A 24-year-old man comes to the emergency department in January due to fever and shortness of breath. A week ago, he developed fever, malaise, muscle aches, and rhinorrhea. The symptoms largely resolved 2 days ago, but this morning the patient began having productive cough of green-yellow sputum, shortness of breath, and pleuritic chest pain. He has had no recent travel or other significant illness. The patient has not received the influenza vaccine. He has a history of type 1 diabetes mellitus and takes insulin.
Temperature is 39.1 C (102.4 F) , blood pressure is 135/67 mm Hg, pulse is 104/min, and respirations are 22/min. Pulse oximetry shows 90% on room air. The patient is ill-appearing and in mild respiratory distress. He coughs frequently during the examination. Lung examination shows bronchial breath sounds and crackles in the right lower lung field.
Leukocyte count is 14,000/mm³ with 82% neutrophils. Chest x-ray shows a dense right lower-lobe consolidation with a small area of lucency and small right-sided pleural effusion. Rapid influenza test is positive.
Which of the following empiric treatments is most appropriate for this patient?

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Quizplus · Accepted Answer

This young patient had influenza symptoms, transiently improved, and then developed worsened fever and lower respiratory manifestations (productive cough, pleurisy, dyspnea), raising strong suspicion for influenza complicated by secondary bacterial pneumonia. Streptococcus pneumoniae and Staphylococcus aureus are the leading pathogens; Haemophilus influenzae is sometimes isolated. Most cases occur in patients age >65 or those with certain underlying conditions. Young, previously healthy patients can also be affected; these cases are often linked to community-acquired methicillin-resistant Staphylococcus aureus (MRSA). underlying conditions The empiric treatment of post-influenza pneumonia should include: Typical community-acquired pneumonia coverage (eg, ceftriaxone and azithromycin)MRSA coverage (eg, vancomycin)Antiviral treatment (eg, oseltamivir) - patients who develop influenza complications such as secondary pneumonia are typically treated with antivirals even if they present >48 hours after influenza symptom onset Typical community-acquired pneumonia coverage (eg, ceftriaxone and azithromycin) MRSA coverage (eg, vancomycin) Antiviral treatment (eg, oseltamivir) - patients who develop influenza complications such as secondary pneumonia are typically treated with antivirals even if they present >48 hours after influenza symptom onset (Choice A) Primary tuberculosis typically presents with the gradual onset of fever and pleuritic chest pain, sometimes with fatigue, cough, or arthralgias. Chest x-ray usually shows hilar adenopathy without the dense consolidation seen in this patient. (Choice B) Community-acquired MRSA is a common cause of secondary bacterial pneumonia following influenza infection and must be covered empirically with vancomycin. If cultures or Gram stain reveal that MRSA is unlikely, vancomycin can be discontinued. (Choice C) Piperacillin/tazobactam is typically added for anti-pseudomonal coverage in hospital-acquired pneumonia. This patient has no risk factors for pseudomonal pneumonia (eg, prior hospitalization, immunocompromised status, cirrhosis, recent antibiotic or glucocorticoid use) and should receive vancomycin plus community-acquired pneumonia treatment. (Choice E) Patients with uncomplicated influenza who have had >48 hours of symptoms are generally managed with supportive care. Supportive care would be insufficient for this patient with pneumonia (fever, productive cough, leukocytosis, pulmonary infiltrate). Educational objective: Secondary bacterial pneumonia is typically characterized by a transient improvement of influenza symptoms followed by worsened fever and lower respiratory tract illness. Most cases are caused by Streptococcus pneumoniae, but methicillin-resistant Staphylococcus aureus (MRSA) is also a frequent culprit, particularly in young, previously healthy patients. Empiric treatment should include coverage for community-acquired pneumonia (eg, ceftriaxone and azithromycin) and for MRSA (eg, vancomycin). __________ References: Bacterial coinfection in influenza: a grand rounds review. (http://www.ncbi.nlm.nih.gov/pubmed/23321766) Staphylococcus aureus community-acquired pneumonia during the 2006 to 2007 influenza season. (http://www.ncbi.nlm.nih.gov/pubmed/18534715)

A 24-Year-Old Man Comes to the Emergency Department in January