Case Study

Pneumonia
Content produced by the Alliance for the Prudent Use of Antibiotics (APUA) through an unrestricted educational grant from Alere Inc.
Copyright 2014 the Alliance for the Prudent Use of Antibiotics (APUA)

Reported by:

Shira Doron, MD, Assistant Professor, Division of Infectious Diseases, Associate Hospital
Epidemiologist, Antimicrobial Management, Tufts Medical Center, Boston, MA

Kirthana Beaulac, PharmD, Clinical Pharmacy Specialist- Infectious Diseases and Antimicrobial
Stewardship, Tufts Medical Center, Boston, MA

Patient Background

RP is a 68 year-old male who was admitted to the hospital from his long-term care facility after 1
week of dyspnea and cough. He was seen by a staff physician at the long-term care facility and was
diagnosed with a COPD exacerbation. He was prescribed azithromycin, but has not improved after 3
days of antibiotics. He has a history of dyslipidemia, COPD, alcoholic cirrhosis, and HTN. He
routinely takes lisinopril, atorvastatin, tiotropium and fluticasone/salmeterol, and has recently had a
heavier reliance on his rescue albuterol inhaler. Review of systems reveals fever, chills, cough
(sometimes productive) and dyspnea (worse than baseline).

Vitals

Tmax = 101.2oF
Heart rate = 89 bpm
Respiratory rate = 18 bpm
Blood pressure = 140/86
Oxygen saturation = 84% on room air, 98% on 4L on nasal cannula

Physical exam
General: elderly male, looks older than stated age
HEENT: mildly icteric, pupils equally round and reactive to light and accommodation
Neck: supple
Resp: coarse breath sounds, rhonchi and wheezes heard throughout
Card: regular rate and rhythm, no murmurs, rubs, or gallops
Abd: slightly distended
Ext: no edema
Skin: excoriated, otherwise normal
Neuro: slightly altered, but baseline

Copyright 2014 the Alliance for the Prudent Use of Antibiotics (APUA) 120001259 11/14
Labs
Na: 141 Creatinine: 1.6
K: 4.2 WBC: 19.6
Cl: 98 Hgb: 10.8
Bicarb: 23 Hct: 36.2
BUN: 24 Platelets: 115

Radiology

Chest X-ray showed focal consolidation in the right lower lobe, suggestive of pneumonia

Microbiology

Blood Culture: No growth at 48 hrs

Sputum Culture
o Gram Stain: 4+ squamous epithelial cells, 4+ segmented neutrophils, no organisms
o Culture: No growth at 48 hours
Pneumococcal Urinary Antigen: Positive
Legionella Urinary Antigen : Negative

Diagnosis

Upon admission, RP was initially given the broad spectrum antibiotics vancomycin, piperacillin/
tazobactam, and tobramycin for the treatment of healthcare-associated pneumonia (HCAP).1 At that
time, he had blood and sputum cultures taken. Upon being seen by the internist on hospital day one,
he had urinary antigen tests performed for pneumococcus and legionella. When the test results
returned with a positive pneumococcal antigen test, he was de-escalated to ceftriaxone and completed
a 7 day course of antibiotics.

The pneumococcal urinary antigen test is a useful method for detecting pneumococcus, especially in
patients who are unable to produce a reliable respiratory sample or those who are already on
antibiotics.2 RP provided a sputum culture that was significantly contaminated with squamous
epithelial cells, suggesting that if a pathogen grew, it would have to be interpreted as a potential
contaminant from the patients oral flora. Furthermore, he had been on antibiotics for several days,
which likely would have penetrated into his sputum sample to inhibit bacterial growth on the culture
media.

Given RPs exposure to multi-drug resistant organisms at his long-term care facility, consensus
guidelines dictate that he receive broad empiric pneumonia therapy with two anti-pseudomonal agents
and an anti-staphylococcal agent.1 This regimen covers most of the potential pathogens that can
potentially cause healthcare associated pneumonia (HCAP), and relies heavily on microbiologic
cultures for de-escalation. In situations, like RPs, in which microbiologic cultures cannot identify a
causative pathogen, alternative microbiologic testing, like urinary antigen tests can be informative and
provide opportunities to de-escalate therapy.

Copyright 2014 the Alliance for the Prudent Use of Antibiotics (APUA) 120001259 11/14
Pneumococcal Urinary Antigen Test

The pneumococcal urinary antigen test (pUAT) is a useful diagnostic tool, especially in patients who
have high risk of pneumococcal pneumonia. Guidelines recommend performing pUAT in patients
requiring intensive care admission, those who have failed outpatient antibiotic therapy, leucopenia,
active alcohol abuse, chronic severe liver disease, asplenia, or pleural effusion.2 It is a relatively
simple and rapid test to perform, requiring only a urine specimen from the patient and taking only 15
minutes. It has a demonstrated specificity of >90%, but is relatively insensitive (70-80%).3-5 It
maintains specificity after several days of antimicrobial therapy.6 Concentration of the urine prior to
testing may enhance the sensitivity, but may decrease the specificity.7

Costs

The cost of treating HCAP is highly variable, depending on the agent chosen. The cost could range
from $50-$300 per day of therapy.1 With the pUAT costing approximately $30, de-escalating therapy
can produce a significant cost savings, plus provide an opportunity to avoid further exposure to broad-
spectrum antibiotics. Furthermore, when a three-drug regimen is changed to a single-drug regimen,
the patient benefits from the lower risk of adverse events potential drug reactions. The pUAT also has
utility in the treatment of CAP. Because of the need to cover both typical and atypical organisms, the
recommended treatment for CAP is either fluoroquinolone monotherapy or a beta-lactam plus
macrolide. The fluoroquinolone and macrolide drug classes are both known to be cardiotoxic drugs,
potentially prolonging the QT interval, which can lead to sudden cardiac death.8 An opportunity to
discontinue one of those agents and use beta-lactam monotherapy for pneumococcus may limit the
incidence of these adverse cardiac events.

References

1. Niederman, M.S. et al. (2005) 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. Mandell, L.A. et al. (2007) Infectious Diseases Society of America / American Thoracic Society
Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clin Inf
Dis. 2007; 44S27-72.

3. Dominguez, J. et al. (2001) Detection of Streptococcus pneumoniae antigen by a rapid

immunochromatographic assay in urine samples. Chest. 2001; 119:2439.

4. Yu, V.L. et al. (2000) Evaluation of the Binax urinary gram stain and sputum culture for
Streptococcus pneumoniae in patients with community-acquired pneumonia. Clin Infect Dis 2000; 32:
258.

5. Murdoch, D.R. et al. (2001) Evaluation of a rapid immunochromatographic test for detection of
Streptococcus pneumoniae antigen in urine samples from adults with community-acquired
pneumonia. J Clin Microbiol. 2001; 39:34958.

Copyright 2014 the Alliance for the Prudent Use of Antibiotics (APUA) 120001259 11/14
6. Smith, M.D. et al. (2003) Rapid diagnosis of bacteremic pneumococcal infections in adults by
using the Binax NOW Streptococcus pneumoniae urinary antigen test: a prospective, controlled
clinical evaluation. J Clin Microbiol. 2003; 41:28103.

7. Stralin, K. (2008) Usefulness of aetiological tests for guiding antibiotic therapy in community-
acquired pneumonia. Int J Antimicrob Agents. 2008; 31: 3-11.

8. Ray, W.A. et al. (2012) Azithromycin and the Risk of Cardiovascular Death. NEJM. 2012; 366;
1881-1890.

Copyright 2014 the Alliance for the Prudent Use of Antibiotics (APUA) 120001259 11/14