For a patient with community-acquired pneumonia and a local macrolide resistance rate of 40%, what is the most appropriate first-line therapy?

In the context of community-acquired pneumonia, the first-line therapy must be effective against the likely pathogens involved, including Streptococcus pneumoniae and atypical bacteria. Given the local macrolide resistance rate of 40%, using a macrolide such as azithromycin may not be the best option, as there's a significant chance the pathogen could be resistant to it.

Oral doxycycline is a suitable first-line treatment in this scenario. Doxycycline has good coverage for both typical and atypical organisms associated with community-acquired pneumonia. It is effective against S. pneumoniae as well as legionella and mycoplasma species, making it a versatile choice in the face of potential macrolide resistance. Additionally, doxycycline tends to have fewer issues with resistance than some broader-spectrum agents, making it a reliable option.

IV cefepime is not indicated for community-acquired pneumonia as it's typically reserved for more severe infections or those requiring hospitalization. Oral ciprofloxacin is also not appropriate as a first line treatment for pneumonia because it primarily targets gram-negative bacteria and has limited efficacy against pneumococci.

Thus, oral doxycycline is the most appropriate choice for the patient in this scenario considering the local resistance pattern and the typical pathogens involved in