Complicated Pneumonia: Pick and Choose, but Don't Choose the PICC.

A 17-month-old boy born at term presented to a pediatric emergency department with respiratory distress in the setting of fever for 2 weeks. He presented with a maximum temperature of 38.3°C, decreased oral intake, lethargy, and work of breathing for 2 days. In the emergency department, he was toxic appearing and had tachypnea with retractions. He received a dose of ceftriaxone, fluid replacement for dehydration, and had a chest radiograph notable for left hydropneumothorax with mediastinal shift. He was transferred to the PICU and underwent endotracheal intubation. On admission, surgery at bedside was performed to place a left pigtail catheter that evacuated 500 mL of purulent fluid; because of persistent tension physiology secondary to bronchopulmonary fistula, a second chest tube was placed with clinical improvement. A central venous catheter was inserted in the left subclavian vein. Antibiotic therapy in the PICU was initiated with vancomycin and piperacillin-tazobactam. Blood cultures and studies of his chest tube drainage were sent. Pleural fluid subsequently grew Prevotella melaninogenicus and Streptococcus pneumoniae . Blood cultures remained negative for bacterial growth for the duration of his hospitalization.He was extubated 2 days later and was stable on room air 4 days after presentation. His subclavian line was removed, and a peripherally inserted central catheter (PICC) was placed in anticipation of long-term antibiotic therapy. S pneumoniae was susceptible to penicillin (minimum inhibitory concentration u003c0.03 μg/mL). Prevotella species sensitivity was unknown because the sample sent for susceptibility was not viable. On the basis of the sensitivities of his pleural fluid culture, piperacillin-tazobactam and vancomycin were discontinued, …