Review Question - QID 210077

A 68-year-old man arrives at the emergency room complaining of fever and shortness of breath. He reports that his symptoms began 1 week ago, but he was too busy to go to the doctor, so he took antibiotics he had “left over.” A physical examination is notable for right basilar crackles and dullness to percussion. A chest radiograph shows a left lower lobe pneumonia and a mild pleural effusion. Labs are drawn and thoracentesis is performed, with results as shown below:

Pleural Fluid:
Gross appearance: Cloudy, yellow
pH: 6.94

Leukocyte count and differential:
Leukocyte count: 80,000
Segmented neutrophils: 95%
Protein: 4.2 g/dL
Lactate dehydrogenase: 245 U/L
Glucose: 26 mg/dL
Adenosine deaminase level: 27 units/L

Serum:
Protein: 5.5 g/dL
Lactate dehydrogenase: 280 U/L

A Gram stain of the pleural fluid is negative, and a culture is pending. The patient refuses to be admitted because he “can’t take off from work” and leaves against medical advice. 4 days afterward, the patient comes to the emergency room with worsening fever, dyspnea, and chest pain. He also reports a harsh cough that brings up putrid-smelling phlegm that is occasionally blood-streaked. The patient’s temperature is 102°F (38.9°C), blood pressure is 124/78 mmHg, pulse is 88/min, and respirations are 18/min with an oxygen saturation of 95% O2 on room air. Another chest radiograph is obtained, as shown in Figure A. What is the appropriate management of this patient’s condition?