🧠 TLDR Primary Care - Test your Knowledge (#053)

Not a subscriber?

Subscribe to TLDR Heme / Onc Subscribe to TLDR Primary Care

TLDR Primary Care #053

August 30, 2023

In This Issue:

🦠 Clear the CAP

✅ Review workup and management of a common condition

📚 Key guideline review for the primary care provider

🧵 And more!

🧠 Test your Knowledge: Clear the CAP

Keep sharpening your clinical skills

A 32-year-old otherwise healthy male presents to the primary care clinic with a 4-day history of increasing cough, greenish sputum production, low-grade fever, and mild fatigue. He denies any significant shortness of breath, chest pain, or other systemic symptoms. On physical examination, his temperature is 100.4°F (38°C), heart rate is 90 beats per minute, respiratory rate is 18 breaths per minute, and blood pressure is 120/70 mm Hg. Lung auscultation reveals scattered rhonchi in the left lower lung field. A chest X-ray shows a left lower lobe infiltrate. Laboratory tests indicate a slightly elevated white blood cell count with a left shift. What is the most appropriate initial management for this patient?

[A] Admission to the hospital for intravenous antibiotics and close monitoring

[B] Initiation of oral antibiotics with levofloxacin

[C] Prescription of cough suppressants and antipyretics for symptom relief

[D] Initiation of oral antibiotics with amoxicillin

Scroll down to find the answer at the end! 👇

Need to refresh your memory before answering this question? Head over to Pathway to review the latest guidelines on Community-Acquired Pneumonia, as well as some landmark trials.

Case Conclusion

Keep your clinical skills sharp

Answer - D. Initiation of oral antibiotics with amoxicillin

Explanation - This patient's clinical presentation is consistent with Community-Acquired Pneumonia, with symptoms including cough, sputum production, low-grade fever, and fatigue. However, he does not exhibit signs of severe illness (tachycardia, dyspnea, hypoxemia, age over 65, etc.) or systemic involvement. The most appropriate initial management is oral antibiotics. Admission to the hospital for IV antibiotics is considered in severe cases. Cough suppressants and antipyretics should be used for symptom relief in addition to antibiotics but not alone.

The choice of antibiotics for community-acquired pneumonia (CAP) should cover the most likely pathogens while taking into account local resistance patterns. Amoxicillin is effective against Streptococcus pneumoniae, the most common bacterial cause of CAP, and doxycycline covers atypical pathogens such as Mycoplasma pneumoniae.

What are the guideline recommendations for the medical management of community-acquired pneumonia?

Administer amoxicillin 1 g PO TID or doxycycline 100 mg PO BID in outpatients with CAP without comorbidities or risk factors for antibiotic-resistant pathogens. (B)
- Administer a macrolide (azithromycin 500 mg PO on the first day and 250 mg daily thereafter, clarithromycin 500 mg PO BID, or clarithromycin ER 1,000 mg PO daily) in areas with pneumococcal resistance to macrolides < 25%. (B)
Select one of the following antibiotic regimens for outpatients with CAP in whom comorbidities are present – such as chronic heart failure, lung, liver, or renal disease; diabetes mellitus, alcoholism, malignancy, or asplenia:
- A beta-lactam – either amoxicillin/clavulanate, cefpodoxime, or cefuroxime – plus a macrolide which can be either azithromycin 500 mg PO on day 1 and then 250 mg daily; or clarithromycin 500 mg PO BID; or clarithromycin extended-release 1,000 mg PO daily
- A beta-lactam - either amoxicillin/clavulanate, cefpodoxime, or cefuroxime - plus doxycycline 100 mg PO BID
- A respiratory fluoroquinolone - either levofloxacin 750 mg PO daily, moxifloxacin 400 mg PO daily, or gemifloxacin 320 mg PO daily. (B)
Complete at least a 5-day course of antibiotics in patients with CAP. Extend the antibiotic therapy beyond 5 days guided by validated measures of clinical stability, including resolution of vital sign abnormalities, ability to eat, and normal mentation. (B)

What are the guideline recommendations for diagnostic investigation of community-acquired pneumonia?

Use a validated clinical prediction rule, preferentially the Pneumonia Severity Index over the CURB-65 tool, in addition to clinical judgment, to assess the risk and determine the need for hospitalization in adult patients with CAP. (B)

⭐ Check out these helpful calculators for assessing community-acquired pneumonia

CURB-65: Assess the need for inpatient management

PSI: Pneumonia Severity Index

Obtain a CXR (or other imaging technique) to demonstrate pulmonary infiltrates, with or without supporting microbiological data, for the diagnosis of pneumonia in patients with suggestive clinical features. (B)
Avoid obtaining urine pneumococcal antigen testing in adult patients with non-severe CAP. (D)
Consider obtaining urine pneumococcal antigen testing in adult patients with severe CAP. (C)
Avoid obtaining routine urine Legionella antigen testing in adult patients with nonsevere CAP. (D)
Consider obtaining urine Legionella antigen testing where indicated by epidemiological factors, such as in the context of a Legionella outbreak or recent travel. (C)
Test for influenza with a rapid influenza molecular assay (influenza NAAT) rather than a rapid influenza diagnostic test (antigen test) in patients with CAP presenting during periods of influenza transmission. (B)
Consider measuring procalcitonin levels to reduce the duration of antibiotic therapy in patients with severe CAP. (C)
Offer more intensive treatment (hospitalization or, where appropriate and available, intensive in-home health care services) in patients with CURB-65 scores ≥ 2. (B)

High Yield AFP Community-Acquired Pneumonia Pearls:

Empiric antibiotic therapy for CAP in adult outpatients without comorbid conditions should include high-dose amoxicillin, doxycycline, or a macrolide (if local macrolide resistance rates for pneumococcus are less than 25%). (B)
Empiric antibiotic therapy for CAP in adult outpatients with comorbid conditions should include amoxicillin/clavulanate (Augmentin) or a third-generation cephalosporin combined with doxycycline or a macrolide, or monotherapy with a respiratory fluoroquinolone. (A)
Corticosteroid treatment is not generally recommended for CAP. (B)
To prevent pneumonia, 20-valent pneumococcal conjugate vaccine (Prevnar 20) alone or 15-valent pneumococcal conjugate vaccine (Vaxneuvance) followed by 23-valent pneumococcal polysaccharide vaccine (Pneumovax 23) one year later should be given to adults 65 years or older and those 19 to 64 years with comorbid or immunocompromising conditions. (A)
Diagnostic cultures and antigen testing should be obtained only in patients with severe CAP. (B)

🔬 Still confused about urine antigen testing for CAP? - Watch Video

Will you change your practice behaviors based on the content in today's newsletter?

Very likely

Somewhat likely

Not likely

If you enjoyed this newsletter, please consider forwarding it to a friend or colleague who would enjoy it too.

If a friend sent you this, get the next newsletter by signing up here.

Who’s Pathway? We’re a global community of clinicians working to democratize medical knowledge and make practicing evidence-based medicine more accessible, fun, and not so overwhelming.

Warm regards,

- The Pathway Team