A 21-month-old girl is brought to the emergency department due to difficulty swallowing. She first became ill 3 days ago with runny nose, cough, and low-grade fever. Over the last 4 hours, she became extremely fussy at home and refused to eat or drink. The patient previously has been well and has received all her immunizations. Temperature is 38.3 C (101 F), pulse is 180/min, and respirations are 40/min. The patient is agitated, drooling, and has suprasternal and intercostal retractions. She has audible stridor. Lung examination reveals diminished breath sounds. Due to impending respiratory failure, the patient undergoes endotracheal intubation. During intubation, the epiglottis is noted to be erythematous and edematous. Which of the following is the best empiric antibiotic therapy for this patient?

Question

A 21-month-old girl is brought to the emergency department due to difficulty swallowing.  She first became ill 3 days ago with runny nose, cough, and low-grade fever.  Over the last 4 hours, she became extremely fussy at home and refused to eat or drink.  The patient previously has been well and has received all her immunizations.  Temperature is 38.3 C (101 F), pulse is 180/min, and respirations are 40/min.  The patient is agitated, drooling, and has suprasternal and intercostal retractions.  She has audible stridor.  Lung examination reveals diminished breath sounds.  Due to impending respiratory failure, the patient undergoes endotracheal intubation.  During intubation, the epiglottis is noted to be erythematous and edematous.  Which of the following is the best empiric antibiotic therapy for this patient?

Quizplus · Accepted Answer

11ec25c8_d5e2_cc13_bc81_cf933b4ec724_MD0003_00 Epiglottitis is an uncommon, potentially fatal infection of the epiglottis that can lead to complete upper airway obstruction. Isolated pathogens are usually nasopharyngeal bacteria, most commonly Haemophilus influenzae type b (Hib). Due to widespread vaccination against Hib, the incidence of epiglottitis has diminished. However, the proportion of epiglottitis caused by other pathogens, such as other strains of H influenzae, Streptococcus species (S pneumoniae, S pyogenes), and Staphylococcus aureus, has increased. Symptoms include the rapid onset of respiratory distress (eg, stridor, retractions), dysphagia, and drooling due to impending airway occlusion from the swelling epiglottis. Therefore, the first step in management of epiglottitis is to secure the airway, usually via endotracheal intubation. Once the airway is secured, broad-spectrum antibiotic therapy with ceftriaxone (targeting H influenzae and Streptococcus species) and vancomycin (targeting S aureus, including methicillin-resistant strains) should be initiated promptly. (Choice A) Empiric therapy for neonatal sepsis is ampicillin and gentamicin, which target the most commonly identified pathogens, including Group B Streptococcus and Escherichia coli. This antibiotic combination does not adequately cover S aureus. (Choice B) Azithromycin is used for lower respiratory tract infection caused by atypical bacteria (eg, Mycoplasma pneumoniae, Chlamydia pneumoniae) and for whooping cough caused by Bordetella pertussis. Azithromycin will not treat S aureus or most Streptococcus species. (Choice D) Clindamycin has activity against most S aureus strains, including methicillin-resistant strains. However, clindamycin does not cover H influenzae and therefore is inappropriate empiric therapy for epiglottitis. (Choice E) Metronidazole can be used in the treatment of Clostridium difficile infection. Metronidazole provides coverage against anaerobic organisms and will not treat H influenzae, Streptococcus species, or S aureus. (Choice F) Piperacillin-tazobactam and tobramycin are used to treat Pseudomonas aeruginosa, commonly seen in pulmonary infections in cystic fibrosis. This antibiotic combination does not provide coverage against S aureus. Educational objective: After securing the airway in patients with epiglottitis, initial treatment consists of broad-spectrum antibiotic therapy with ceftriaxone (targeting Haemophilus influenzae and Streptococcus species) and vancomycin (targeting Staphylococcus aureus). References: Epiglottitis. (http://www.ncbi.nlm.nih.gov/pubmed/28613691) Antibiotic use in acute upper respiratory tract infections. (http://www.ncbi.nlm.nih.gov/pubmed/23113461)

A 21-Month-Old Girl Is Brought to the Emergency Department Due