Response #2

Please respond to my colleague’s post below, you don’t have to contradict what she said on her treatment. You can put more suggestion on treatment or additional education. Please have two or three references. Thank you!

 

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  The fight against infection requires knowledge of the pathophysiology of disease conditions and treatment strategies to ensure positive patient outcomes. For several decades, antimicrobial agents have been the cornerstone in the reduction of morbidity and mortality caused by infections. The evolution of newer drugs and treatment advances will be rendered useless if significant considerations such as drug toxicity, microbial susceptibility, and microbial resistance are excluded in the decision making on the clinical use of antimicrobials (Rosenthal & Burchum, 2018). For this week’s forum, the discussion will be based on the assigned case study as follows:                                                                                               

HH is a 68 yo M who has been admitted to the medical ward with community-acquired pneumonia for the past 3 days. His PMH is significant for COPD, HTN, hyperlipidemia, and diabetes. He remains on empiric antibiotics, which include ceftriaxone 1 g IV qday (day 3) and azithromycin 500 mg IV qday (day 3). Since admission, his clinical status has improved, with decreased oxygen requirements. He is not tolerating a diet at this time with complaints of nausea and vomiting.

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Ht: 5’8” Wt: 89 kg Allergies: Penicillin (rash)

Community-acquired pneumonia (CAP) is a common disease that remains one of the leading causes of morbidity and mortality among the elderly population costing the United States billions of dollars in healthcare expenditure (Arnold, 2017). In CAP patients, an antibiotic strategy such as following a set of guidelines in utilizing a combination of antibiotics seems to improve significantly the length of both hospitals stay, and mortality (Pereira et al., 2018). Based on the patient’s age in the scenario at 68 years-old, comorbidities of COPD, hypertension, and diabetes, the patient qualifies to be admitted to the hospital, especially that COPD might be exacerbated by CAP (Arnold, 2017).  Also, current guidelines for CAP by the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) include several vital recommendations such as the timing of antimicrobial initiation (has to be started within 6 hours from ER arrival time), the initial antimicrobial selection, as well as the criteria to switch from intravenous to oral therapy (Arnold, 2017). Careful consideration in antibiotic prescription is imperative to prevent further subsequent risks such as antimicrobial resistance, causing superinfection, which is now a global concern (Thiessen et al., 2017). Also, it is noted that the patient has been initiated on empiric therapy wherein treatment has been started due to the severity of the infection before test results are available, on the precept that cultures are obtained prior to initiation of treatment (Rosenthal & Burchum, 2018).

For this patient, therapy with antibiotic combinations, which is indicated for severe infection similar to the scenario, was implemented (Rosenthal & Burchum, 2018). Since the patient is allergic to penicillin, the use of cephalosporins (ceftriaxone 1 gm iv) and macrolides (azithromycin 5oo mg iv) were initiated.  Ceftriaxone is a beta-lactam, broad-spectrum antibiotic usually used as first-line treatment for patients with community-acquired pneumonia (CAP) (Ying-Qi, Shui-Lan Zou, Zhao, Zhang & Cai-Li 2018). Also, cephalosporins are generally considered safe, less toxic, well-tolerated, and severe adverse effects are rare. On the other hand, azithromycin, a macrolide, was also initiated is a broad-spectrum antibiotic that inhibits protein synthesis and also considered one of the safer antibiotics (Rosenthal & Burchum, 2018).  Macrolides, in combination with a ?-lactam such as ceftriaxone, are recommended by the Infectious Diseases Society of America/American Thoracic Society guidelines for community-acquired pneumonia (CAP) for a patient being admitted to a ward (Arnold et al., 2018). Adding a macrolide has an added advantage in lowering the in-hospital mortality in comparison to non-macrolide treatment (Arnold et al., 2018). As noted in the scenario, the patient’s clinical status has improved. It has a lower oxygen requirement after being on ceftriaxone and azithromycin for three days, which is considered a clinical indicator of the success of antimicrobial therapy (Rosenthal & Burchum, 2018). Once the patient is stable, intravenous antibiotics can be switch to oral antimicrobial once criteria are met like being afebrile, arterial oxygen saturation >90%, normal mental status, and able to tolerate oral intake (Arnold, 2017). The presence of nausea and vomiting are common reactions from azithromycin, and if it persists, changing to oral is not indicated until it subsides or addressed. Switching therapy should be decided base on the patient’s status regarding hemodynamic stability and oral toleration and may happen when it is safe to discharge the patient (Arnold, 2017). Education on adverse effects and interaction of azithromycin, such as the potential for fatal heart dysrhythmias and enhancing the effects of warfarin, causing a pose for bleeding should be considered (Rosenthal & Burchum, 2018).                                                           

Lastly, essential issues that need to be considered are the renal function of an elderly, exacerbation of comorbidities like cardiovascular conditions, and COPD are significant risks in the presence of CAP (Arnold, 2017). Also, prevention is vital; therefore, patients aged above 65 years-old should be counseled on the importance of vaccination against influenza and pneumonia unless contraindicated (Arnold, 2017).

 

(Please response the above post from colleague)

 

Resources: Please use two or three of these resources on top of other resources you may use for reference

 

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advacned practice providers. St. Louis, MO: Elsevier.

  • Chapter 44, “Anticoagulant and Antiplatelet Drugs” (pp. 451–472)
  • Chapter 45, “Drugs for Deficiency Anemias” (pp. 473–483)
  • Chapter 48, “Estrogens and Progestins: Basic Pharmacology and Noncontraceptive Applications” (pp. 521–533)
  • Chapter 49, “Birth Control” (pp. 535–547)
  • Chapter 50, “Androgens” (pp. 549–556)
  • Chapter 51, “Drugs for Erectile Dysfunction and Benign Prostatic Hyperplasia” (pp. 557–569)
  • Chapter 68, “Basic Principles of Antimicrobial Therapy” (pp. 769–781)
  • Chapter 69, “Drugs That Weaken the Bacterial Cell Wall I: Penicillins” (pp. 783–790)
  • Chapter 73, “Sulfonamides and Trimethoprim” (pp. 619–826)
  • Chapter 74, “Drug Therapy of Urinary Tract Infections” (pp. 827–831)
  • Chapter 75, “Antimycobacterial Agents” (pp. 833–847)
  • Chapter 76, “Miscellaneous Antibacterial Drugs” (pp. 849–853)
  • Chapter 77, “Antifungal Agents” (pp. 855–866)
  • Chapter 78, “Antiviral Agents I: Drugs for Non-HIV Viral Infections” (pp. 867–886)
  • Chapter 80, “Drug Therapy of Sexually Transmitted Diseases” (pp. 905–911)

 

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