American Board of Internal Medicine (ABIM) Certification Practice Exam

In treating CAP in an inpatient setting, what are the recommended antibiotics for patients with high-level macrolide-resistant pneumococci?

1. β-lactam plus a macrolide

2. Respiratory fluoroquinolone as monotherapy

3. Antipseudomonal β-lactam with pneumococcal coverage

4. Doxycycline plus macrolide

The correct answer is: Antipseudomonal β-lactam with pneumococcal coverage

For treating community-acquired pneumonia (CAP) in an inpatient setting, the management strategies need to account for local resistance patterns, particularly when dealing with high-level macrolide-resistant Streptococcus pneumoniae. In these cases, option C — prescribing an antipseudomonal β-lactam with pneumococcal coverage — is the most appropriate choice. Antipseudomonal β-lactams, such as piperacillin-tazobactam or cefepime, offer broad-spectrum coverage, including effective treatment against resistant pneumococcal strains. These antibiotics provide coverage against both typical pathogens (including susceptible strains of S. pneumoniae) and atypical pathogens commonly associated with CAP. By ensuring strong activity against resistant strains of S. pneumoniae, this approach is crucial for adequately treating patients with severe infections where antibiotic resistance is a concern. Using a β-lactam in combination with coverage for other potential pathogens (like those associated with more severe cases or co-infections) is essential in managing the clinical complexity of patients with higher resistance patterns. In contrast, the other options do not adequately address the specific concern of high-level macrolide resistance. While β-lactam plus macrolide or respiratory fluoroquinolone as