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9}A 70-year-old man with a history of heavy smoking and moderately severe chronic obstructive pulmonary disease (COPD) has been feeling poorly. He reports cough, chills, pleuritic chest pain, and low-grade fever. Chest x- ray reveals a small dense infiltrate in the right lower lobe. Gram's stain of the patient's sputum reveals numerous gram-negative cocci, many of which occur in pairs. The most appropriate therapy would be:
A)no antimicrobial therapy is required
B)tetracycline
C)ciprofloxacin
D)trimethoprim/sulfamethoxazole (TMP/SMZ)
E)penicillin/clavulanic acid
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this looks like moraxella
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E)penicillin/clavulanic acid
Explanation:In addition to Haemophilus influenzae and Streptococcus pneumoniae, the gram-negative coccus Moraxella (Branhamella) catarrhalis is a common cause of exacerbations of chronic bronchitis and pneumonia in patients with moderately severe COPD. The symptoms are typically modest in severity, although chills, pain, and malaise often are noted. Low-grade fevers and a lack of leukocytosis are also common. If the patient actually has pneumonia, the radiologic appearance is variable, and clinical parameters do not permit one to determine the organism causing illness in a heavy smoker with COPD. However, the Gram's stain in this case, which depicts the abundant presence of gram-negative cocci in pairs, is typical of M. catarrhalis. Cephalosporins, tetracycline, erythromycin, TMP/SMZ and quinolones are all effective. However, since resistance to both TMP/SMZ and tetracycline has been reported, those with pneumonia require treatment with the most effective agent. Therefore, the most appropriate choice is the combination of a penicillin and clavulanic acid, which suppresses the M. catarrhalis -lactamases
