From the Guidelines
The correct answer is B. Intravenous vancomycin. This 6-year-old boy with cystic fibrosis presenting with pneumonia and influenza should receive vancomycin as part of his empiric antibiotic regimen. Patients with cystic fibrosis are at high risk for Staphylococcus aureus infections, particularly methicillin-resistant S. aureus (MRSA), which is best covered by vancomycin 1. The patient's history of multiple skin infections requiring drainage further suggests possible MRSA colonization. While cefepime provides good coverage for many gram-negative organisms including Pseudomonas aeruginosa (another common pathogen in cystic fibrosis), it does not adequately cover MRSA.
The combination of cefepime and vancomycin provides appropriate broad-spectrum coverage for the most likely pathogens in this critically ill child with cystic fibrosis, respiratory distress, and hypoxemia. Key considerations in the management of such patients include:
- The need for broad-spectrum antibiotic coverage due to the high risk of infections with resistant organisms
- The importance of considering the patient's history of infections and colonization with specific pathogens, such as MRSA
- The role of vancomycin in covering MRSA infections, as recommended for specific clinical indications 1
Once culture results are available, antibiotics can be narrowed based on susceptibilities. Oseltamivir is appropriate for the confirmed influenza infection, but antibacterial coverage is still necessary due to the high risk of bacterial superinfection in this immunocompromised host. The use of intravenous antipseudomonal antibiotic therapy, such as cefepime, is also supported by guidelines for the management of cystic fibrosis patients with respiratory infections 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient's Condition
The patient is a 6-year-old boy with cystic fibrosis, presenting with symptoms of a respiratory infection, including shortness of breath, runny nose, fever, chills, and productive cough. He has a history of multiple hospitalizations for respiratory infections and skin infections.
Current Treatment
The patient is currently being treated with cefepime and oseltamivir, and oxygen supplementation is being used to improve his oxygen saturation.
Empirical Antibiotic Treatment
Given the patient's history of cystic fibrosis and recurrent infections, it is likely that he may have a methicillin-resistant Staphylococcus aureus (MRSA) infection. According to the studies 2, 3, 4, 5, 6, vancomycin is a commonly used antibiotic for the treatment of MRSA infections.
Recommended Antibiotic
Based on the evidence, the recommended antibiotic to administer empirically in this patient is:
- Intravenous vancomycin, as it is effective against MRSA and is commonly used in the treatment of serious MRSA infections 2, 3, 4, 5, 6.
Key Points
- The patient's history of cystic fibrosis and recurrent infections increases the likelihood of an MRSA infection.
- Vancomycin is a commonly used antibiotic for the treatment of MRSA infections.
- The patient is already being treated with cefepime and oseltamivir, and the addition of vancomycin would provide coverage against MRSA.