Distinguishing Between Pneumonitis and Pneumonia: When Antibiotics Become Fatal

To prescribe or not to prescribe? — That is the question that practitioners face regarding antibiotics. While they can be extremely beneficial, the medication proved to be the deadly approach for one patient.

A report posted on JAMA Internal Medicine tells the story of a 50-year-old man who was taken to the emergency room with a witnessed generalized tonic-clonic seizure. Unclear distinctions between aspiration pneumonitis and pneumonia led to the patient’s unfavorable outcome.

The man had cerebral palsy and a seizure condition for which he took valproate sodium to control. The patient’s blood pressure improved from 70/40 mm Hg the day of the seizure to 110/70 the following day and seemingly was more alert — requiring little pressure support ventilation. However, a chest radiograph rose concerns for aspiration pneumonia, so he was administered a 7-day treatment for piperacillin-tazobactam. After completing the treatment, the patient was deemed stable and was transferred to the medical unit and then discharged to his chronic care home 10 days after.

“A week later, he presented again to the hospital with a 2-day history of lethargy, decreased oral intake, and frequent watery bowel movements,” the article informed. “He was tachycardic hypotensive, and had a serum white blood cell count of 30 400/µL (30.4 x 10⁹/L).”

The patient tested positive for severe C difficile infection, was treated with oral vancomycin and intravenous metronidazole, and denied a colectomy. He died from the C difficile colitis on day 18 in the hospital.

So what went wrong?

“Our patient presented with acute aspiration in the setting of tonic-clonic seizure, and antimicrobial therapy was initiated because bacterial pneumonia could not be confidently excluded,” the publication said. “Despite improvement, he was prescribed a full course of antimicrobial therapy ‘just-in-case.’”

Making the distinction between aspiration pneumonitis and pneumonia is already a challenge, but when a history of aspiration isn’t witnessed it makes a diagnosis more problematic. The report said that there should be a confident decision against antibiotics for the first 48 hours — with continued supportive management – for patients with witnessed aspiration events.

“Lack of expected improvement within 48 hours, or recurrence of fever and worsening respiratory status 2 or more days following the aspiration event, suggest the development of pneumonia that warrants initiation of antimicrobial therapy,” JAMA continued.

Medication, such as prophylactic antimicrobial therapy, which is commonly prescribed for pneumonitis, has yet to show that they stop the illness from progressing into pneumonia. Therefore, a patient could be exposed damaging, unnecessary antibiotics.

Aspiration pneumonitis patients are often in critical condition and need antimicrobial therapy. The clearest difference between the 2 is that pneumonitis comes on suddenly while pneumonia builds up gradual symptoms. However, in this case the aspiration status was unknown, making the distinction unclear, so the patient was given the antibiotics as precaution. Regardless of the observed rapid improvement, the medication turned out to be the reason behind his death.

This is just one example of when antibiotics are not the answer, even “just-in-case.”