A 5-year-old vaccinated boy presents to the urgent care clinic with ill appearance, persistent fever, dehydration, and worsened work of breathing at home, after a diagnosis of CAP by his pediatrician and 2 days of amoxicillin therapy. On examination, you hear decreased breath sounds over the right lower lung field. A chest x-ray shows opacification on the right, with concern for pleural fluid. Which of the following is the best next step?
- Consider ordering laboratory studies and drawing a blood culture to assess for complications associated with CAP.
- Change the antibiotics to azithromycin to cover for atypical pneumonia.
- Tell the family to stop the amoxicillin as the most likely etiology of the pneumonia is viral and antibiotics are not helping.
- Transfer to a higher level of care for further evaluation and management of complicated CAP.
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Answer: D. For an otherwise healthy child with suspected CAP in the urgent care setting, the decision to refer or transfer to a higher level of care should consider the severity of illness, the patient’s medical history and age, the suspected pathogen(s), social factors, and available resources. Criteria for transfer include moderate-to-severe distress, inability to tolerate oral medications or maintain hydration, and moderate-to-large parapneumonic effusion. Blood cultures are not recommended in the urgent care setting and should be deferred to the admitting clinician. Though azithromycin is the mainstay of treatment for atypical pneumonia, evidence is lacking for its efficacy in treating this infection.