A 50-year-old man with chronic bronchitis is admitted for pneumonia with positive blood culture for Streptococcus pneumoniae, with an MIC to penicillin of 0.0125 mg/l. Treatment was started with penicillin 2 million every 4h. On the fifth day, she still has a fever of 38ºC. Which of the following decisions do you think is correct?
The patient is a man with pneumonia with isolated germ in blood culture and antibiogram. According to the data provided, it is a pneumococcus sensitive to penicillin (MIC < 0.125), so treatment is started with penicillin at high doses every 4 h, despite which the fever persists. If we analyze the case carefully, the treatment should be effective since the germ is totally sensitive to the drug and the dosage is adequate (so that high concentrations of the drug should be maintained at all times, remember that the efficacy of beta-lactams is time-dependent and the antibiotic concentrations in blood should be above the MIC permanently to achieve effectiveness and avoid the production of resistance). In such a case, what could be happening, probably, although the antibiotic is the right one, it is not reaching the infectious focus adequately because an empyema has probably occurred. We should rule out the existence of an empyema and drain it while continuing with the antibiotic treatment. If the dosage had not been adequate and the presence of drug resistance was possible, one option could have been to treat with ceftriaxone at high doses, since we should remember that streptococcus does not produce beta-lactamase and beta-lactam resistance is produced by another mechanism (using amoxicillin-clavulanate would not provide us with anything). With quinolone we do not increase the spectrum and it is evident that the poor evolution of the patient is not only a problem of time.
I would change the treatment to ceftriaxone because of its greater efficacy.
I would add a quinolone to the treatment.
I would switch to amoxicillin/clavulanic acid.
It would rule out the presence of pleural empyema.
I would continue with the same treatment, assuming it is simply a timing issue.
If the dosage had not been adequate and the presence of drug resistance was possible, one option could have been to treat with ceftriaxone at high doses, since we should remember that streptococcus does not produce beta-lactamase
With quinolone we do not increase the spectrum and it is evident that the poor evolution of the patient is not only a problem of time.
beta-lactam resistance is produced by another mechanism (using amoxicillin-clavulanate would not provide us with anything).
although the antibiotic is the right one, it is not reaching the infectious focus adequately because an empyema has probably occurred. We should rule out the existence of an empyema and drain it while continuing with the antibiotic treatment.