What is the best course of action for an elderly patient with persistent fever, stiff neck, and shoulder pain, who has had flu-like symptoms for 2 weeks and took a Z-pack (azithromycin) for 3 days without resolution?

Urgent Evaluation for Meningitis and Bacterial Superinfection Required

This elderly patient with persistent fever for 2 weeks, new-onset stiff neck, and failure to respond to azithromycin requires immediate evaluation for bacterial meningitis and/or severe bacterial superinfection—this is a medical emergency that demands urgent hospital assessment, not continued outpatient management.

Immediate Actions Required

Why This Patient Cannot Be Managed Outpatient

• The combination of persistent fever beyond 2 weeks plus new stiff neck is a red flag for central nervous system infection, particularly in an elderly patient who failed initial antibiotic therapy 1, 2
• Stiff neck (nuchal rigidity) with fever in an elderly patient presenting after prolonged illness raises concern for bacterial meningitis, epidural abscess, or severe deep tissue infection 1, 2
• The 3-day course of azithromycin was inadequate—azithromycin is not appropriate empiric therapy for influenza-related bacterial pneumonia or severe respiratory infections because it lacks adequate coverage for Staphylococcus aureus, a critical pathogen in post-influenza bacterial complications 3

Critical Differential Diagnoses to Exclude

• Bacterial meningitis (most urgent—requires lumbar puncture and immediate IV antibiotics) 1
• Epidural abscess (can present with neck pain/stiffness and fever, may progress to neurologic deficits) 1
• Severe community-acquired pneumonia with bacteremia (particularly S. pneumoniae or S. aureus post-influenza) 3
• Pneumococcal pyomyositis of neck muscles (can mimic meningitis with severe neck pain and high fever) 2
• Deep neck space infection or retropharyngeal abscess 2

Hospital Evaluation Protocol

Immediate Assessment Upon Arrival

• Assess for meningeal signs: Kernig's sign, Brudzinski's sign, photophobia, altered mental status 1
• Neurologic examination: Look for focal deficits, decreased grip strength, or signs of spinal cord compression 1
• Vital signs and severity assessment: Temperature, respiratory rate, oxygen saturation, blood pressure 3
• Respiratory examination: Listen for focal consolidation, assess work of breathing 3

Essential Diagnostic Testing

• If meningeal signs present: Emergent CT head (if no contraindications) followed by lumbar puncture with CSF analysis (cell count, protein, glucose, Gram stain, culture) 1
• Blood cultures (before antibiotics): Essential given prolonged fever and potential bacteremia 3
• Complete blood count, comprehensive metabolic panel, lactate, C-reactive protein: Assess severity and organ dysfunction 3
• Chest X-ray: Evaluate for pneumonia or pleural effusion 3
• If neck pain is severe or neurologic signs develop: MRI of cervical spine to exclude epidural abscess or deep tissue infection 1, 2

Empiric Antibiotic Therapy (Start Immediately if Severe)

For suspected meningitis (if LP delayed or contraindicated):

• Vancomycin 15-20 mg/kg IV PLUS ceftriaxone 2g IV PLUS consider dexamethasone 10mg IV before or with first antibiotic dose 1

For severe influenza-related pneumonia with bacterial superinfection:

• IV co-amoxiclav 1.2g three times daily PLUS clarithromycin 500mg twice daily IV (covers S. pneumoniae, H. influenzae, S. aureus) 3
• Alternative: IV cefuroxime 1.5g three times daily PLUS clarithromycin 500mg twice daily IV 3
• For penicillin allergy: Levofloxacin 500mg twice daily IV (has enhanced pneumococcal and S. aureus activity) 3

Consider Antiviral Therapy

• Oseltamivir 75mg twice daily for 5 days should still be considered even though symptoms began 2 weeks ago, particularly if the patient is elderly or has underlying conditions 4
• High-risk and hospitalized patients benefit from oseltamivir even when started beyond 48 hours, with mortality benefit demonstrated up to 96 hours after symptom onset 4
• Dose adjustment required if creatinine clearance <30 mL/min (reduce to 75mg once daily) 4

Why Azithromycin Failed

• Azithromycin monotherapy is inadequate for influenza-related bacterial pneumonia because it does not reliably cover S. aureus, the most critical post-influenza bacterial pathogen 3, 5
• The Z-pack provides only 3 days of therapy (500mg day 1, then 250mg days 2-5), which is insufficient duration for established bacterial infection 5
• Azithromycin is listed as an alternative choice (not preferred) for influenza-related pneumonia, specifically for patients intolerant of first-line agents 3

Critical Pitfalls to Avoid

• Do not delay hospital evaluation while attempting further outpatient management—stiff neck with prolonged fever requires urgent assessment for life-threatening CNS infection 1, 2
• Do not assume this is simply "viral illness that needs more time"—2 weeks of fever with new symptoms indicates either severe bacterial superinfection or alternative serious diagnosis 6
• Do not start another course of oral antibiotics without proper evaluation—this patient needs IV therapy and diagnostic workup 3
• Do not forget to obtain blood cultures before starting antibiotics if the patient is stable enough for brief delay 3

Transport and Communication

• Arrange immediate emergency department evaluation or direct hospital admission depending on local resources and patient stability
• Communicate clearly to receiving team: "Elderly patient with 2-week fever, failed azithromycin, now with new stiff neck—concern for meningitis vs. severe bacterial superinfection requiring urgent evaluation"
• If patient refuses transport: Document extensively and explain risk of death or permanent neurologic injury from untreated meningitis or epidural abscess 1