GetMeOuttaThisMess Posted May 21, 2017 Share Posted May 21, 2017 Had a gentleman a couple weeks ago with traditional snot/cough for this time of year in N. Texas (along with everyone else being seen) and on exam he had rales at the left base. No fever, either obj./subj. Nothing on the right and no prior hx. of diagnosed lung/cardiac disease. Went ahead and treated him for presumptive pneumonia with instructions to see his PCP next day for "consideration" of CXR (see how I didn't tell him that he had to get his PCP to obtain a CXR?) since we can't obtain them in our setting. Had our monthly doctor meeting the next day and amongst the four providers with I'd guess close to 100 years of accumulative experience, no one could recall one w/o fever. Mine for example 10-15 years ago was fixed temp at 103 w/o a lick of coughing which I've seen numerous times. Callback was done 48 hours later and sure enough, CXR showed pneumonia. For whatever reason the pt. had been placed on clarithromycin but for whatever the reason the PCP chose to change it to something else. BTW, nothing in medical hx. or treatment prior to presentation that would inhibit fever development. Link to comment Share on other sites More sharing options...
sk732 Posted May 21, 2017 Share Posted May 21, 2017 I've seen it in the elderly...I did catch one in a middle aged person that was complaining of RUQ pain, minimal cough and no fever, but they were on a biologic at the time, which is something I'm afraid we're going to be seeing more and more of. SK Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 21, 2017 Author Share Posted May 21, 2017 Yep, I could see/suspect it in an elderly soul but this was a middle-aged guy. Uh, maybe not quite so accurate. "Middle-aged" like me in late 50's. Link to comment Share on other sites More sharing options...
sk732 Posted May 21, 2017 Share Posted May 21, 2017 Yep, I could see/suspect it in an elderly soul but this was a middle-aged guy. Uh, maybe not quite so accurate. "Middle-aged" like me in late 50's. I kinda consider that middle aged too :-D. Did you do a reflection test to make sure they weren't a vampire or something, lol? Was just thinking, they might have changed the meds on this guy because of antibiograms or something - macrolides are pretty much useless where I work because of mentally challenged overuse of ZPacks - I only use azithro or clarithro if double covering someone now or they're allergic to everything else. I was thinking of this since, after two + years of working where I am and complaining about it (one of my supervising docs hides behind EBM so they don't have to make a decision about something - if it's not in Up To Date, it doesn't count and pneumonia guidelines don't take regional sensitivities into consideration), they've finally published an antibiogram for our area and issued us each one for our crib notes. SK Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 21, 2017 Author Share Posted May 21, 2017 We're ok with clarithromycin in my neck of the woods for pmonia. Link to comment Share on other sites More sharing options...
Joelseff Posted May 21, 2017 Share Posted May 21, 2017 We're ok with clarithromycin in my neck of the woods for pmonia.Clarithro or Azithro still works here too for CAP. If it's a chronic lunger or Atypical suspicion then of course it changes the picture. Sent from my SAMSUNG-SM-G891A using Tapatalk Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted May 21, 2017 Moderator Share Posted May 21, 2017 early aspiration pneumonitis or oncology pt may not have fever..... Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 21, 2017 Author Share Posted May 21, 2017 early aspiration pneumonitis or oncology pt may not have fever..... Yep, we were discussing the known (big assumption) walking well between bites of burgers and other healthy food items. Link to comment Share on other sites More sharing options...
marktheshark89 Posted May 21, 2017 Share Posted May 21, 2017 Are there sill pockets where cipro or azithro are acceptable for CAP? Latest I had read, I think on UTD, the entire US has >25% pneumococcal resistance to azithro as a single agent. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted May 21, 2017 Moderator Share Posted May 21, 2017 I usually use vantin, biaxin, or doxy now for single agent. Link to comment Share on other sites More sharing options...
marktheshark89 Posted May 21, 2017 Share Posted May 21, 2017 I've typically been using levaquin. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted May 21, 2017 Moderator Share Posted May 21, 2017 trying not to use quinolones, except for GU stuff. Link to comment Share on other sites More sharing options...
sk732 Posted May 21, 2017 Share Posted May 21, 2017 I usually use amoxiclav or doxy for first line use, sometimes cefuroxime...I avoid respiratory quinolones as first line agents because I want them to work when I actually need them to (and in places I used to work, they were in fact not allowed to be used as first line agents). Quite a bit of our TB out here is moxi/levo sensitive and I'd like to help keep it that way and keep them out of the gene pool...not to mention the average drug resistant S.pneumo and Moraxella and crap we usually see. Antibiograms are out there for a reason - people should ask for and use them and be tight arsed with their Rx pads (I know you're the choir, but every little bit helps, lol). In my hospital, it takes both an act of God AND Parliament to get moxifloxacin released from the pharmacy (tried it for an active TB case that came in coughing up gallons of green pea soup - unsuccessful). SK Link to comment Share on other sites More sharing options...
marktheshark89 Posted May 22, 2017 Share Posted May 22, 2017 kind of the opposite guidelines I've seen in my neck of the woods - most of the docs around here recommend either dual therapy (azithro/doxy + another agent that covers pneumococcus) or a respiratory quinolone for outpatient CAP tx. Seems like this is what UTD suggests too. I do know we have pretty high % of azithro/clarithro/doxy resistant pneumococcus so I'm sure that has something to do with it. Interesting to hear what is recommended by others and in other parts of the country! Link to comment Share on other sites More sharing options...
Reality Check 2 Posted May 22, 2017 Share Posted May 22, 2017 Our pulm docs here save zith for MAI in COPD patients and prefer us to use Levaquin for pneumonia first line most of the time. Right or wrong - it is what we see Sometimes Augmentin or doxy - occasionally Bactrim. I try to work on respiratory with bronchodilators in a lot of folks and some prednisone helps. Then some of mine wait until sats are 89% and they are retracting and then call in saying they have the flu and I send them to the hospital for a lovely stay with round the clock nebs, IV steroids and abx and copious visits from the resp therapist with CPT or the dreaded vest of shaking death. Right now we run 180 degrees - either barely a sniffle and they are dying or they really are trying to die and didn't come in soon enough Link to comment Share on other sites More sharing options...
newton9686 Posted May 22, 2017 Share Posted May 22, 2017 Doxy is God's gift to the earth. It gives me hope that many bugs have lost resistance to it since it fell out of favor for newer drugs. Link to comment Share on other sites More sharing options...
newton9686 Posted May 22, 2017 Share Posted May 22, 2017 But yes, those with hampered immune systems can have life threatening infections without fever, elevated WBCs, erythema, chills and even infiltrate. That's why you have to be so concerned when any patient presents with non specific symptoms who is over 65 or any other risk factor for being immunocompromised. Link to comment Share on other sites More sharing options...
d2305 Posted May 22, 2017 Share Posted May 22, 2017 Good review Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 22, 2017 Author Share Posted May 22, 2017 I should've clarified in original post. I'm referencing walking well. I use doxy to cross cover chest and sinuses depending on wind direction and day of week. Don't use for presumptive strep. If they need something for that give them a souvenir GI gift. Clinda. Link to comment Share on other sites More sharing options...
Joelseff Posted June 10, 2017 Share Posted June 10, 2017 trying not to use quinolones, except for GU stuff.For COPD exacerbation PNA for pts over 65 or other RF (FEV1 below 50% expected value etc) fluoroquinolones are considered first line. Just make sure to warn about tendinopathy and candidiasis etc. Sent from my SAMSUNG-SM-G891A using Tapatalk Link to comment Share on other sites More sharing options...
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