01-23-2009, 01:09 PM
A 79-year-old woman is hospitalized for treatment of community-acquired pneumonia. The patient is frail but is able to live at home. Two months ago, she had a urinary tract infection that was treated with ciprofloxacin. She had an apparent upper respiratory tract infection 7 days ago and developed left-sided pleuritic chest pain and shaking chills 1 day before admission.
On physical examination, temperature is 38.7 °C (101.7 °F), pulse rate is 110/min and regular, respiration rate is 24/min, and blood pressure is 90/60 mm Hg. Examination of the chest discloses crackles, diminished breath sounds at the left lung base, and egophony. The leukocyte count is 31,000/μL (31 × 109/L) with 85% segmented neutrophils and 7% band forms. The patient is unable to produce sputum for examination. A chest radiograph shows a left lower lobe pulmonary infiltrate.
According to the hospital's antibiogram, local isolates of Streptococcus pneumoniae are often multi-resistant (i.e., 30% of isolates are resistant to penicillin, of which two thirds of these are high-grade resistance) and a comparable number are resistant to macrolides.
Which of the following is the most appropriate therapy for this patient at this time?
A Intravenous vancomycin plus ceftriaxone
B Intravenous ceftriaxone plus azithromycin
C Intravenous levofloxacin
D Oral telithromycin
On physical examination, temperature is 38.7 °C (101.7 °F), pulse rate is 110/min and regular, respiration rate is 24/min, and blood pressure is 90/60 mm Hg. Examination of the chest discloses crackles, diminished breath sounds at the left lung base, and egophony. The leukocyte count is 31,000/μL (31 × 109/L) with 85% segmented neutrophils and 7% band forms. The patient is unable to produce sputum for examination. A chest radiograph shows a left lower lobe pulmonary infiltrate.
According to the hospital's antibiogram, local isolates of Streptococcus pneumoniae are often multi-resistant (i.e., 30% of isolates are resistant to penicillin, of which two thirds of these are high-grade resistance) and a comparable number are resistant to macrolides.
Which of the following is the most appropriate therapy for this patient at this time?
A Intravenous vancomycin plus ceftriaxone
B Intravenous ceftriaxone plus azithromycin
C Intravenous levofloxacin
D Oral telithromycin