Episode Details

The sun rises over the San Joaquin Valley, California, today is October 9, 2020. 

About one year ago, the American Thoracic Society and Infectious Diseases Society of America issued an official clinical practice guideline regarding the diagnosis and treatment of adults with community acquired pneumonia (CAP). 

There you can find the answer to 16 common questions about CAP in adults. For example, question 8 refers to the antibiotics recommended for empiric treatment of CAP in adults as outpatients. 

For healthy outpatient adults without comorbidities (chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia) or risk factors for antibiotic resistant pathogens (prior respiratory isolation of MRSA or Pseudomonas, or recent hospitalization AND receipt of parenteral antibiotics in the last 90 d), It is recommended monotherapy with amoxicillin or doxycycline or a macrolide.

For outpatient adults with comorbidities, the antibiotics recommended (without specific order) are 

1. Combination of amoxicillin/clavulanate or cephalosporin (such as Cefuroxime) PLUS Macrolide (such as azithromycin) or doxycycline or

2. Monotherapy with respiratory fluoroquinolone (such as levofloxacin).

CAP with no comorbidities in adult: Monotherapy with amoxicillin, doxy or a macrolide. CAP with comorbidities: Combined Augmentin or cephalosporin PLUS a macrolide or doxycycline. It’s a tongue twister, may it’s better if you take a look at the official recommendation.

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. 

“Courage isn’t having the strength to go on – it is going on when you don’t have strength. – Napoleon Bonaparte.

Dr. Arreaza: Courage means to keep going even when you don’t have strength. Feeling discouraged is not uncommon during residency. You may feel inadequate at times, you may feel like “you don’t know enough,” but don’t worry, it is not easy, but the extra work is worth it. Get the courage to keep going. 

Dr. Patel: Hi listeners, I’d like to introduce myself, name is Ravi Patel, I’m a non-practicing MD who recently moved to Bakersfield and just met Dr. Arreaza, and his quote resonates with me because my journey to practicing medicine has been quite long and I definitely feel the importance in not giving up in the face of discouragement. 

Dr. Arreaza: Can you tell us a little bit of your background on working with pain management and opioids?

Dr. Patel: I have several years of experience working in pain management and primary care with the Vegas metro population, huge indigent population which faces unique challenges especially in regards to opiate therapy. I’m here to discuss with Dr. Arreaza issues involving opiate usage, when it is appropriate, when it is not appropriate, and the importance of limiting usage, and in what cases long term usage is appropriate.

Dr. Arreaza: That’s going to be our first topic – opiate therapy. When is it appropriate? How do you screen patients for therapy?

Dr. Patel: It’s important to follow CDC guidelines, great place to begin, in screening patients it is inevitable due to the nature of opiates, to have drug-seeking patients. I like to begin with CDC guidelines. It’s important to stay under 90 MMEs per day, just in terms of efficacy and of course legal reasons, and most importantly patient safety. I like to follow the rule of 3 and 7, meaning acute patients, acute care in acute care settings, more so ED settings rather than urgent care, where 3-day courses of opiates are more suitable. Of course, there are other reasons as well, such as peri-surgical pain,