ratio ≤250
Confusion or disorientation
Thrombocytopenia (platelets <100,000 cells/mm3)
Uraemia (BUN 20 mg/dL)
Hypothermia (core temp <36oC)
Multilobar infiltrates
Hypotension requiring aggressive fluid resuscitation
Click here to continue
with the case
ATS, American Thoracic Society; BUN, blood urea nitrogen; IDSA, Infectious Diseases Society of America; PaO 2/FiO2 ratio, ratio of arterial oxygen partial
pressure (PaO2 in mmHg) to fractional inspired oxygen (FiO2 expressed as a fraction, not a percentage); RR, respiratory rate; WBC, white blood cell.
Mandell LA, et al. Clin Infect Dis 2007;44:S27–S72.
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 Clinical features of this case

Choose one of the ATS-IDSA minor criteria for pneumonia severity

which is a clinical features of this case:
RR 30 breaths/min

Confusion or disorientation
Clinical features of this case
Uraemia (BUN 20 mg/dL)
PaO2/FiO2 ratio ≤250
Leucopenia (WBC <4000 cells/mm3) Correct answers:
Multilobar infiltrates
RR 30 breaths/min
PaO2/FiO2 ratio ≤250 Confusion or disorientation
Thrombocytopenia (platelets <100,000 cells/mm3)
Uraemia (BUN 20 mg/dL)
Hypothermia (core temp <36oC) Multilobar infiltrates
Hypotension requiring aggressive fluid resuscitation
Click here to continue
with the case
ATS, American Thoracic Society; BUN, blood urea nitrogen; IDSA, Infectious Diseases Society of America; PaO 2/FiO2 ratio, ratio of arterial oxygen partial
pressure (PaO2 in mmHg) to fractional inspired oxygen (FiO2 expressed as a fraction, not a percentage); RR, respiratory rate; WBC, white blood cell.
Mandell LA, et al. Clin Infect Dis 2007;44:S27–S72.
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 Clinical features of this case

Choose one of the ATS-IDSA minor criteria for pneumonia severity

which is a clinical features of this case:
RR 30 breaths/min

Confusion or disorientation
Clinical features of this case
Uraemia (BUN 20 mg/dL)
Thrombocytopenia (platelets <100,000 cells/mm3)
Leucopenia (WBC <4000 cells/mm3)
Correct answers:
Multilobar infiltrates
RR 30 breaths/min
PaO2/FiO2 ratio ≤250
Confusion or disorientation
Thrombocytopenia (platelets <100,000 cells/mm3)
Uraemia (BUN 20 mg/dL)
Hypothermia (core temp <36oC)
Multilobar infiltrates
Hypotension requiring aggressive fluid resuscitation
Click here to continue
with the case
ATS, American Thoracic Society; BUN, blood urea nitrogen; IDSA, Infectious Diseases Society of America; PaO 2/FiO2 ratio, ratio of arterial oxygen partial
pressure (PaO2 in mmHg) to fractional inspired oxygen (FiO2 expressed as a fraction, not a percentage); RR, respiratory rate; WBC, white blood cell.
Mandell LA, et al. Clin Infect Dis 2007;44:S27–S72.
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 Clinical features of this case

Choose one of the ATS-IDSA minor criteria for pneumonia severity

which is a clinical features of this case:
RR 30 breaths/min

Confusion or disorientation
Clinical features of this case
Uraemia (BUN 20 mg/dL)
Hypothermia (core temp <36oC)
Leucopenia (WBC <4000 cells/mm3)
Correct answers:
Multilobar infiltrates
RR 30 breaths/min
PaO2/FiO2 ratio ≤250
Confusion or disorientation
Thrombocytopenia (platelets <100,000 cells/mm3)
Uraemia (BUN 20 mg/dL)
Hypothermia (core temp <36oC)
Multilobar infiltrates
Hypotension requiring aggressive fluid resuscitation
Click here to continue
with the case
ATS, American Thoracic Society; BUN, blood urea nitrogen; IDSA, Infectious Diseases Society of America; PaO 2/FiO2 ratio, ratio of arterial oxygen partial
pressure (PaO2 in mmHg) to fractional inspired oxygen (FiO2 expressed as a fraction, not a percentage); RR, respiratory rate; WBC, white blood cell.
Mandell LA, et al. Clin Infect Dis 2007;44:S27–S72.
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 Clinical features of this case

Choose one of the ATS-IDSA minor criteria for pneumonia severity

which is a clinical features of this case:
RR 30 breaths/min

Confusion or disorientation
Clinical features of this case
Uraemia (BUN 20 mg/dL)
Hypotension requiring aggressive fluid resuscitation
Leucopenia (WBC <4000 cells/mm3)
Correct answers:
Multilobar infiltrates
RR 30 breaths/min
PaO2/FiO2 ratio ≤250
Confusion or disorientation
Thrombocytopenia (platelets <100,000 cells/mm3)
Uraemia (BUN 20 mg/dL)
Hypothermia (core temp <36oC)
Multilobar infiltrates
Hypotension requiring aggressive fluid resuscitation
Click here to continue
with the case
ATS, American Thoracic Society; BUN, blood urea nitrogen; IDSA, Infectious Diseases Society of America; PaO 2/FiO2 ratio, ratio of arterial oxygen partial
pressure (PaO2 in mmHg) to fractional inspired oxygen (FiO2 expressed as a fraction, not a percentage); RR, respiratory rate; WBC, white blood cell.
Mandell LA, et al. Clin Infect Dis 2007;44:S27–S72.
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 Diagnosis

The presence of four modified ATS-IDSA criteria indicate this patient

has severe community-acquired pneumonia
Let’s look at the causes of this in more detail

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 Aetiology of CAP in ICU patients

Bacteraemia present in 9% of cases,

mainly due to Streptococcus
pneumoniae (80%) Aetiology S pneumo

22% H infl
Overall mortality: 7% 42%
Atypical

5% Virus
Mortality increased with CAP severity 1% S aureus
2%
• S. pneumoniae had the highest number of GNEB
4%
deaths, while GNEB, Pseudomonas Pseudo
aeruginosa, Staphylococcus aureus and 14% Mixed
3%
mixed aetiologies had the highest mortality
rates

CAP, community-acquired pneumonia; GNEB, Gram-negative enteric bacilli; ICU, intensive care unit.
Cillóniz C, et al. Thorax 2011;66:340–6.
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 Early follow-up

Later that day, the laboratory informs you that:

 Blood cultures are positive for S. pneumoniae

1. WHO Meningitis Manual. 2011. Chapter 8: Identification and Characterization of Streptococcus pneumoniae. Available online on: https://www.cdc.gov/meningitis/lab-manual/chpt08-id-characterization-streppneumo.html.
Accessed August 30, 2022.
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 Initial treatment

At this point, which of the following antibiotics would you consider

treating this patient with?

a) Clarithromycin
b) Moxifloxacin
c) Levofloxacin
d) Clarithromycin plus rifampin

Before deciding, consider the evidence from clinical trials comparing

fluoroquinolones and macrolides.

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 Fluoroquinolones versus macrolides in the treatment of S.
pneumoniae infection
Diagnoses were
made using S.
pneumoniae blood
culture
MIC between
different
fluoroquinolone and
macrolides in
sequence sample

Pérez-Trallero,et al. Emerg Infect Dis. 2003 Sep; 9(9): 1159–1162..

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 Initial treatment

At this point, which of the following antibiotics would you consider

treating this patient with?

Clarithromycin

Moxifloxacin
Antibiotic therapy

Levofloxacin

Clarithromycin plus rifampin

Click on which antibiotic you would use

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 Initial treatment

At this point, which of the following antibiotics would you consider

treating this patient with?

Clarithromycin

Moxifloxacin
Antibiotic therapy
Clarithromycin
Levofloxacin
Correct answer: Moxifloxacin or
Clarithromycin plus rifampin Levofloxacin

Click here to continue

with the case

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 Initial treatment

At this point, which of the following antibiotics would you consider

treating this patient with?

Clarithromycin

Moxifloxacin
Antibiotic therapy
Moxifloxacin or levofloxacin
Levofloxacin

Clarithromycin plus rifampin

Click here to continue

with the case

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 Initial treatment

At this point, which of the following antibiotics would you consider

treating this patient with?

Clarithromycin

Moxifloxacin
Antibiotic therapy
Clarithromycin plus rifampin
Levofloxacin
Correct answer: Moxifloxacin or
Clarithromycin plus rifampin Levofloxacin

Click here to continue

with the case

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 Which fluoroquinolone?

Both moxifloxacin and levofloxacin should provide effective therapy

The presence of renal insufficiency favours moxifloxacin1,2

1. AVELOX® (moxifloxacin) tablets, injection prescribing information. Bayer HealthCare Pharmaceuticals Inc; July 2016 [Accessed October 2020]; 2.
LEVAQUIN® (levofloxacin) tablets, oral solution, injection prescribing information. Janssen Pharmaceutical Inc; June 2016 [Accessed October 2020].
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 Case follow-up

Following the identification of S. pneumoniae, the patient was

treated with sequential IV/PO moxifloxacin 400 mg/day
The case resolved without sequelae

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 Summary

Most major decisions regarding the management of community-acquired

pneumonia, including diagnostic and treatment issues, centre around
initial assessment of severity1
For patients with S. pneumoniae infection, clinical trials suggest that
fluoroquinolones are superior to macrolides, being associated with:2
• Lower MIC in subsequent samples

Both moxifloxacin and levofloxacin provide effective therapy for S.

pneumoniae, though moxifloxacin is favoured in the presence of renal
insufficiency3,4

1. Mandell LA, et al. Clin Infect Dis 2007;44:S27–S72; 2. Pérez-Trallero,et al. Emerg Infect Dis. 2003 Sep; 9(9): 1159–1162.
2.; 3. AVELOX® (moxifloxacin) tablets, injection prescribing information. Bayer HealthCare Pharmaceuticals Inc; July 2016 [Accessed October
2020]; 4. LEVAQUIN® (levofloxacin) tablets, oral solution, injection prescribing information. Janssen Pharmaceutical Inc; June 2020 [Accessed
October 2020]. 33
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