The Real-World Boards: Question #42
Patient with pneumonia going to the floor. What's the right antibiotic course?
These are the Real-World Boards. As in the real world, there is often no “right” answer, and you are only competing against yourself. Upgrade to the Lifelong Learner level for full access to all the questions and unlimited CME credits with an included Learner+ account.
A 67-year-old man with pulmonary fibrosis and chronic obstructive pulmonary disease and heart failure who uses ambulatory oxygen at 2 liters/minute with exertion presents to the ED with worsening dyspnea and cough.
He has been hospitalized for respiratory exacerbations (about twice per year, most recently six months ago), with no history of resistant organisms or Pseudomonas, and has never required mechanical ventilation.
He is febrile, hypotensive, and has an elevated lactate; he requires high-flow nasal cannula oxygen (FiO2 50% / 50L) to maintain oxygen saturation >90%. His chest film shows a new right lower lobe infiltrate. He is provided one liter of crystalloid, norepinephrine, ceftriaxone, azithromycin, and hydrocortisone, and is admitted to the ICU.
On hospital day 3, he has improved significantly. He has been afebrile for almost 24 hours; he requires only 4 liters/minute of oxygen; blood pressure is normal off vasopressors; heart rate is 110 (down from 140); respiratory rate is 24 and unlabored. Blood cultures are negative thus far. Sputum cultures and nasal respiratory PCR were not collected. His mental status is at baseline, according to his wife.
You decide he is ready for transfer to the medical unit.
