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Difficulty: EasyPulmonary and Critical Care

A 5858-year-old man is evaluated in the hospital on the third day of his admission for community-acquired pneumonia. His symptoms at presentation included fever, productive cough, and pleuritic chest pain. A chest radiograph on admission showed a left lower lobe consolidation. He was empirically started on intravenous ceftriaxone and azithromycin. Today, the patient reports significant improvement in his symptoms. He has been afebrile for the past 2424 hours. Current vital signs show a heart rate of 7878/min, blood pressure of 128/82128/82 mmHg, and respiratory rate of 1616/min. His oxygen saturation is 96%96\% on room air. Sputum culture obtained on admission has grown *Streptococcus pneumoniae*. Antimicrobial susceptibility testing demonstrates that the isolate is sensitive to penicillin, amoxicillin, ceftriaxone, and levofloxacin. Which of the following is the most appropriate next step in the management of this patient?

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

Answer

Transition to oral amoxicillin
The patient has clinically improved, is hemodynamically stable, and is able to take oral medications, indicating he is ready to be transitioned from intravenous to oral antibiotics. Based on the principles of antimicrobial stewardship, therapy should be narrowed to the most targeted, effective agent according to culture and sensitivity results. Since the isolated *Streptococcus pneumoniae* is sensitive to penicillin and amoxicillin, oral amoxicillin is the most appropriate narrow-spectrum choice for step-down therapy.

Step-by-Step Solution

1
Evaluate clinical stability
The patient is afebrile, hemodynamically stable, and oxygenating well.
Determines whether the patient meets the criteria for transitioning from intravenous to oral therapy.
2
Analyze culture and susceptibility data
Sputum culture confirms Streptococcus pneumoniae that is susceptible to multiple agents, including amoxicillin.
Guides the selection of a targeted, pathogen-specific antibiotic regimen.
3
Apply antimicrobial stewardship principles
Select oral amoxicillin as the step-down therapy.
It is the narrowest spectrum oral agent that is effective against the isolated pathogen, minimizing the risk of resistance and side effects.

Key Concept

Antimicrobial stewardship and step-down therapy in community-acquired pneumonia
Estimated Time:45s
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Topics

Pulmonary and Critical Care

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