Which medication should be stopped first in a patient with pneumonia who is now afebrile and on intravenous (IV) ceftriaxone, azithromycin, tramadol, and paracetamol (acetaminophen)?

Which Medication to Stop First in an Improving Pneumonia Patient

Paracetamol (acetaminophen) should be stopped first in this patient who is now afebrile and clinically improving on treatment for community-acquired pneumonia.

Rationale for Stopping Paracetamol First

Paracetamol serves only as symptomatic treatment for fever and pain, and once the patient is afebrile, it no longer serves a therapeutic purpose for the pneumonia itself. 1 Since the patient is now afebrile, the antipyretic indication has resolved, making paracetamol the most appropriate medication to discontinue first.

Why Continue Antibiotics

Duration of Antibiotic Therapy Guidelines

The IDSA/ATS guidelines clearly specify that patients with CAP should be treated for a minimum of 5 days, should be afebrile for 48-72 hours, and should have no more than 1 CAP-associated sign of clinical instability before discontinuation of therapy. 2

• The patient being "now afebrile" does not specify how long they have been afebrile
• Both ceftriaxone and azithromycin must be continued until the patient has been afebrile for 48-72 hours 2
• The combination of a β-lactam (ceftriaxone) plus a macrolide (azithromycin) is the recommended regimen for hospitalized patients with CAP 2

Evidence Supporting Combination Therapy

Multiple studies demonstrate that the combination of ceftriaxone plus azithromycin is highly effective for moderate to severe CAP, with clinical success rates of 84-95%. 3, 4, 5 This combination provides:

• Coverage against Streptococcus pneumoniae (including resistant strains) 5
• Coverage against atypical pathogens (Mycoplasma, Chlamydophila, Legionella) 2
• Synergistic effects that may improve outcomes in pneumococcal bacteremia 2

Why Not Stop Tramadol First

While tramadol is also symptomatic treatment for pain, paracetamol should be discontinued before tramadol because:

• Paracetamol has no role once fever resolves 1
• Tramadol may still be needed for pleuritic chest pain or other pneumonia-associated discomfort that can persist even after defervescence
• The patient's pain status is not specified, so tramadol may still have a therapeutic indication

Clinical Algorithm for Medication Discontinuation

Follow this sequence for medication discontinuation in improving pneumonia:

1. Stop paracetamol immediately once afebrile (no ongoing indication) 1
2. Continue both antibiotics until afebrile for 48-72 hours AND clinically stable 2
3. Reassess tramadol based on ongoing pain symptoms
4. Consider IV-to-oral antibiotic switch when hemodynamically stable, improving clinically, able to ingest medications, and with normally functioning GI tract 2
5. Complete minimum 5-7 days total antibiotic therapy for uncomplicated CAP 2

Common Pitfalls to Avoid

• Do not stop antibiotics prematurely just because the patient is afebrile—they must be afebrile for 48-72 hours 2
• Do not discontinue only one antibiotic from the combination regimen; both should be continued together until completion criteria are met 2
• Do not continue paracetamol unnecessarily once fever has resolved, as it provides no benefit and adds unnecessary medication exposure 1

Answer: D. Paracetamol