A 68-year-old man is brought to the emergency department due to confusion that started this morning. He lives with his daughter, who says that the patient has had 3 days of fever and cough productive of yellow sputum. He has a history of coronary artery disease and has smoked a pack of cigarettes daily for 40 years. Temperature is 39.4 C (103 F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 24/min. Pulse oximetry is 92% on room air. Chest auscultation reveals crackles and reduced breath sounds over the right lower chest. Laboratory results are as follows: Chest x-ray reveals alveolar infiltrates in the right lower lobe. Which of the following is the most appropriate next step in management of this patient?

Question

A 68-year-old man is brought to the emergency department due to confusion that started this morning.  He lives with his daughter, who says that the patient has had 3 days of fever and cough productive of yellow sputum.  He has a history of coronary artery disease and has smoked a pack of cigarettes daily for 40 years.  Temperature is 39.4 C (103 F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 24/min.  Pulse oximetry is 92% on room air.  Chest auscultation reveals crackles and reduced breath sounds over the right lower chest.  Laboratory results are as follows:  Chest x-ray reveals alveolar infiltrates in the right lower lobe.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d4ad_0b53_bc81_43ae35848e69_MD0003_00 This patient with productive cough, fever, leukocytosis, mild hyponatremia, and a right lower lobe infiltrate has community-acquired pneumonia (CAP). Patients with CAP are risk stratified using the pneumonia severity index or CURB-65 criteria to help guide treatment and treatment location (home, medical floor, intensive care unit). This patient with a score of 3 on the CURB-65 criteria (age >65, confusion, blood urea nitrogen >20 mg/dL) likely needs hospitalization on the medical floor. CURB-65 criteria Sputum culture and blood culture should be sent to attempt to identify the organism, and empiric treatment with a beta-lactam plus macrolide (eg, ceftriaxone plus azithromycin) should be initiated. This combination treats the most common bacterial CAP organisms-Streptococcus pneumoniae, Haemophilus influenzae, Legionella, and Mycoplasma pneumoniae. Although fluoroquinolones (eg, levofloxacin, moxifloxacin) that target respiratory tract organisms can also be used for CAP in the inpatient setting, this class of medication is generally avoided (when possible) in elderly patients due to increased risk of Clostridium difficile infection, tendon rupture, and aortic dissection. This patient also would benefit from smoking-cessation counseling and, prior to discharge, influenza and pneumococcal vaccination. (Choice A) Ampicillin/sulbactam is an acceptable choice for the beta-lactam portion of empiric antibiotic therapy; however, hospitalized patients also require a macrolide or doxycycline to cover for atypical bacterial pathogens (eg, Legionella, Mycoplasma). (Choices C, D, and E) This patient requires hospitalization due to his CURB-65 score, which indicates a higher risk of morbidity and mortality. Moxifloxacin can be used as monotherapy for inpatients with CAP, but a beta-lactam plus macrolides/doxycycline is preferred for elderly patients due to increased risk of adverse events. Doxycycline is commonly used for CAP in the outpatient setting. Trimethoprim-sulfamethoxazole is often used to treat methicillin-resistant Staphylococcus aureus; however, it is not commonly used in the empiric treatment of CAP. Educational objective: Treatment for community-acquired pneumonia (CAP) is dependent on the required level of care (eg, outpatient, medical floor, intensive care). Common tools for risk stratification include the pneumonia severity index and CURB-65 criteria. Patients with CAP who are hospitalized on the medical floor require treatment with a beta-lactam plus macrolide (eg, ceftriaxone plus azithromycin) or fluoroquinolone (eg, moxifloxacin). Fluoroquinolones should generally be avoided in elderly patients (when possible) due to the risk of Clostridium difficile infection, tendon rupture, and aortic dissection. References: The hospitalist perspective on treatment of community-acquired bacterial pneumonia. (http://www.ncbi.nlm.nih.gov/pubmed/24685965)

A 68-Year-Old Man Is Brought to the Emergency Department Due