A 79-year-old female treated with Zithromax (azithromycin) and Augmentin (amoxicillin-clavulanate) and Medrol (methylprednisolone) dose for community-acquired pneumonia (CAP) and sinusitis, is she not improving with persistent sinus symptoms?

From the Guidelines

For a 79-year-old female who isn't improving after treatment with Z-Pak (azithromycin), Augmentin (amoxicillin-clavulanate), and Medrol Dose Pack (methylprednisolone) for community-acquired pneumonia (CAP) and sinusitis, I recommend reassessment by her healthcare provider to consider a different antibiotic approach, such as a fluoroquinolone like levofloxacin 750 mg daily for 5-7 days, or a respiratory quinolone such as moxifloxacin 400 mg daily for 7 days, as suggested by the most recent guidelines 1.

The patient's persistent symptoms could indicate antibiotic resistance, inadequate coverage of the causative pathogen, or a non-bacterial cause. A sinus CT scan might be warranted to evaluate for complications like chronic sinusitis or structural issues. For symptom relief while awaiting medical reassessment, she should continue nasal saline irrigation twice daily, use a humidifier, stay well-hydrated, and take acetaminophen for pain or fever.

Elderly patients often have atypical presentations of infections and may require longer treatment courses or different antibiotic choices due to age-related immune changes and potential comorbidities affecting drug metabolism. The American College of Physicians and the Centers for Disease Control and Prevention recommend reserving antibiotic treatment for acute rhinosinusitis for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening) 1.

Given the patient's age and lack of improvement with initial treatment, a more tailored approach considering the latest guidelines and potential for antibiotic resistance is necessary. The choice of antibiotic should be guided by the most recent and highest-quality evidence, which suggests that fluoroquinolones or respiratory quinolones may be effective alternatives in cases where initial treatment fails 1.

From the FDA Drug Label

Azithromycin should not be used in patients with pneumonia who are judged to be inappropriate for oral therapy because of moderate to severe illness or risk factors such as any of the following: patients with cystic fibrosis, patients with nosocomially acquired infections, patients with known or suspected bacteremia, patients requiring hospitalization, elderly or debilitated patients, or patients with significant underlying health problems that may compromise their ability to respond to their illness (including immunodeficiency or functional asplenia).

The patient is a 79-year-old female, which puts her in the elderly category. According to the drug label, azithromycin should not be used in elderly patients with pneumonia who are judged to be inappropriate for oral therapy.

• The patient's age and condition (elderly) may be a risk factor for azithromycin use.
• The FDA drug label warns against using azithromycin in elderly or debilitated patients with pneumonia who are judged to be inappropriate for oral therapy 2. Given the patient's age and the fact that she is not feeling better, it would be prudent to reassess her treatment plan and consider alternative therapies or closer monitoring. 2

From the Research

Treatment of Community-Acquired Pneumonia (CAP) and Sinusitis

• The patient, a 79-year-old female, was treated with Z-Pak (azithromycin), Augmentin (amoxicillin/clavulanate), and Medrol (methylprednisolone) for CAP and sinusitis, but still experiences sinus symptoms.
• According to a study published in 2004 3, Augmentin is a broad-spectrum antibacterial effective in treating community-acquired respiratory tract infections, including CAP and sinusitis.
• However, another study from 2010 4 found that treatment failure rates for CAP were higher with amoxicillin/clavulanate (23.9%) compared to levofloxacin (20.8%), particularly in high-risk patients (age ≥65 and/or on Medicaid).

Efficacy of Azithromycin in CAP Treatment

• A 2021 study 5 found that azithromycin remains protective against pneumococcal CAP in the intensive care unit, despite macrolide resistance.
• Another study from 2003 6 compared azithromycin to erythromycin and amoxicillin in treating community-acquired pneumonia in children, finding that azithromycin was an effective therapeutic option for both classic and atypical pneumonia.
• A 1998 study 7 also demonstrated the safety and efficacy of azithromycin in treating community-acquired pneumonia in children, with fewer side effects compared to amoxicillin/clavulanate or erythromycin.

Considerations for Treatment Failure

• The patient's persistent sinus symptoms despite treatment with Z-Pak, Augmentin, and Medrol may indicate treatment failure or the presence of a resistant pathogen.
• The studies cited above suggest that azithromycin may be an effective option for treating CAP, but the choice of antibiotic should be guided by local resistance patterns and patient-specific factors.
• Further evaluation and consideration of alternative treatment options may be necessary to address the patient's ongoing symptoms.