Match each patient's clinical presentation with the most appropriate antimicrobial steward… — USMLE Step 2 CK

Match each patient's clinical presentation with the most appropriate antimicrobial stewardship-guided management step.

A $30$ -year-old man with $4$ days of nasal congestion, clear rhinorrhea, and facial pressure. He is afebrile.Recommend supportive care with decongestants and defer antimicrobial therapy
A $65$ -year-old woman admitted with a severe COPD exacerbation characterized by increased dyspnea, increased sputum volume, and increased sputum purulence.Prescribe a short course of oral azithromycin or doxycycline
A $22$ -year-old woman with a severe sore throat, a temperature of $38.5^\circ\text{C}$ ( $101.3^\circ\text{F}$ ), tender cervical lymphadenopathy, and a positive rapid streptococcal antigen test.Initiate a $10$ -day course of oral penicillin or amoxicillin
A $75$ -year-old man with a chronic venous stasis ulcer on his medial malleolus that is weeping clear fluid but has no surrounding erythema, warmth, or purulence.Provide standard wound care and compression without empiric antimicrobials
A $55$ -year-old man hospitalized with acute interstitial pancreatitis who develops a fever of $38.2^\circ\text{C}$ ( $100.8^\circ\text{F}$ ) on hospital day $2$ , with no signs of infected necrosis on imaging.Maintain intravenous fluid resuscitation and withhold prophylactic antimicrobials

Answer

Viral rhinosinusitis matches with supportive care. COPD exacerbation matches with a short course of azithromycin/doxycycline. Streptococcal pharyngitis matches with a 10-day course of penicillin/amoxicillin. The uninfected venous ulcer matches with standard wound care without antibiotics. Sterile acute pancreatitis matches with maintaining intravenous fluids and withholding prophylactic antibiotics.

Each correct pairing reflects the principles of antimicrobial stewardship by ensuring antibiotics are prescribed only when clearly indicated (e.g., COPD exacerbation with cardinal symptoms, confirmed streptococcal pharyngitis) and avoided when not indicated (e.g., viral sinusitis, colonized wound, sterile pancreatitis).

Step-by-Step Solution

Evaluate the indication for antibiotics in the patient with acute rhinosinusitis.

The duration of symptoms is only

4

days, indicating a viral etiology.

Antimicrobial stewardship dictates avoiding antibiotics for self-limiting viral illnesses unless symptoms persist for more than

10

days.

Assess the criteria for antimicrobial therapy in the patient with a COPD exacerbation.

The presence of all three cardinal symptoms warrants targeted antibiotic use.

Bacterial triggers are common in severe COPD exacerbations, and antibiotics improve outcomes in this specific subgroup.

Determine the management for confirmed streptococcal pharyngitis.

Antibiotic treatment with penicillin or amoxicillin is required.

Treatment eradicates the pathogen, shortens symptom duration, and significantly reduces the risk of acute rheumatic fever.

Analyze the need for antibiotics in the patient with a chronic venous ulcer.

Systemic antibiotics are unnecessary.

The ulcer shows no signs of acute infection (erythema, warmth, purulence). Treating colonization promotes antibiotic resistance without providing clinical benefit.

Review the role of prophylactic antibiotics in the patient with acute pancreatitis.

Prophylactic antibiotics are contraindicated.

Early fever in pancreatitis is usually due to the systemic inflammatory response syndrome (SIRS), not a bacterial infection.

Key Concept

Antimicrobial Stewardship in Internal Medicine

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