A 73-year-old man has a 1-day history of increasin - pacemaker

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A 73-year-old man has a 1-day history of increasing cough, dyspnea, fever, and chills. He has chronic obstructive pulmonary disease and type 2 diabetes mellitus complicated by mild azotemia. The patient has a 60-pack-year smoking history and continues to smoke. Current medications are inhaled ipratropium bromide, inhaled salmeterol, and glyburide.

On physical examination, he is obese and in mild respiratory distress. Temperature is 38 °C (100.4 °F), pulse rate is 100/min, respiration rate is 20/min, and blood pressure is 135/85 mm Hg. Chest examination discloses decreased breath sounds bilaterally, scattered rhonchi, and a few crackles at the left base posteriorly. Arterial oxygen saturation is 86% by pulse oximetry with the patient breathing room air.

The leukocyte count is 9700/μL (9.7 × 109/L) with 72% neutrophils, 10% band forms, and 18% lymphocytes. Blood urea nitrogen is 40 mg/dL (14.3 mmol/L), and serum creatinine is 2.4 mg/dL (112.16 μmol/L). A chest radiograph shows a patchy infiltrate at the left lung base. The patient is hospitalized.

Which of the following is the most appropriate intravenous antibiotic therapy at this time?

A Ceftriaxone plus azithromycin
B Ampicillin“sulbactam
C Ticarcillin plus tobramycin
D High-dose penicillin
E Trimethoprim“sulfamethoxazole

[ArchivalUser]

A Ceftriaxone plus azithromycin

[ArchivalUser]

A..

[ArchivalUser]

Correct Answer = A)
Key Points

* The recommended empiric therapy for a patient with community-acquired pneumonia who is hospitalized on a general medical floor is either monotherapy with an intravenous fluoroquinolone or combination therapy with an intravenous β-lactam plus either an intravenous or oral macrolide or doxycycline.
* The recommended empiric therapy for a patient with community-acquired pneumonia who is hospitalized in an intensive care unit is an intravenous β-lactam plus either an intravenous macrolide or an intravenous fluoroquinolone.

Recommendations for initial empiric antibiotic therapy for a patient with community-acquired pneumonia are based upon specific factors that determine a particular subset into which the patient can be categorized. These factors include the place of treatment (outpatient, inpatient, or intensive care unit), the presence or absence of underlying cardiopulmonary diseases, and the presence or absence of other modifying factors that may increase the risk that a particular organism, especially Pseudomonas aeruginosa, is causing the infection.

This patient has an underlying cardiopulmonary disease and is hospitalized. However, it is not stated whether he is on a general medical floor or in the intensive care unit. The recommended empiric antibiotic therapy for a hospitalized patient with community-acquired pneumonia who is not in an intensive care unit is either 1) an intravenous β-lactam plus an intravenous or oral macrolide or doxycycline or 2) monotherapy with an intravenous fluoroquinolone. The recommended treatment for a patient in the intensive care unit is an intravenous β-lactam (ceftriaxone or cefotaxime) plus either an intravenous macrolide (azithromycin) or an intravenous fluoroquinolone. If the patient is at risk for P. aeruginosa infection, an anti-pseudomonal β-lactam should be used.

The most appropriate treatment for this patient, whether or not he required admission to the intensive care unit, is the combination of ceftriaxone and azithromycin. The other regimens do not cover the atypical pathogens that commonly cause community-acquired pneumonia, including Mycoplasma pneumoniae, Chlamydophila pneumoniae (formerly Chlamydia pneumoniae), and Legionella pneumophila.