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Difficulty: MediumGeneral Internal Medicine

A 64-year-old man is evaluated on the medical ward on hospital day 3. He was initially admitted for a two-day history of productive cough, right-sided pleuritic chest pain, and fever. At the time of admission, his temperature was 38.9°C (102.0°F), and a chest radiograph revealed a right lower lobe consolidation. He was started on empiric intravenous ceftriaxone and azithromycin.

Today, the patient reports feeling much better and asks when he can be discharged. He is tolerating his meals without difficulty.

Vital signs are:
Temperature: 37.2°C (99.0°F)
Blood pressure: 128/82 mm Hg
Pulse: 84/min
Respirations: 16/min
Oxygen saturation: 96% on room air

Physical examination reveals diminished crackles at the right lung base, which are significantly improved compared to admission.

A sputum culture obtained on admission has grown Streptococcus pneumoniae. Susceptibility testing results are as follows:
Penicillin: Susceptible
Amoxicillin: Susceptible
Ceftriaxone: Susceptible
Levofloxacin: Susceptible
Azithromycin: Resistant

Which of the following is the most appropriate modification to this patient's antimicrobial therapy?

  1. A
    Discontinue current antibiotics and start oral amoxicillin-clavulanate
  2. B
    Continue the current regimen of intravenous ceftriaxone and azithromycin
  3. Discontinue current antibiotics and start oral amoxicillinAnswer
  4. D
    Discontinue current antibiotics and start oral levofloxacin
  5. E
    Discontinue azithromycin and complete the course with intravenous ceftriaxone

Answer

Discontinue current antibiotics and start oral amoxicillin
This patient was admitted with community-acquired pneumonia and started on standard empirical therapy. By hospital day 3, he demonstrates clinical stability: he is afebrile, hemodynamically stable, has a normal respiratory rate, and is tolerating an oral diet. These findings indicate he is ready to transition from intravenous to oral antibiotics. The sputum culture grew Streptococcus pneumoniae that is susceptible to penicillin and amoxicillin. According to principles of antimicrobial stewardship, therapy should be de-escalated to the narrowest-spectrum effective agent available. Oral amoxicillin is the treatment of choice for penicillin-susceptible S. pneumoniae. This approach facilitates safe hospital discharge while minimizing collateral damage to the patient's microbiome.

Step-by-Step Solution

1
Assess the patient's clinical stability for oral step-down therapy.
The patient is afebrile, hemodynamically stable, off supplemental oxygen, and tolerating oral intake, indicating he is ready for oral transition.
Transitioning from intravenous to oral antibiotics reduces hospital length of stay, healthcare costs, and the risk of catheter-related complications.
2
Interpret the culture and susceptibility results to select the optimal targeted agent.
The pathogen is Streptococcus pneumoniae, which is susceptible to penicillin and amoxicillin.
Antimicrobial stewardship dictates using the narrowest-spectrum effective agent. Amoxicillin is the preferred oral step-down agent for penicillin-susceptible S. pneumoniae.

Key Concept

Clinically stable patients with community-acquired pneumonia should be transitioned from empirical intravenous therapy to targeted, narrow-spectrum oral antibiotics based on culture susceptibilities.
Estimated Time:1m 15s
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Topics

General Internal Medicine

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