Nursing

Read a selection of your colleagues’ responses from Week 9 provide recommendations for alternative drug treatments to address the patient’s pathophysiology. Be specific and provide examples.

Original scenario:

CASE STUDY 1

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

CLASSMATE RESPONSE

Community-acquired pneumonia (CAP) is pneumonia contracted in the community with the incidence and severity increasing with age (Wyrwich, Yu, Sato, & Powers, 2015).  COPD is a significant predisposing comorbidity in patients with CAP, and it may be caused by many pathogens such as streptococcus pneumonia, haemophilus influenza, staphylococcus aureus, and influenza (Rogliani, Luca, & Lauro, 2015).

HH a 68-year-old male admitted to the medical ward with community-acquired pneumonia (CAP) for the past 3 days. His PMH is significant for COPD, HTN, hyperlipidemia, and diabetes.  He is on empiric antibiotics, ceftriaxone 1 g IV daily, and azithromycin 500 mg IV daily on day 3.  His clinical status has improved, with decreased oxygen requirements. He is not tolerating a diet and complains of nausea and vomiting.

Recommendations for empiric treatment with antibiotics for CAP patients involves selecting the drug that will be most effective in treating the cause.  Initial treatment recommendations are to treat empirically for bacterial and co-infection.  According to the American Thoracic Society, the recommended treatment regimen for inpatient CAP includes combination therapy B-lactam ceftriaxone 1-2 g IV daily and macrolide azithromycin 500 mg IV daily (Liu, Han, & Liu). The recommended treatment for CAP patients in the hospital is up to 7 to 10 days of antibiotic therapy.  The patient’s current dose is appropriate. Combination therapy with a beta-lactamases drug and macrolide is recommended (Correa et al., 2019). The patient’s penicillin allergy would not be a contraindication to therapy. Patient’s with a mild penicillin allergy may be prescribed cephalosporins with minimal concern, however, should not be given to patients with severe allergies to PCN (Rosenthal & Burchum, 2018).The patient has not complained of signs and symptoms of a rash in this case.

Identifying patients who may be candidates for early switch from IV to oral antibiotic therapy and potentially early hospital discharge is important in the management of CAP. Switch therapy is generally considered appropriate and safe when four criteria indicative of clinical stability are met, including improvement in cough and respiratory distress-related symptoms, defervescence of fever for at least 8 hours, normalizing white blood cell count, and adequate oral intake and gastrointestinal tract absorption. The majority of patients with non-severe disease can switch from IV to oral therapy within 2–4 days (Ramirez, 2012).

In this case scenario, the patient requires less oxygen and shows improvement around day 3. It would be appropriate to start the transition to oral.  The patient could transition to oral once clinically stable and preparing for discharge.  At this point, the patient could switch to oral Azithromycin 500 mg once, and then 250 mg once daily on days 2 through 5.

The patient is experiencing nausea and vomiting which is a common adverse effect of antibiotic therapy, and should be prescribed medications as needed. A dopamine antagonist, such as prochlorperazine, is especially effective for opioid-induced nausea, but can be beneficial for nausea caused by other medications as well. Dopamine agonists are a good choice for short-term offenders, such as antibiotics and NSAIDS (Glare, Miller, Nikolova & Tickoo, 2011). Dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal or cardiac function, and of concomitant disease or other drug therapy. Prochlorperazine 5mg three every 8 hours as needed for nausea/vomiting would be an appropriate dose for this patient.

Patient education would include teaching the patient to effectively manage COPD including risk factors the patient should avoid (exposure to tobacco, chemicals, dust, indoor and outdoor pollutants). The patient will learn to assess, monitor the disease, and identify signs and symptoms of worsening conditions and prevent exacerbation. The patient will be instructed to take medications as prescribed and know when to notify the provider or seek medical care. The patient should know that prochlorperazine is a medication that may cause drowsiness and not to drive a car or operate machinery until he knows how the medication affects him. The provider should discuss the benefits of receiving influenza and pneumococcal vaccinations indicated and the importance of managing and controlling blood glucose levels, blood pressure, and hyperlipidemia.

References

Correa, R. D., Costa, A. N., Lundgren, F., Michelin, L., Figueiredo, M. R., Holanda, M., … Pereira, M. C. (2019). 2018 recommendations for the management of community acquired pneumonia. Journal Brasileiro de Pneumologia, 44, 405-423. http://dx.doi.org/10.1590/S1806-37562018000000130

Kolditz, M., & Ewig, S. (2017). Community-Acquired Pneumonia in Adults. Deutsches

Glare P, Miller J, Nikolova T, Tickoo R. Treating nausea and vomiting in palliative care: a review. Clin Interv Aging 2011;6:243-59. 10.2147/CIA.S13109

Liu, D., Han, X. D., & Liu, X. D. (, May 5, 2018). Current Status of Community-Acquired Pneumonia in Patients with Chronic Obstructive Pul. Chinese Medical Journal, 132, 1891-1893. http://dx.doi.org/10.1097/CM9.0000000000000366

Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., … Musher, D. M. (2019). Diagnosis and treatment of adults with community-acquired pneumonia. american journal of respiratory and critical care medicine, 200, 45-67. http://dx.doi.org/10.1164/rccm.201908-1581ST

DIRECTION:

Read a selection of your colleagues’ responses from Week 9 provide recommendations for alternative drug treatments to address the patient’s pathophysiology. Be specific and provide examples.

ANSWER

American Thoracic Society recommends a treatment regimen for Community-acquired pneumonia that includes combination therapy B-lactam ceftriaxone 1-2 g IV daily and macrolide azithromycin 500 mg IV daily (Liu et al 2018). An alternative to this would be an empirical treatment with a macrolide, doxycycline or a respiratory fluoroquinolone (Niederman 2004). Considering the patient is 68 years old and is admitted in a medical ward barely tolerating any diet, a fluoroquinolone or a combination of beta-lactam and macrolide antibiotics would be preferable for treatment (Niederman 2004). Depending on the level of infection on arrival, this treatment requires that is accompanied by antibiotic therapy including a third-generation cephalosporin and a macrolide with a fluoroquinolone such as gemifloxacin, levofloxacin, and moxifloxacin (Niederman 2004).

Additionally, giving the patient a corticosteroid such as prednisone, betamethasone or triamcinolone within the first few hours after admission ensures that the risk of adult respiratory distress syndrome and by extension the amount of time the patient will require treatment (Murray 1988). Similarly, a 23-valent pneumococcal polysaccharide and 13-valent pneumococcal conjugate vaccinations are highly required for the patient since he is more than 65 years old and requires protection from the risk of invasive pneumococcal disease including pneumonia (Murray 1988).

Patient education will be vital including the importance of avoiding dust and smoke among other air pollutants. The patient should be able to self-diagnose and tell when the situation gets worse from how he feels reporting it immediately to the attention of his caregiver. Similarly, the intake of the recommended medicine must be done on time and accurately even after the patient leaves the hospital.

References

Liu, D., Han, X. D., & Liu, X. D. (, May 5, 2018). Current Status of Community-Acquired Pneumonia in Patients with Chronic Obstructive Pul. Chinese Medical Journal, 132, 1891-1893. http://dx.doi.org/10.1097/CM9.0000000000000366

Murray, J. F., Matthay, M. A., Luce, J. M., & Flick, M. R. (1988). An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis, 138(3), 720-723.

Niederman, M. S. (2004). Review of treatment guidelines for community-acquired pneumonia. The American Journal of Medicine Supplements, 117(3), 51-57.