A 70-year-old man is brought to the emergency department by his daughter due to 2 days of fever, chills, shortness of breath, and cough productive of yellow-green sputum. According to the daughter, the patient appeared lethargic and mildly confused this morning and refused to eat breakfast as he wanted to stay in bed. He regularly sees a physician and is up to date on vaccinations, including the annual flu vaccine. The patient has a history of hypertension and type 2 diabetes mellitus. He currently takes hydrochlorothiazide, lisinopril, and metformin. He smokes a pack of cigarettes a day and drinks alcohol occasionally. The patient lives alone but his daughter lives nearby. Temperature is 39.4 C (103 F), blood pressure is 104/62 mm Hg, pulse is 118/min, and respirations are 28/min. Pulse oximetry shows 86% on room air but improves to 93% on 2 L of oxygen. He appears mildly lethargic. Bronchial breath sounds and crackles are heard over the right middle and lower chest fields. Heart sounds are normal. Neurological examination shows no focal deficits. Complete blood count shows a leukocyte count of 17,000/mm³ with 80% neutrophils. Blood glucose is 100 mg/dL. Chest x-ray reveals consolidation in the right middle and lower lobes. Blood cultures are obtained. Which of the following is the best next step in management of this patient?

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Explanation: 11ec2b69_bf93_3a74_8f63_ef911767e2fa_MD0005_00 This patient with acute pulmonary symptoms and a multilobar pulmonary infiltrate has community-acquired pneumonia (CAP). To determine the appropriate clinical setting for treatment, 2 major risk stratification tools are commonly used: the pneumonia severity index and the CURB-65 score. Although the pneumonia severity index is recommended when possible due to better validation and accuracy, the CURB-65 score is often employed due to the few data points required. This patient with hypoxia has a CURB-65 score of 2 or 3 (ie, confusion, age ≥65, BUN is not available) indicating a need for hospitalization on the medical floor. Blood cultures have been sent; the patient now requires empiric intravenous antibiotics with an anti-pneumococcal beta lactam (eg, ceftriaxone) plus a macrolide (eg, azithromycin) or with a respiratory fluoroquinolone (eg, levofloxacin). This provides coverage for the most common typical (eg, Streptococcus pneumoniae) and atypical (eg, Legionella) CAP organisms. CURB-65 (Choices A and C) Gentamicin, piperacillin-tazobactam, and levofloxacin may be used to treat Pseudomonas aeruginosa. Although Pseudomonas often causes hospital-acquired pneumonia, it is an unusual cause of CAP unless a patient is immunocompromised, has recently received antibiotics, or has structural lung disease (eg, bronchiectasis, chronic obstructive pulmonary disease with recent glucocorticoids/antibiotics). This patient is at low risk for Pseudomonas. (Choice D) Vancomycin is typically added to the empiric treatment of CAP in the setting of septic shock plus respiratory failure, imaging findings consistent with MRSA (eg, multilobar pneumonia with cavitation), or conditions associated with a high likelihood of colonization (eg, chronic hemodialysis, heart failure, history of MRSA colonization). This patient comes to the hospital from the community setting and does not have major risk factors for MRSA; he would require coverage for atypical organisms (eg, macrolide), rather than for MRSA. (Choice E) This patient is significantly hypoxic with a CURB-65 score of 2 or 3; hospitalization is recommended to reduce morbidity and mortality. Educational objective: Patients with community-acquired pneumonia (CAP) require risk stratification with the pneumonia severity index or CURB-65 score to determine if hospitalization is needed. Patients hospitalized on the medical floor should be initiated on empiric intravenous antibiotics with a beta lactam that targets Streptococcus pneumoniae (eg, ceftriaxone) and a macrolide (eg, azithromycin) to cover for atypical organisms. Respiratory fluoroquinolones (eg, levofloxacin) are also effective.

A 70-Year-Old Man Is Brought to the Emergency Department by His