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inpatient CAP: Amoxicillin or ZPak?

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Hi I was doing a question in Rosh Review and I was wondering if you guys would prescribe Amoxicillin in this situation below? 

 

A 12-year-old girl presents to clinic with one day of cough, fever to 102°F, and extreme fatigue. She is awake and alert but appears tired. Her oxygen saturation is 95%, and respiratory rate is 15 breaths per minute. Lung auscultation reveals fine crackles in the left upper lobe. Which of the following is treatment of choice?

 

AAmoxicillinCorrect Answer

BAzithromycinYour Answer

 
 
Explanation: Azithromycin (B) is the treatment of choice for atypical bacterial pneumonia, which are commonly caused byMycoplasma pneumoniae and Chlamydia pneumoniae. In comparison to typical bacterial pneumonias, atypical bacterial pneumonias have a more insidious onset and subacute course. Lung auscultation typically reveals diffuse, non-focal abnormalities, and chest radiographs reveals perihilar or interstitial infiltrates. 
 
Sidenote: Current and PPP recommend a macrolide as the DOC for outpatient CAP...

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UpToDate says...

 

"In otherwise healthy children five years and older with CAP who are not ill enough to require hospitalization, M. penumoniae and C. pneumoniae are the most likely pathogens"

 

But it looks like the real reason to try PCNs as opposed to macrolides is increasing macrolide drug resistance... :-(

 

... but did you mean inpatient our outpatient?

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Make sure you pay attention to all parts of the question... 

This question is not testing your knowledge on treatment of CAP, it is testing your treatment/ID of atypical vs bacterial CAP in pediatric population. Remember-- children are not small adults :)

No respiratory distress, fever, cough, fatigue, all say atypical. This kid is ok to go home, a kid with bacterial pneumonia would be more likely to need an admission. 

 

Edit- on reread of OP post, I realize I am confused. Was the rosh correct answer azithromycin or amoxicillin? And I was assuming this is outpatient...

sorry- My answer may not actually apply in anyway that is helpful. 

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I can not remember the last time I wrote for a zpak

 

If someone really has PNA then they get augmentin or doxycycline

 

 

 

Don't use zpak - resistance is climbing.....

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IF you use Amox for PNA in kids, the correct dose is 100 mg/kg/d.

I definitely still use azithro for uncomplicated CAP in otherwise healthy adults who are stable for outpt tx and have not had recent abx exposure. Did just this yesterday in an atypical PNA dude with no focal infiltrate and nontoxic-appearing, not hypoxic. Atypicals most likely in his case. I still gave him a slug of Rocephin in the office and close f/u instructions to RTC if not improving within 48 hr.

I like Augmentin a lot for PNA, sinusitis and LRTI. It gets anaerobes and gram pos and some gram neg fairly well, but remember has NO anti-pseudomonal coverage. I save my quinolones for hospitalized or NH pts or adults who've already failed a lesser abx, or my fragile COPD folks. We have a tremendous problem with quinolone resistance in my hospital and region so we have really been changing our management quite a lot.

Your practice will vary a lot (and should!) depending on regional trends where you work, and of course the population you serve.

Choose your antibiotics rationally. What are you treating? What bugs are you trying to beat into submission? Match the bug to the drug.

Of course, for a test question this is very frustrating. My approach to the case mentioned is to realize I'm treating an otherwise healthy 12 yo. What's the most likely organism for PNA in that age group? Gram positives. From where? The mouth and respiratory tract. What gets gram positives? A beta lactam...a penicillin. Yes, azithro gets gram pos too, but not necessarily as well. You do get better gram neg coverage with the macrolide and azithro gets H. Flu which good old erythromycin doesn't. Of course, immunized kids don't get H. Flu anymore...but adults certainly do.

The only TWO cases of epiglottitis I've seen in my 17-yr career were 30-somethings in the southeast, within the past 3 yr.

Lol confused yet?

 

Sent from my SAMSUNG-SM-N910A using Tapatalk

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Easy way to remember, in kids amoxicillin for everything from diaphragm upward for the most part.  You just have to know the dosing/kg. and max. daily dose.  Macrolide in adults you have to watch for CV hx. and potential for QT prolongation, as well as interaction with serotonin impacting antidepressants.  FQ is the tendonitis (Achilles).  For no other rationale reason, if your not sick and need a door prize, after I stress not to fill it at this time and to follow my instructions, you get a ZPak.  If I think you actually have a LRT infection, Biaxin or FQ depending on risk factors.  How many folks know to avoid DM as a cough suppressant in those on serotonin impacting medications (serotonin syndrome risk)?

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Sorry guys...I meant outpatient. Thank you for your responses. I asked a friend who is a pediatrician, and she said that since it is a higher grade fever, focal crackles, more acute sx - prescribe amoxicillin. If it was a lower grade fever, more diffuse lung sounds, less acute symptoms - more likely to be Mycoplasma and in this case, prescribe Zpak. 

 

Answer was amoxicillin in this question. 

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I left a province that had resistance rates so high, you couldn't use Azithro as a first line agent for anything except chlamydia it seemed.  If I'm admitting, I use dual coverage until something is isolated, outpatient I use high dose amoxil or amoxiclav as first line for kids...or by whatever the local antibiograms are saying.

 

A side note, when I asked about antibiograms for my area, all I got was crickets - some folks thought I was speaking a foreign language.  I'd consider it advisable to find out what's going around and what's killing it.

 

SK

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