CV: RRR, normal S1, S2; no murmurs, rubs, or gallops

Lungs: Decreased breath sounds on the left side compared with the right and rales in the left lower lobe

Abd: Soft, nontender, nondistended; (+) bowel sounds, no hepatosplenomegaly, heme (-) stool

Neuro: Oriented to name and place but not to date. She is easily confused by questions asked of her

Diagnostic Tests: Chest x-ray: left lower lobe infiltrates; oxygen saturation 92% on room air

Labs: Unavailable in the clinic

Given this additional information, what is your assessment of the patient's condition? Identify your treatment goals for the patient

For HCAP, HAP, and VAP, the risk of infection from an MDR pathogen is relatively high. The number and type of organisms that are MDR vary from hospital to hospital making it more difficult to generate guidelines for treatment. Therefore, the treatment recommendations may be too broad or too narrow for any given institution. Treating patients with HCAP, HAP, or VAP is more complex than treating patients with CAP. There are many factors to consider and one of those relates the timing of infection to the most likely pathogens. Early-onset infection is less likely to be caused by MDR pathogens than late-onset infection. In early-onset infection, community pathogens such as pneumococcus, Legionella, and Mycoplasma need to be considered as well as some of the hospital pathogens. Patients developing late-onset pneumonia are at increased risk of having a resistant pathogen or MDR pathogen such as MRSA, enteric gramnegative bacilli, Pseudomonas, and Acinetobacter. Another issue is how HCAP and HAP are studied compared to VAP. The majority of studies were performed using patients that were intubated. Therefore, the body of literature supporting the treatment recommendations is greatest for VAP and not for HCAP or HAP. The evidence-based guidelines generated by the American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) were derived from VAP and applied to HCAP and HAP.

Table 71-2 Percentage of Resistance for Various Antimicrobials Against S. pneumoniae

Antimicrobial 1999 2001 2003 2005 2007


Azithromycin Ceftriaxone1 Levofloxacin I ri met h-sulfa Tetracycline

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