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Question 4#

A middle-aged man comes to the Emergency Department complaining of 2 days of shaking chills, as well as a cough with foul-smelling sputum and small amounts of blood. He admits to drinking a pint of vodka and smoking 3 packs of cigarettes each day. He has been to prison twice in the last year. A chest x-ray shows right upper lobe infiltrates. His laboratory tests are shown below.

• Hemoglobin 13.6 g/dL
• Leukocyte count 16,400/mm³
• Sodium 135 mEq/L
• Potassium 4.2 mEq/L
• Creatinine 0.9 mg/dL
• Glucose 110 mg/dL

An HIV and tuberculin skin test are both negative. What is the best next step in management?

A. Begin ceftriaxone and clindamycin
B. Obtain a CT scan of the chest with contrast
C. Begin vancomycin and ceftriaxone
D. Begin trimethoprim–sulfamethoxazole and prednisone
E. Begin rifampin, isoniazid, pyrazinamide, and ethambutol

Correct Answer is A

Comment:

Begin ceftriaxone and clindamycin. This patient’s history of alcohol abuse combined with his chest x-ray findings and foulsmelling sputum support a diagnosis of aspiration pneumonia, which should be treated with clindamycin and ceftriaxone to cover both gram-negative and anaerobic pathogens. (B) CT scan of the chest would not change the management. (C) Vancomycin and ceftriaxone is the treatment for health care associated pneumonia; however, the patient has not been hospitalized recently. (D) The patient is HIV negative, making PCP an unlikely diagnosis. (E) Although the patient has risk factors for tuberculosis (TB), the tuberculin skin test was negative.