From the Guidelines
The best next step in management of this patient is to repeat the chest x-ray (option D). This 12-year-old girl with pneumonia is not responding appropriately to 48 hours of appropriate antibiotic therapy with ampicillin, despite the Streptococcus pneumoniae isolate being sensitive to this medication, as indicated in the guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America 1. She remains febrile with tachypnea and has physical exam findings consistent with a possible pleural effusion (dullness to percussion and diminished breath sounds at the right lung base). A repeat chest x-ray would help identify complications such as a parapneumonic effusion, empyema, or lung abscess that might explain her lack of clinical improvement, as suggested by the guidelines for managing community-acquired pneumonia in infants and children older than 3 months of age 1. These complications would require additional interventions beyond antibiotics alone, such as drainage procedures. The other options are less appropriate at this time:
- adding azithromycin is unnecessary since the pathogen is already identified and sensitive to current therapy;
- procalcitonin levels would not change management;
- immunoglobulin testing is premature without recurrent infections;
- and repeating sputum culture is unlikely to yield new information since the pathogen is already identified and appropriately treated. The guidelines emphasize the importance of reassessing the patient's condition and considering further diagnostic testing, such as chest radiography, to guide management decisions 1. In this case, repeating the chest x-ray is the most appropriate next step to determine the cause of the patient's lack of response to treatment and to guide further management.
From the Research
Patient Evaluation
The patient is a 12-year-old girl with pneumonia, currently being treated with intravenous ampicillin. Her sputum culture is growing Streptococcus pneumoniae, which is sensitive to ampicillin and ceftriaxone.
- The patient's symptoms include a worsening cough, shortness of breath, and fever.
- Physical examination reveals dullness to percussion and diminished breath sounds at the right lung base, indicating a possible pleural effusion.
Diagnostic Approach
Given the patient's presentation and the presence of Streptococcus pneumoniae in her sputum culture, a pleural effusion is a possible complication.
- According to 2, thoracocentesis should be performed for new and unexplained pleural effusions to determine the etiology of the effusion.
- 3 recommends the use of point-of-care ultrasound in addition to chest radiography to evaluate the pleural space and guide thoracentesis.
- The patient's fever and respiratory symptoms suggest a possible complicated parapneumonic effusion, which would require prompt consultation for catheter or chest tube drainage 3.
Next Steps in Management
Considering the patient's clinical presentation and the diagnostic approach outlined above, the best next step in management would be to:
- Obtain a chest radiograph to confirm the presence of a pleural effusion and to assess its size.
- Perform thoracocentesis to determine the etiology of the effusion and to guide further management.
- Based on the results of the thoracocentesis, consider consultation for catheter or chest tube drainage if a complicated parapneumonic effusion is suspected.
- Among the provided options, D. Repeat chest x-ray would be the most appropriate next step to confirm the presence of a pleural effusion and to assess its size, as suggested by 3 and 4.