Question

A 42-year-old man presents with a 3-day a history of fever with chills, cough with greenish-yellow sputum, and chest pain. He finds himself short of breath after walking 1 block. He has body aches, headache, and lack of appetite. Since this morning, he has been nauseated, and he has thrown up 3 times. His past medical history is significant for an appendectomy at age 16 and right knee arthroscopy 3 years prior to presentation. He has no drug allergies. He is not presently on any medications. Family history is significant for coronary artery disease in his father.

On exam, he has a temperature of 101.1°F, and pulse rate is 104/min; BP is 110/67 mm Hg, and SPO2 is 91%. Chest X-ray shows consolidation in the right lower lobe of the lung. EKG has sinus tachycardia; troponin is 0.1, BUN is 17 mg/dL, creatinine is 1.2 mg/dL, electrolytes are normal, and urinalysis is normal.

What regimen should you start pending blood and sputum cultures?

1. Levofloxacin 500mg IV Q24H
2. Levofloxacin 500mg PO daily
3. Levofloxacin 250mg IV Q24H and azithromycin 250mg IV Q24H
4. Ceftriaxone 1gm IV Q24H and azithromycin 500mg IV Q24H
5. Ceftazidime 1gm IV Q24H and vancomycin 1gm IV Q12H

Answer 1

For a patient presenting with symptoms and findings consistent with pneumonia, the recommended regimen is Ceftriaxone 1gm IV Q24H and azithromycin 500mg IV Q24H for broad coverage against typical and atypical pathogens.

Step-by-step explanation:

Recommended Antibiotic Regimen

The 42-year-old man's presentation of fever with chills, productive cough with greenish-yellow sputum, and consolidation in the right lower lobe of the lung on chest X-ray is consistent with pneumonia. Given his symptoms and the findings, a dual antibiotic regimen is often recommended to cover both typical and atypical pathogens. The most appropriate choice among the listed options is: Ceftriaxone 1gm IV Q24H and azithromycin 500mg IV Q24H. This regimen provides broad coverage against both gram-positive and gram-negative bacteria, as well as atypical organisms that could be causing the pneumonia.

While levofloxacin is an alternative single-agent therapy for community-acquired pneumonia, the severity of the patient's symptoms and his hypoxemia (SPO2 91%) suggests that a more aggressive intravenous therapy with broader coverage is warranted. Additionally, the patient's vital signs showing tachycardia and the fact he is not responding adequately to the oral therapy supports the use of intravenous antibiotics. Ceftazidime and vancomycin is a more appropriate regimen for nosocomial pneumonia or if there is a suspicion of methicillin-resistant Staphylococcus aureus (MRSA), which does not appear to be the case here.