MKSAP Quiz: 2-day history of cough, fever
A 29-year-old woman is evaluated for cough and fever of 2 days' duration. She has a history of cystic acne, which is treated with a topical retinoid cream and daily minocycline. Following a physical exam and other testing, what is the most appropriate treatment?
A 29-year-old woman is evaluated for cough and fever of 2 days' duration. She has a history of cystic acne, which is treated with a topical retinoid cream and daily minocycline.
On physical examination, temperature is 38.3 °C (100.9 °F), blood pressure is 110/70 mm Hg, pulse rate is 90/min, and respiration rate is 20/min. Oxygen saturation is 93% breathing ambient air. Decreased breath sounds are heard at the right lung base.
COVID-19 testing is negative.
A chest radiograph shows a right lower lobe infiltrate.
Which of the following is the most appropriate treatment?
A. Amoxicillin
B. Ceftriaxone and azithromycin
C. Cefuroxime and doxycycline
D. Doxycycline
E. Levofloxacin
MKSAP Answer and Critique
The correct answer is A. Amoxicillin. This content is available to MKSAP subscribers as Question 72 in the Infectious Disease section. More information about MKSAP is available online.
Amoxicillin is the most appropriate therapy for this patient (Option A). Her score on the Pneumonia Severity Index screening scale is zero; therefore, outpatient therapy for community-acquired pneumonia (CAP) is appropriate. In healthy persons, treatment options are amoxicillin or doxycycline (Option D). Amoxicillin is preferred in this patient because of her chronic therapy with another tetracycline, minocycline, which is a recognized risk factor for development of doxycycline resistance. An alternative treatment option would be monotherapy with a macrolide if local pneumococcal resistance is less than 25%.
Ceftriaxone and azithromycin or levofloxacin monotherapy are recommended regimens for hospitalized patients with nonsevere pneumonia (Option B, E). Because this patient has no risk factors for adverse outcomes, she does not require hospitalization and can be safely treated with an oral regimen as an outpatient.
Cefuroxime and doxycycline or levofloxacin monotherapy are appropriate choices for outpatient therapy in patients with medical comorbidities but are overly broad for a healthy patient with minimal risk factors for resistant organisms (Option C). Specific conditions for which combination oral therapy or a respiratory fluoroquinolone are indicated include underlying cardiac, respiratory, liver, or kidney disease; diabetes mellitus; malignancy; alcohol use disorder; or asplenia. Specific respiratory fluoroquinolones recommended in the 2019 American Thoracic Society/Infectious Diseases Society of America CAP management guideline include levofloxacin, moxifloxacin, and gemifloxacin; ciprofloxacin is not active against Streptococcus pneumoniae, precluding use of this agent for CAP monotherapy.
Key Point
- In otherwise healthy persons with community-acquired pneumonia, amoxicillin or doxycycline are appropriate treatment options.