CICM SAQ 2012.1 Q18

Questions

  • a) List the clinical features that indicate a poor prognosis in a patient with community-acquired pneumonia?
  • b) List 5 common organisms causing severe community acquired pneumonia in immunocompetent adults.
  • c) What are the possible reasons for non-response to empiric treatment for patients treated for severe community acquired pneumonia?
  • d) Briefly outline your approach to stopping antibiotics given for CAP responding to empiric treatment in ICU?

Answers

Answer and interpretation

a) List the clinical features that indicate a poor prognosis in a patient with community-acquired pneumonia?

Major criteria

  • invasive mechanical ventilation
  • septic shock with the need for vasopressors

Minor criteria

  • respiratory rate >30/min
  • PaO2/FiO2 ratio >250
  • multilobar infiltrates
  • confusion/ disorientation
  • uremia
  • leukopenia (WBC <4,000 cells/mm3)
  • thrombocytopenia (<100,000 cells/mm3)
  • hypothermia (T<36C)
  • hypotension requiring aggressive fluid resusitation

b) List 5 common organisms causing severe community acquired pneumonia in immunocompetent adults.

  1. Streptococcus pneumonia
  2. Legionella spp
  3. Haemophilus influenza
  4. Klebsiella pneumonia
  5. Staphylococcus aureus
  6. Respiratory viruses
  7. Mycoplasma

c) What are the possible reasons for non-response to empiric treatment for patients treated for severe community acquired pneumonia?

 Wrong diagnosis

  • Cardiac failure
  • PE
  • Pulmonary haemorrhage
  • Interstitial lung disease

Wrong antibiotics

  • Resistant organism e.g.: MRSA
  • Wrong organism: e.g.: viral pneumonitis

Wrong dose

  • Under dosing (gentamicin, vancomycin)
  • Wrong interval (vancomycin, cephalosporins)

Complication of the disease

  • Empyema
  • Lung abscess

Complication of treatment

  • Antibiotic reaction
  • Superinfection

 Underlying disease

  • Cancer
  • Airway obstruction
  • Severe emphysema with bullae

d) Briefly outline your approach to stopping antibiotics given for CAP responding to empiric treatment in ICU?

  • Evidence in area is complicated, but in resolving CAP- 7-10 days most common in studies
  • 5 days seems the minimum
  • More than 8 days may be associated with super infection with resistant organisms.
  • Pseudomonas- may need 15 days Legionella 3 weeks
  • Biomarkers e.g. procalcitonin in some RCTS
Exams LITFL ACEM 700

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CICM

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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