Treating CAP: Which Oral Drug Is Best After Discharge?

Jason E. Bowling, MD


May 06, 2019

Community-Acquired Pneumonia

What's the best de-escalation antibiotic therapy for community-acquired pneumonia (CAP) when no definitive pathogen is found? It's a common scenario, but with all of the bad news about fluoroquinolones lately, the right course isn't as straightforward as it used to be. As an infectious diseases specialist, I'll share my thoughts about choosing an effective alternative to a fluoroquinolone in a patient who needs continuing therapy for CAP.

Here are the details:

He's 68 years of age, with a history of osteoarthritis and gastroesophageal reflux disease (GERD), for which he takes an antacid. Upon arriving at the emergency department a few days ago, he was febrile (101.5˚F), his white blood cell count was 16,000 cells/µL, and his procalcitonin level was elevated to 2.15 µg/L. A chest x-ray revealed a left lower lobe infiltrate, and he was admitted with a diagnosis of CAP.

A nasopharyngeal swab was negative for all pathogens tested, as was a urine Legionella antigen assay. Pending the results of sputum and blood cultures, the physician ordered ceftriaxone at a dose of 1 g, given intravenously (IV), plus 500 mg of IV azithromycin every 24 hours.

It's now hospital day 3, so the patient has received three doses of IV antibiotics. His admission cultures continue to show no growth. He has been afebrile for 48 hours, his leukocytosis has resolved, and his oxygen saturation levels on room air are 96% or higher. It's time to discharge him but it's not yet time to discontinue the antimicrobial.


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