21.Wk10Response2

EST/ARU

Read a selection of your colleagues’ responses from Week 9 and respond to at least two of your colleagues on two different days who were assigned a different patient case study, and provide recommendations for alternative drug treatments to address the patient’s pathophysiology. Be specific and provide examples.

(So both examples I send to you are the same. They split the class so you already did mine last week. These 2 responses will be the other example they gave)

This is a case scenario about H.H a 68-year-old male patient who is admitted for community-acquired pneumonia (CAP). He was started on antibiotics such as intravenous Ceftriaxone and Azithromycin and his clinical status has improved, with decreased oxygen requirement. His past medical history includes COPD, HTN, hyperlipidemia, and diabetes. He is allergic to penicillin (rash). He is not tolerating a diet at this time with complaints of nausea and vomiting.

Community-Acquired Pneumonia

Pneumonia occurs when organisms like bacteria, fungi, or viruses enter the body through the upper airway and result in an acute infection of the lungs. Pneumonia has a high prevalence in individuals 65 or older and children 2 years or younger. Towairqi, et al., (2018) reported that “The incidence of pneumonia among elderly is 4 times higher than younger individuals, with elevated risks of hospital admissions and high mortality rates.” The authors further stated that “the most important and common infectious cause of death among old patients remains to be community-acquired pneumonia.” (p.1468). Based on the case study provided for this week's discussion, a specific description of the patient’s health needs will be provided with an explanation of the type of treatment regimen recommended for treating the patient, including pharmacotherapeutics. Finally, an explanation of a patient’s educational strategy recommends assisting patient with the management of their health needs.

Patient Health Needs

Each patient that presents to a health care provider with health needs or complains goes through the process of being examined, followed by the provider ordering appropriate pharmacotherapy and the implementation of individualized care plans based on the patient's age and co-mobilities. Case study 1 is about a 68-year older adult with chef complaints of community-acquired pneumonia and co-mobilities which include chronic obstructive pulmonary disease (COPD), hypertension (HTN), hyperlipidemia, and diabetes. Although the patient is showing some clinical improvement post empiric antibiotic therapy, he still presents with new complains of nausea and vomiting, inability to tolerate diet and elevated white blood count which needs close monitoring. It should be noted that close monitoring is recommended because community-acquired pneumonia is a high probability and it is a leading cause of death for patients older than 65 years. (Towairqi, et al., 2018, p.1468). The patient’s advanced age and being Diabetics are also risk factors for community-acquired pneumonia.

Recommended Treatment Regimen

CAP is an infectious disease affecting the pulmonary parenchyma and adjacent organs with Streptococcus pneumoniae as the most frequently identified causative pathogen (Towairqi, et al., 2018, p.1468). In the bronchial alveolar lavage, the organism is seen with multiple growths. The provider taking care of this patient will order chest radiography that usually shows a right lower lobe infiltrate that confirms the diagnosis. Within three days of starting treatment, vital signs and laboratory results are seen with improvement. Blood culture sensitivity showed susceptibility to certain medications such as penicillin, ceftriaxone, vancomycin, and levofloxacin; however, it showed resistance to erythromycin and tetracycline. The oxygen saturation rates are seen to be improving from 90% (on 4 liters of oxygen) to 92% (room air).

Determining the site of care such as a hospital, ICU, or outpatient is the first vital clinical decision that the care provider has to make in treating CAP followed by making a determination on using antibiotic therapy (antibiotic therapy differs for ICU, inpatients vs outpatients), delivering supportive care ie oxygen, hydration, or the need for ventilatory support. (Niederman, 2015). Beta-lactam with or without macrolide, fluoroquinolones and macrolide (azithromycin alone) are recommended antibiotics treatment options for inpatient. (Arcangelo & Peterson, 2016). Due to the fact, that HH is allergic to penicillin, beta-lactam antibiotics were not recommended. Consequently, the patient was started on alternative therapy; azithromycin and ceftriaxone as treatment options for pneumonia in this case. So far, the patient has been on treatment for 3 days and according to Arcangelo & Peterson, (2016), mild CAP sometimes requires 5-day treatment with azithromycin, but since the lab results indicate heavy growth of streptococcus pneumoniae, the required treatment length is 7-14 days for the patient. In addition, because the patient has two coexisting conditions; CAP and COPD, azithromycin can be used to manage patient COPD as well. CAP on a patient with COPD can be life-threatening because it can trigger COPD and exacerbation causing airway obstruction or risk of respiratory failure. Many studies show a great correlation between CAP and COPD, for instant, a study by Cilli, et al., (2013) reported CAP as the leading cause of death from infectious diseases. In patients with COPD, CAP weakens lung defense resulting in a 35% to 50% hospitalization rate and even more so for patients 65 and older. Another treatment will consist of first-line short-acting bronchodilators inhaler to manage potential COPD exacerbation trigger by pneumonia infection and intravenous fluids to keep the patient hydrated since the patient is having nausea and vomiting, a possible side effect of the antibiotics, and is not tolerating diet.

Education Strategies

Although the patient is showing some improvement, it is imperative to educate the patient on the importance of the full/complete course of drug therapy. Arcangelo & Peterson, (2016) reported that the development of micro-organisms resistant can occur with early discontinuation of antibiotic therapy. Further education will consist of recommended vaccinations, both pneumococcal and influenza vaccinations. Niederman, (2016) reported that older adults aged 65 years or older with co-mobilities and risk factors such as diabetes and COPD and other high-risk for CAP and its complications, should be offered pneumococcal and influenza vaccination at recommended doses and frequencies. Assisting the patient with early mobilization should also be encouraged as part of an education strategy. The fact that the patient is not tolerating diet well and is having nausea and vomiting, the provider should order IV Zofran , an antiemetic to help treat and control nausea and vomiting symptoms. For patients experiencing nausea and vomiting, the provider must be a concern for dehydration. The provider should prescribe a proton pump inhibitor such as Protonix to help relax gastric acid secretion in the stomach. (Rosenthal & Burchum,2018). Therefore, adequate rehydration should be administered such as IV fluids. In addition, the patient labs should be monitored for sodium level and potassium level as well. Loss of taste, nausea, and vomiting are reported side effects of macrolides and cephalosporins (Rosenthal & Burchum, 2018). The patient should be placed on cardiac monitoring due to the fact that azithromycin and ondansetron can cause an elevation of QT prolongation (Jelic, & Antolovic, 2016).

Summary

CAP can be deathly especially in older adults and requires early intervention and appropriate timely treatment with antibiotics which is the commonly recommended treatment. Based on co-mobilities and allergy predisposition, azithromycin and ceftriaxone were preferred a choice of therapy for Mr. HH. Although the patient started showing some improvement after 3 days of therapy, completing the course of therapy is important. In addition, continuous monitoring of the patient's response to antibiotics therapy through labs, diagnostic imaging, and the promotion of vaccination through education is recommended to positively impact patient health needs.

  References

Arcangelo, V. P., & Peterson, A. M. (2016). Pharmacotherapeutics for

               Advanced practice: A practical approach (3rd ed.). Ambler, PA: Lippincott

             Williams & Wilkins.

Cilli, A., Erdem, H., Karakurt, Z., Turkan, H., Yazicioglu-Mocin, O., Adiguzel, N, Bilgic, H.           

            (2013). Community-acquired pneumonia in patients with a chronic obstructive pulmonary disease requiring admission to the intensive care unit: Risk factors for mortality. Journal of Critical Care, 28(6), 975–979. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jcrc.2013.08.004

Jelic, D., & Antolovic, R. (2016). From erythromycin to azithromycin and new potential ribosome-binding antimicrobials. Antibiotics, 5(3), 29. doi:10.3390/antibiotics5030029

            Niederman, M. S. (2015). In the Clinic: Community-Acquired Pneumonia. Annals Of Internal   

                          Medicine, 163(7), ITC1-ITC17. https://doi-           

 org.ezp.waldenulibrary.org/10.7326/AITC201510060

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

Towairqi, A. S., Mutwally, L. H., Baateiyyah, Y. A., Alshuwaier, R. A. I., Kraiz, I. N. O., Alarfaj, H. M., … Omar Bukhari, R. S. (2018). Pneumonia in Elderly and Intensive Care Management. Egyptian Journal of Hospital Medicine, 70(9), 1468–1470. https://doi-org.ezp.waldenulibrary.org/10.12816/0044670