American Board of Internal Medicine (ABIM) Certification Practice Exam

What is a recommended treatment strategy for patients taking immunosuppressive medications who develop CAP?

1. Macrolide therapy only

2. Antipseudomonal therapy with β-lactam and included respiratory fluoroquinolone

3. Oral glucocorticoids

4. Increased dose of SABA

The correct answer is: Antipseudomonal therapy with β-lactam and included respiratory fluoroquinolone

When treating patients with community-acquired pneumonia (CAP) who are on immunosuppressive medications, it is crucial to tailor the therapy to address their increased risk of severe infections and specific pathogens that may be involved. Patients on immunosuppressive therapy may have altered immune responses, making them susceptible to infections by various organisms, including resistant strains. Antipseudomonal therapy, particularly with a combination of a β-lactam antibiotic (such as piperacillin-tazobactam or cefepime) and a respiratory fluoroquinolone (like levofloxacin or moxifloxacin), provides broad-spectrum coverage. This approach is important because it not only targets common community-acquired pathogens such as Streptococcus pneumoniae and Haemophilus influenzae but also covers for Pseudomonas aeruginosa, which poses a risk for patients who are immunocompromised. In contrast, macrolide therapy alone may not provide adequate coverage for more resistant bacteria, and while oral glucocorticoids might be beneficial in certain contexts (such as wheezing or inflammation), they do not directly address the pneumonia caused by infectious agents. Increasing the dose of short-acting beta-agonists (SABA) is typically