A 54-year-old man presents in follow-up from an emergency department (ED) visit a day prior. He was told to see his doctor for a recheck, after presenting to the ED with fever, malaise, and occasional cough.

The patient is a long-time smoker of a pack per day. His chronic medical problems include hypertension, hyperlipidemia, and low back pain.

In the emergency department, he was found to have a white blood cell (WBC) count of 16,000 WBC/mm3, with a neutrophil predominance.

He was afebrile when seen, but said that the prior evening he had chills and the feeling of fever.

His chest x-ray was negative, but some wheezing was noted on exam. He was discharged with a prescription for doxycycline 100mg PO for five days for a presumed COPD exacerbation and asked to follow-up with his PCP.

In clinic, the patient is non-toxic appearing and afebrile. He says that, after returning home from the ED, he still felt tired and had some chills, but perhaps not as much as the night prior.

His blood pressure is 132/76 mm Hg. He denies headache, nausea, or vomiting, but still has some occasional nonproductive cough.

On examination, he still has some wheezes on lung exam, but no other findings. No heart murmur or petechial rash is noted.

A review of the electronic medical record (EMR) shows that blood cultures drawn the day prior, in the ED, were both positive for gram positive cocci in clusters.

Answer Options:

Continue the current doxycycline treatment but extend course to ten days.

Change the antibiotic to levofloxacin orally and see patient in two days for reevaluation.

Hospitalize for intravenous vancomycin therapy, echocardiogram, and Infectious Disease consultation.

Change therapy to once daily intravenous ceftriaxone and arrange outpatient CT scan of chest, abdomen and pelvis.

Gerard Kiernan, MD, FAAFP, FHM is a Dartmouth-Hitchcock Clinic hospitalist in Keene, NH. He attended the University of Rochester School of Medicine and Dentistry, followed by a Family Medicine residency at the University of Wisconsin, Madison, where he was a chief resident. Dr. Kiernan is a Lean Six Sigma Greenbelt and has led hospital medicine quality improvement efforts. He is a fellow of both the American Academy of Family Physicians and the Society of Hospital Medicine. He has achieved the Recognition of Focused Practice in Hospital Medicine offered through the AAFP and ABIM via their joint examination pathway.

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