What is the treatment for a 35-year-old man with cough, yellow sputum, bilateral crackles, normal blood pressure (BP), and tachypnea (RR 22/min)?

Treatment for Community-Acquired Pneumonia in a 35-Year-Old Man

The patient should be treated with oral azithromycin (Option A) as the first-line therapy for this case of mild to moderate community-acquired pneumonia (CAP) in an otherwise stable patient.

Assessment of Severity

This 35-year-old man presents with:

• Cough with yellow sputum
• Bilateral crackles on chest examination
• Normal blood pressure (120/85 mmHg)
• Mild tachypnea (respiratory rate 22/min)

To determine appropriate treatment, we must first assess the severity of pneumonia:

• Using the CURB-65 score 1:

  • Confusion: Not mentioned (0 points)
  • Urea/BUN: Not mentioned (0 points)
  • Respiratory rate: 22/min (< 30/min, 0 points)
  • Blood pressure: 120/85 mmHg (normal, 0 points)
  • Age: 35 years (< 65 years, 0 points)
  • Total CURB-65 score: 0 points

• A CURB-65 score of 0 indicates low risk with a predicted mortality of 0.7%, suggesting outpatient management is appropriate 1.

Treatment Decision

Why Oral Azithromycin (Option A) is Appropriate:

1. Guideline Recommendation: For outpatient treatment of CAP in patients without comorbidities, a macrolide such as azithromycin is recommended as first-line therapy 1.

2. Pathogen Coverage: Azithromycin provides coverage for the most common pathogens in CAP including:

   • Streptococcus pneumoniae
   • Mycoplasma pneumoniae
   • Chlamydia pneumoniae
   • Haemophilus influenzae 2

3. Clinical Stability: The patient has:

   • Normal blood pressure
   • Mild tachypnea only
   • No evidence of severe illness or sepsis

Why Other Options Are Not Appropriate:

1. Ceftriaxone and Azithromycin (Option B): This combination is typically reserved for:

   • Hospitalized non-ICU patients
   • Patients with comorbidities or risk factors for drug-resistant pathogens 1
   • This patient has no indication for combination therapy

2. Admission and IV Antibiotics (Option C): Not indicated because:

   • CURB-65 score of 0 suggests outpatient management
   • No evidence of respiratory failure, hemodynamic instability, or inability to take oral medications 1

3. ICU Admission (Option D): Clearly not indicated as the patient lacks:

   • Major criteria: No mechanical ventilation needed, no septic shock 3
   • Minor criteria: No hypotension, no evidence of multilobar disease 3

Important Considerations

• Follow-up: The patient should be advised to return if:

  • Symptoms persist beyond 3 days of antibiotic treatment
  • Fever lasts more than 4 days
  • Dyspnea worsens
  • Any deterioration in general condition 1

• Supportive Care: Cough suppressants, expectorants, mucolytics, and bronchodilators are not recommended for routine use in acute lower respiratory tract infections 1

• Caution with Azithromycin: Be aware of potential side effects:

  • QT prolongation (especially in patients with cardiac risk factors)
  • Hepatotoxicity
  • Clostridium difficile-associated diarrhea 2

In conclusion, this patient presents with clinical features consistent with mild to moderate CAP and should be managed as an outpatient with oral azithromycin, with appropriate follow-up instructions.