A previously healthy 4-year-old boy is brought to the physician in July with fever, productive cough, and left-sided chest pain that began yesterday. He attends a preschool where other children have had a cough and runny nose. Past medical history is negative for asthma or other respiratory illnesses. The child's immunizations are up-to-date and he takes no medications. He lives with his parents and has not traveled outside the country. His temperature is 39.5 C (103.1 F), blood pressure is 98/64 mm Hg, pulse is 104/min, and respirations are 25/min. Oxygen saturation by pulse oximetry is 97%. Examination shows a cooperative boy with intermittent coughing. The left lower lung lobe has decreased breath sounds. A 2-view chest radiograph shows mild alveolar consolidation with air bronchograms in the left lower lobe. What is the most appropriate pharmacotherapy for this patient's condition?

Question

A previously healthy 4-year-old boy is brought to the physician in July with fever, productive cough, and left-sided chest pain that began yesterday.  He attends a preschool where other children have had a cough and runny nose.  Past medical history is negative for asthma or other respiratory illnesses.  The child's immunizations are up-to-date and he takes no medications.  He lives with his parents and has not traveled outside the country.  His temperature is 39.5 C (103.1 F), blood pressure is 98/64 mm Hg, pulse is 104/min, and respirations are 25/min.  Oxygen saturation by pulse oximetry is 97%.  Examination shows a cooperative boy with intermittent coughing.  The left lower lung lobe has decreased breath sounds.  A 2-view chest radiograph shows mild alveolar consolidation with air bronchograms in the left lower lobe.  What is the most appropriate pharmacotherapy for this patient's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf93_fdc5_8f63_23bd22133af7_MD0005_00 Pneumonia is a lung infection characterized by fever, tachypnea, cough, and adventitious lung sounds. Severe cases may be accompanied by hypoxia and respiratory distress (eg, grunting, nasal flaring, intercostal retractions), especially in patients with a history of underlying respiratory disease (eg, asthma, chronic lung disease in premature infants) or immunodeficiency. When the diagnosis is equivocal on examination, a 2-view (posteroanterior and lateral) chest x-ray showing infiltrates supports the diagnosis. This child's presentation is consistent with uncomplicated community-acquired pneumonia. The physical examination and x-ray findings point to a lobar process, which is most commonly due to Streptococcus pneumoniae. The treatment of choice in the outpatient setting is high-dose oral amoxicillin, as low-dose amoxicillin is less efficacious. (Choice B) Azithromycin is the treatment of choice for atypical pneumonia (Flow chart) caused byMycoplasma pneumoniae but is often ineffective for S pneumoniae. (Choice C) Ciprofloxacin is not recommended for pneumonia treatment due to poor lung penetration. Respiratory fluoroquinolones (eg, levofloxacin, moxifloxacin) have activity against Streptococcus and Mycoplasma. However, these broad-spectrum antibiotics are reserved for patients with comorbidities, as repeated fluoroquinolone use increases the risk of fluoroquinolone resistance. (Choice D) Doxycycline is sometimes used in the treatment of atypical pneumonia caused by M pneumoniae. It is generally contraindicated in children age <8 due to the potential for permanent teeth staining. (Choice E) Viral pneumonia is common in infants and young toddlers. The typical onset is gradual upper respiratory symptoms and bilateral lower respiratory tract involvement. Although influenza can have a more sudden and severe onset, it typically occurs in the fall and winter and is treated with oseltamivir in high-risk patients. Educational objective: Community-acquired bacterial pneumonia in toddlers with focal findings is most likely caused by Streptococcus pneumoniae. High-dose amoxicillin is the first-line outpatient treatment. References: The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/21880587) Community-acquired pneumonia in children. (http://www.ncbi.nlm.nih.gov/pubmed/23062094) Chest radiographs for acute lower respiratory tract infections. (http://www.ncbi.nlm.nih.gov/pubmed/24369343)

A Previously Healthy 4-Year-Old Boy Is Brought to the Physician