QI Committee

Antimicrobial Stewardship  

An elderly patient presents with fevers and new oxygen requirement. Labs reveal a leukocytosis and chest x-ray reveals a lower right lung consolidation. You are concerned about an aspiration pneumonia and instinctively choose a regimen with anaerobic coverage, but is anaerobic coverage necessary? A recent article by Dr. Vedamurthy and others published in the Journal of Hospital Medicine attempts to answer this question. 

Highlights 

• Data regarding anaerobes as a major pathogen in aspiration pneumonia stems from studies in the 1970’s evaluating patients with presumed aspiration pneumonia. Many patients had complicated pneumonia with abscesses or pulmonary necrosis. 
• More recent data in patients with uncomplicated aspiration pneumonia have shown aerobic gram-positive and/or gram-negative bacteria to be the predominant pathogenic organisms.  
• Potential harms associated with unnecessary anerobic coverage include gut dysbiosis, higher incidences of antibiotic resistance organisms and C. difficile infections.  
• Recommendations: Treat for CAP/HAP without specific anaerobic coverage unless patient have the following risk factors or findings:
  • Macroaspiration with severe periodontal disease 
  • Putrid sputum 
  • Prolonged illness (>7 days)
  • Lung abscess 
  • Empyema 

Article: 
Amar Vedamurthy, MD, MS, MRCP (UK), FACP, Iniya Rajendran, MD, MPH, Farrin Manian, MD, MPH, FACP, FIDSA, FSHEA, Things We Do for No Reason™: Routine Coverage of Anaerobes in Aspiration Pneumonia. J. Hosp. Med 2020;12;754-756. Published Online First September 23, 2020. doi:10.12788/jhm.3506 

Additional Resources:  

Mandell LA, Niederman MS. Aspiration Pneumonia. N Engl J Med. 2019 Feb 14;380(7):651-663. doi: 10.1056/NEJMra1714562. PMID: 30763196. 

On Monday’s morning report, we discussed the case of an elderly female presenting with hemoptysis and AKI. Part of our discussion focused on  FeNa and FeUrea. These tests are commonly ordered reflexively during evaluation of AKI, but are they the best use of hospital resources. A 2016 article by Dr. Pahwa and Dr. Sperati attempted to address this question.  

Key Points :

• The initial studies investigating FeNa and FeUrea focused on select populations with small sample sizes. These findings are likely not reflective of the general inpatient population.  
• FeNa and FeUrea often had minimal impact on the pre-test probability.  
• Rather than obtaining FeNa and FeUrea, the authors suggest focusing on management: 
  • Fluid administration vs diuresis in the setting of suspected pre-renal AKI. 
  • Fluid administration in the setting of suspected ATI if hypovolemia is present. 
• Urine sediment can help differentiate between ATN and pre-renal AKI, in addition to evaluating for other etiologies of AKI (glomerulonephritis and acute interstitial nephritis) .
• FeNa can be helpful in the diagnosis of hepatorenal syndrome.  

Link to article: https://www.journalofhospitalmedicine.com/jhospmed/article/127988/urinary-excretion-indices-aki

Additional review article: https://cjasn.asnjournals.org/content/7/1/167