Demonstrates synthesis and understanding of learning objectives.
PHARMACOLOGY WK 10 DISCUSSION RESPONSE QUESTION
Discussion: Women’s and Men’s Health, Infectious Disease, and Hematologic Disorders
To Prepare
o Review the discussion below and reflect on the different health needs and body systems presented.
o Review your peers case study from Week 9.
o Consider how you will practice critical decision making for prescribing appropriate drugs and treatment to address the complex patient health needs in the patient case study you selected.
THE RESPONSE QUESTION: (please provide subtitles) Thanks.
• Respond to the following CASE STUDY DISCUSSION below and provide recommendations for ALTERNATIVE drug treatments to address the patient’s pathophysiology.
• Provide the reason for your alternative treatments CASE STUDY DISCUSSION.
• Be specific and provide examples.
• Support your response by at least three current, credible sources (1 or 2 from learning resources plus 1 or 2 from outside).
PEERS CASE STUDY AND DISCUSSION:
Nikki Cherryholmes
Case Study 1-CAP
Scenario Summary
H.H. is a 68 year old male patient with a history of COPD, HTN, HLD, and DM and an allergy to penicillin which causes a rash when taken. He has been admitted to the medical/surgical unit for 3 days with an admitting diagnosis of community acquired pneumonia. Antibiotic treatment regimen includes ceftriaxone 1 g IV daily (currently on day 3) and azithromycin 500 mg IV daily (currently on day 3.) Over the past three days the patient has improved and requiring less oxygen. Patient sating at 92% on room air. Blood cultures were obtained x2 with no growth so far. Chest x-ray shows right lower lobe infiltrate. Bronchial culture shows streptococcus pneumoniae and non-reactive legionella and pneumococcal antigen in the urine. Pt is still febrile at 100.9 but temp has decreased over the three day course. BP, HR, and respirations all within normal limits. Electrolytes all within normal limits. BUN and Creatnine both within normal range, and WBC elevated at 14.6 but trending down since admission.
Recommended Regimen
Penicillin G is the first drug of choice and safest to treat the patients community acquired pneumonia. However, conditions that might rule out a first-choice agent include allergy to that specific drug (Rosenthal & Burchum, 2018). It is stated in the scenario provided that the patient has a mild allergy to penicillin as evident with a rash. The first step would be to assess the patients current allergy by doing a skin test. Ten percent of the population claims an allergy to penicillin, but 90% or more of these individuals are not allergic (2019b). This test entails making sure the patient is at a facility where respiratory support and epinephrine are available and then injecting a small amount of allergen between the layers of skin and waiting for a reaction. If the patient is allergic to penicillin it is no longer an option for use. However, if it is not a true allergy then that opens up more possibilities for the treatment.
I am assuming that this patient was started on two different antibiotics prior to getting the cultures and sputum sample back to help cover for several different infections. Azithromycin is typically used to cover all of the different organisms that ceftriaxone does not cover. According to Donovan (2018) the typical bacterial pathogens that cause CAP include Streptococcus pneumonia, but now that it is confirmed in the sputum culture we need to move from a broad spectrum antibiotic to a narrow spectrum. For this reason I would suggest removing azithromycin from the treatment regimen. The main reason for doing this is because as stated in the case study the Streptococcus pneumonia is resistant to Erythromycin and probably Azithromycin as well since it is also a macrolide-type antibiotic. In turn, this may also take care of the patients adverse effects such as the nausea and vomiting. Common side effects of macrolides include, nausea, vomiting, and diarrhea (Lutfiyya, Henley, Chang, & Reyburn, 2006). Continuing the patient on ceftriaxone 1 gm IV daily for the course of the treatment will be adequate coverage. Expected regimen course should be 5-7 days for patients who have a good clinical response within the first few days of treatment according to IDSA (Infectious Disease Society of America) but treatment can extend up to 10 days if necessary (Van Schoonefeld & Rolek, 2015).
Typically you want to move the patient over to a PO antibiotic regimen once they are stable hemodynamically, afebrile, improvements in white blood cell count and stable and able to tolerate oral intake. This saves money and allows for earlier discharge, minimizing the risk of a hospital acquired infection (Lutfiyya, Henley, Chang, & Reyburn, 2006). However, since the patient is complaining of nausea and vomiting at this time it is not appropriate to switch to oral antibiotics. You could consider adding in a PRN anti-emetic. If removing the azithromycin causes the nausea and vomiting to dissipate then it would be appropriate to switch the patient to a PO regimen. In this case I would recommend an oral third generation cephalosporin. For patients who have experienced a mild reaction to penicillins, guidelines recommend a cephalosporin such as Cefdinir (Rosenthal & Burchum, 2018). More specifically Cefdinir 300 mg PO BID (2019a). Keeping the oral antibiotic in the same class as the IV antibiotic allows you to refrain from switching drug classes multiple times, thus decreasing your risk of resistance.
Patient Education Strategy
Patient education is an important tool to help patients understand their plan of care thus reducing hospital readmissions, costs, and overall morbidity and mortality. For specific patient education geared towards community acquired pneumonia it is important to instruct patients to wash hands appropriately and reduce their time around individuals who are sick. Adherence to prescribed drug therapy such as taking all of an antibiotic and not stopping it once you begin to feel better is important. This will help to ensure the infection was taken care of that antibiotic resistance is not a future concern. Another education tip is for preventative vaccines such as the flu vaccine since the flu is a very common way to contract pneumonia. Patient should be warned about no smoking and avoid second hand smoke since this irritates and weakens your lungs. Pneumonia vaccine for individuals 65 years and older (File Jr., 2019). Staying active and eating a healthy diet will allow you the necessary tools and strength to fight of infections. Most importantly it is imperative that you assist the patient in making a follow up appointment with the doctor within one week of discharge.
References
Cefdinir dosing, indications, interactions, adverse effects, and more. (2019a, September 28). Retrieved from https://reference.medscape.com/drug/omnicef-cefdinir-342502
Donovan, F. M. (2019, November 10). Community-Acquired Pneumonia Empiric Therapy: Empiric Therapy Regimens. Retrieved from https://emedicine.medscape.com/article/2011819-overview
File Jr., T. (2019, November). Treatment of community-acquired pneumonia in adults who require hospitalization. Retrieved from https://www.uptodate.com/contents/treatment-of-community-acquired-pneumonia-in-adults-who-require-hospitalization/print?search=length of antibiotics for community acquired pneumonia&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Lutfiyya, M. N., Henley, E., Chang, L. F., & Reyburn, S. W. (2006, February 1). Diagnosis and Treatment of Community-Acquired Pneumonia. Retrieved from https://www.aafp.org/afp/2006/0201/p442.html
Penicillin skin testing accurately rules out penicillin allergy: AAAAI. (2019b, March). Retrieved from https://www.aaaai.org/global/latest-research-summaries/New-Research-from-JACI-In-Practice/penicillin
Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier
Van Schoonefeld, T., & Rolek, K. (2015, March). Antibiotic Protocol for Empiric Therapy of Community-Acquired Pneumonia (CAP). Retrieved from https://www.nebraskamed.com/sites/default/files/documents/for-providers/asp/cap-guideance-2015-revision.pdf
THE RESPONSE GRADING RUBRIC:
Response exhibits synthesis, critical thinking, and application to practice settings.
Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
Demonstrates synthesis and understanding of learning objectives.
Communication is professional and respectful to colleagues. .
Response is effectively written in standard, edited English.
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