The following scenarios are fictitious but similar to those experienced by real patients and are designed to help you reflect on what you have learnt after reading the article. They could also be used for group discussion in an education or practice meeting. There are no right or wrong answers but some pitfalls to avoid.
The following case studies written by Dr Caroline Ward relate to her article, Key learning points: NICE community-acquired pneumonia. In this article, Dr Ward highlights the key learning points from the recent NICE guideline on antimicrobial prescribing for community-acquired pneumonia (NICE Guideline 138).
Emma, age 42 years
‘I’m feeling awful, doctor. I’ve been coughing up greeny-yellow phlegm for 4 days, my chest feels really tight. I’m struggling to get out of bed and finding it difficult to do the school run as I feel like I can’t breathe properly. I can hardly even walk up my stairs without having to rest. I’ve been shivery and waking up at night covered in sweat. I haven’t able been to get into the office so I have been working from home.’
Context
Emma is a single mum of two children in primary school and works as a solicitor. She has no significant past medical history, takes no regular medication, has no allergies, and has never smoked.
Examination
Emma’s temperature is 38.2°C, respiratory rate is 26/min, blood pressure is 85/60 mmHg, heart rate is 95/min, and oxygen saturations at rest are 95%. Upon auscultation of her chest, coarse crepitations in her right lower zone can be heard.
Questions for reflection
- Which parts of the history and examination concern you?
- How would you assess the severity of her pneumonia?
- Where should she be managed?
Reveal how to manage this patient
You should use a CRB65 score when diagnosing pneumonia to assess severity and help inform management decisions. Emma has a CRB65 score of 1 (due to her systolic BP of <90), which puts her in the moderate-severity category. Therefore, admission should be considered and discussed. You should outline the risks and benefits of admission or home management and take the patient’s circumstances and concerns into account. Emma is a single mother so childcare is likely to be a factor in her decision-making. If Emma is not admitted, careful safety-netting should take place. NICE recommends advising patients with community acquired pneumonia to seek medical help if:
- symptoms worsen rapidly or significantly or
- symptoms do not start to improve within 3 days or
- the person becomes systemically very unwell.
When considering admission, other factors such as co-morbidities and oxygen saturations should be taken into account along with the CRB65 score.
George, age 58 years
‘I’ve had this terrible cough for a few days, and I’m coughing up some brown stuff. I haven’t been able to go to work because I’m feeling really tired, weak, and out of breath. My wife thinks I’ve got a temperature because I keep shivering.’
Context
George works as a self-employed electrician. He has hypertension and hypercholesterolaemia, and takes ramipril 5 mg once daily and atorvastatin 20 mg once daily. He has no allergies and has never smoked.
Examination
George has no signs of an upper respiratory tract infection, his temperature is 38.6°C, respiratory rate is 20/min, blood pressure is 140/90 mmHg, heart rate is 85/min, and oxygen saturations at rest are 96%. Upon auscultation of his chest, a few crepitations in his left mid zone can be heard.
Questions for reflection
- What is George’s CRB65 score?
- Which antibiotic would you prescribe and for how long?
Reveal how to manage this patient
George’s CRB65 score is 0, which means he has a low-severity CAP. Patients with a CRB65 score of 0 and no concerning clinical features or significant co-morbidities can normally be safely managed in the community.
The first choice antibiotic for low-severity CAP is amoxicillin 500 mg three times a day for 5 days. Antibiotics should be started within 4 hours of diagnosis where possible. George should be given safety netting advice to return if symptoms are not improving as expected.
George returns 4 days after his last consultation:
‘I’m taking those antibiotics you gave me doctor, but I’m not feeling any better. I’m still coughing up brown muck and still haven’t been able to work because I’m still feeling so tired and breathless.’
Examination
George’s temperature is 37.9°C, respiratory rate is 20/min, blood pressure is 145/80 mmHg, heart rate is 88/min, and oxygen saturations at rest are 97%. Upon auscultation of his chest, crepitations in his left mid zone can still be heard.
Questions for reflection
- What is George’s CRB65 score?
- Which antibiotics should you consider?
- What other investigations should be considered?
Reveal how to manage this patient
George’s CRB65 score remains at 0. It is important to reassess this when he re-presents as his infection may be worsening.
George’s symptoms have not improved, therefore he still requires antibiotic treatment. There are several options for his ongoing management. Second choice antibiotics include clarithromycin 500 mg twice daily for 5 days, or doxycycline 200 mg on day 1 then 100 mg once daily for a further 4 days. However, George is currently taking a statin, which is contraindicated with clarithromycin. Clarithromycin, and other macrolide antibiotics, can increase plasma levels of statins and lead to increased risk of rhabdomyolysis. The best option may therefore be doxycycline, or alternatively, asking George to stop his statin while taking clarithromycin.
If George’s symptoms were improving with amoxicillin, an alternative option might have been to extend his treatment from 5 to 7 days in total.
As George’s symptoms have not been responsive to first choice antibiotics, you should consider sputum sampling at this stage. This would be helpful in order to guide further antibiotic choice should his symptoms not improve with alternative antibiotics.
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