Q&A Medicine>>>>>Infectious Diseases
Question 1#

A 72-year-old woman is admitted to the hospital for an acute exacerbation of heart failure. She has a history of congestive heart failure (CHF), hypertension, and diabetes. While in the hospital, she is diuresed with IV furosemide and her symptoms improve. However, 3 days later she develops worsening shortness of breath. Her temperature is 38.1°C, blood pressure is 104/68 mmHg, heart rate is 94 beats per minute, respiratory rate is 26 breaths per minute, and oxygen saturation is 92% on room air. A chest x-ray is ordered and is shown in Figure below:

What is the most appropriate empiric treatment?

A. Ceftriaxone and azithromycin
B. Ceftriaxone, levofloxacin, and vancomycin
C. Clindamycin
D. Increase the dose of IV furosemide and administer morphine

Correct Answer is B


Ceftriaxone, levofloxacin, and vancomycin. In a patient with pneumonia, it is important to first define the type of pneumonia since this identifies the likely organism and the necessary empiric antibiotic therapy. Hospital-acquired pneumonia (HAP) refers to the development of pneumonia >48 hours after admission, with no evidence of pneumonia on admission. A type of HAP is ventilator-associated pneumonia (VAP), which occurs 48 to 72 hours after mechanical ventilation.

Common Etiologies of Pneumonia and Empiric Antibiotic Regimens:

Healthcare-associated pneumonia (HCAP) develops in a patient with recent or ongoing contact with healthcare facilities or personnel (e.g., hospitalized ≥2 days in the last 90 days, lives in a long-term care facility, receives dialysis, etc.). Finally, community-acquired pneumonia (CAP) refers to pneumonia that develops in all other patients. Table 6-1 shows the common organisms causing each type of pneumonia as well as the appropriate empiric antibiotic therapy

(A) Empiric antibiotics for inpatient CAP consist of an anti-pneumococcal β-lactam (e.g., ampicillin-sulbactam, ceftriaxone, cefotaxime, ceftaroline, ertapenem) and a macrolide (e.g., azithromycin or clarithromycin). An alternative is a respiratory fluoroquinolone alone (e.g., levofloxacin, moxifloxacin). (C) Clindamycin is a good agent to use for suspected aspiration pneumonia and may be used as monotherapy. (D) This answer would be correct if the patient’s heart failure symptoms were not improving; however, the presence of fever and consolidation on chest x-ray indicate pneumonia.