NCCEd: Neurocritical Care Education for Residents

We don't actually have enough information to decide if he has a pneumonia. We have a radiographic finding that is compatible with pneumonia. We also now have bacterial growth in the BAL. However, this could simply represent colonization. What other data points do we need to determine whether he has a pneumonia? Presence of any of the following additional features would help confirm the diagnosis: worsening oxygenation, leukocytosis or leukopenia, and increase in secretion burden and character.

In terms of whether to start antibiotics empirically, we should hold off and not start them purely on the basis of the BAL. However, if we have a higher actual suspicion for pneumonia (i.e. the above added features become present), then we should. Which antibiotics, though? This patient has now been in the hospital for ≥ 48 hours, and he's also been on the ventilator for ≥ 48 hours. Thus, we would have to treat for VAP, which requires coverage of MRSA and Pseudomonas. We could accomplish this by using IV vancomycin (pending MRSA swab results, which would be predictive of the causative pneumonia organism) and cefepime or piperacillin/tazobactam.