Pneumonia Kills Patient After Treatment is Discontinued

This case takes place in Louisiana and involves an elderly male patient with a past medical history of end-stage renal disease, diabetes, COPD, an arrhythmia which was treated with a pacemaker, as well as a stroke several years prior to the presenting complaint. The patient initially presented to the ER with pneumonia at which time he was admitted and treated with antibiotics. While in the hospital, the patient’s white blood count ranged between a low of 11.1 to high of 23.8. The patient suffered two falls while in the hospital, and the second fall resulted in bilateral lower extremity fractures. The patient was seen by an infectious disease physician one week after initially being admitted, who decided to discontinue the antibiotic therapy. The patient was then discharged a few days later. On the day before the patient was discharged, his white blood cell count was 20.3. Just a few days after he was discharged from the hospital, he presented to another hospital with symptoms of a respiratory tract infection. At that time, he had a white blood count of 19.2, and was diagnosed with pneumonia again. The patient was admitted to the hospital immediately, but died from the infection the following day. It is alleged that antibiotic treatment should not have been discontinued during the initial hospitalization.

Question(s) For Expert Witness

1. Do you treat patients with pneumonia? If so, how often?

2. When is it appropriate to discontinue antibiotic therapy for patients suffering from pneumonia?

Expert Witness Response E-004446

I treat patients with community and healthcare pneumonia daily. There are standard guidelines for duration of therapy for pneumonia, which is 5- 7 days for community, and 8 days for healthcare/hospital. There are studies that show that 8 days is sufficient if therapy is equivalent to 15 days, and the meta-analysis in CHEST 2103:144:1759-67 support shorter courses of therapy. Shorter courses of therapy are associated with a higher risk of relapse, so the duration of RX is usually individualized, based on the micro-organism, and patient risk factors. Stroke patients (or sequela) are also at higher risk of aspiration syndromes, so it is not unusual to see patients like this swallow poorly and have recurrent events. One would need to know if the patient was assessed for aspiration risk with a swallow study.