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Difficulty: EasyInfectious Diseases

A 65-year-old man is hospitalized for community-acquired pneumonia. Upon admission, he was empirically started on intravenous ceftriaxone and azithromycin. Two days later, his clinical condition has significantly improved. He is now afebrile, his oxygen saturation is 96% on room air, and his cough has decreased. He is eating well and tolerating oral intake. Sputum culture results return positive for Streptococcus pneumoniae. Susceptibility testing shows the organism is highly sensitive to penicillin, amoxicillin, ceftriaxone, and levofloxacin. Which of the following is the most appropriate next step in pharmacotherapy?

  1. Transition to oral amoxicillinAnswer
  2. B
    Continue intravenous ceftriaxone and azithromycin
  3. C
    Transition to oral levofloxacin
  4. D
    Transition to oral amoxicillin-clavulanate
  5. E
    Add oral clindamycin to the current regimen

Answer

Transition to oral amoxicillin
The patient has community-acquired pneumonia that has clinically improved, and he is now able to tolerate oral intake. This marks the appropriate time to transition from intravenous to oral antibiotics. Furthermore, culture results show Streptococcus pneumoniae that is highly sensitive to amoxicillin. According to principles of antibiotic stewardship, therapy should be de-escalated to the narrowest spectrum agent that is effective. Oral amoxicillin perfectly fits these criteria, minimizing the risk of adverse effects and antimicrobial resistance.

Step-by-Step Solution

1
Evaluate the patient's clinical trajectory.
The patient is afebrile, oxygenating well on room air, and tolerating oral intake, indicating readiness to switch from intravenous to oral therapy.
Clinical stability dictates whether a patient can be safely de-escalated to oral antibiotics.
2
Analyze the culture and susceptibility data.
Sputum culture confirms Streptococcus pneumoniae that is sensitive to penicillin and amoxicillin.
Culture data allows for de-escalation from empiric broad-spectrum coverage to targeted narrow-spectrum therapy.
3
Select the most appropriate targeted therapy.
Oral amoxicillin provides the narrowest effective spectrum for this pathogen in an orally bioavailable form.
Antibiotic stewardship principles require using the narrowest spectrum, most effective, and least toxic agent available.

Key Concept

Antibiotic stewardship and de-escalation in community-acquired pneumonia
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Topics

Infectious Diseases

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