Discussion: Women’s and Men’s Health, Infectious Disease, and Hematologic Disorders

Discussion: Women’s and Men’s Health, Infectious Disease, and Hematologic Disorders

 A global leading cause of death ranking in third place is pneumonia (Chou et al., 2019). In the case study for this week 9 we have a 68-year-old male that has been in the medical ward for 3 days and was admitted with community-acquired pneumonic (CAP). He has a past medical history (PMH) of hypertension (HTN), hyperlipidemia, diabetes, and chronic obstructive pulmonary disease (COPD). His current treatment consists of antibiotics that include azithromycin 500mg Intravenous (IV) every day and ceftriaxone 1g IV every day, both on day 3 of treatment. Although the client has shown improvement and has had decreased oxygen needs, he has a poor diet intake due to his nausea (N) and vomiting (V).

My plan of care would consist of obtaining a sputum and blood culture (BC) and consider his allergy to penicillin (PCN) with a delayed rash reported. I would continue ceftriaxone or azithromycin until sputum and BC results. Depending on his results possibly continuing with his antibiotics for a total of five days then re-evaluated on or before the seventh day. PCNs the ideal antibiotic because they are effective against a large range of bacteria and have a low risk of toxicity (Rosenthal & Burchum, 2021).

I would add a regimen of  a Histmine2 receptor antagonist such as Famotidine to help prevent any possible stress ulcers which can be an added complication (Chou et al., 2019). It is also imperative to keep the client on a unit where his vital signs (VS) can be monitored closely as well as cardiac rhythm (telemetry) for any changes. I would have the client on IV antiemetics such as ondansetron (Zofran) 4mg IV every 6 hours as needed (PRN) to help alleviate his N/V and prevent aspiration pneumonia. I would order IV fluids such as 0.9% normal saline (NS) at 100ml/hour initially and taper down depending on tolerance, daily weight, and client status to help prevent dehydration due to his N/V and help facilitate and or loosen the clients’ secretions and clear his airway when coughing. While at the same time monitoring for risk of fluid overload and closely monitor his intake and output (I&O) and treat accordingly if output is less than 30ml/hour or dark in color as it would be an imperative factor and indicator of proper hydration (Chou et al., 2019). If N/V continue placing patient on nothing to eat or drink (NPO) orally until well controlled, then start him on a clear liquid diet and advance as tolerated.

I would also order daily chest x-rays to monitor for any changes as well as ordering morning labs such as arterial blood gases (ABG’s)

Discussion Women’s and Men’s Health, Infectious Disease, and Hematologic Disorders

to assess PaCO2 to maintain CO2 near 50mm hg for a patient with COPD and encourage client to use incentive spirometer (IS) and teach rational for its use. I would also order the following labs, complete blood count (CBC) and comprehensive metabolic panel (CMP) to monitor the client’s overall health such as his red blood cell (RBC) count which are responsible for carrying oxygen throughout the body. Including monitoring his white blood cell (WBC) count to monitor his infection and his CMP can monitor 14 different substances in the blood including his chemical balance and metabolism such as his electrolyte imbalances and replace them if needed.

Monitoring his glucose levels is also imperative as they will be affected due to medications like steroids, or any stress the body is going through increasing the risk of hypoglycemia due to N/V. Checking blood sugars before meals (AC) and at bedtime (HS). I would order for regular insulin sliding scale depending on what his blood sugars run is what would determine if the low dose, moderate or high/aggressive scale should be utilized and administered according to his accu check. This scale would change according to any sudden or drastic large increase or decrease per protocol.

There are four salts available for PCN G, they are benzathine penicillin; potassium penicillin; procaine penicillin; and sodium penicillin. They are different depending on their course of action and route. All of them are available in intramuscular (IM) route however are absorbed at different rates. They distribute well in the body fluids and most tissues depending on if there is any inflammation as affects can be altered. PCNs go through little metabolism and are eliminated unchanged by the kidneys (Rosenthal & Burchum, 2021).

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In addressing the client’s other health conditions, I would research his home medication list to see if he is on any antihypertensives for his HTN, anti-cholesterols for his hyperlipidemia, anti-diabetic for his diabetes and any respiratory or corticosteroids for his COPD and determine weather to continue or complete any adjustments. If he is not on any medications, I would treat his diabetes as stated above for the mean time. Start him on a hypertension first-line pharmacologic treatment such as thiazide diuretics, calcium channel blockers, angiotensin receptor blockers and angiotensin-converting enzyme inhibitors.

As for the client’s hyperlipidemia I would prescribe a statin drug such as atorvastatin depending on his low-density lipoprotein (LDL-C) level. If it is 130-149, 150-159 and great or equal to 160mg/dL I would dose in the following order depending on their LDL-C level; 10, 20 and 40mg by mouth (PO) at HS.

Although the patient has CAP, we must also treat his COPD. I would treat his treatment with his current supplemental oxygen and adjust according to his oxygen saturations and his ABG’s. If needed I would prescribe corticosteroids for his inflammation and breathing treatments as needed for difficulty breathing. As well as any needed cough medications (CDC, 2021). Continued encouragement of using his IS for lung exercises as well as encourage patient to get a pneumonia vaccine before discharge.

References

Centers for Disease Control and Prevention (CDC).(October 20, 2021). Chronic Obstructive Pulmonary Disease (COPD). COPD: Symptoms, Diagnosis, and Treatment. Retrieved from COPD: Symptoms, Diagnosis, and Treatment (cdc.gov)

Chih-Chen Chou, Ching-Fen Shen, Su-Jung Chen, Hsien-Meng Chen, Yung-Chih Wang, Wei-Shuo Chang, Ya-Ting Chang, Wei-Yu Chen, Ching-Ying Huang, Ching-Chia Kuo, Ming-Chi Li, Jung-Fu Lin, Shih-Ping Lin, Shih-Wen Ting, Tzu-Chieh Weng, Ping-Sheng Wu, Un-In Wu, Pei-Chin Lin, Susan Shin-Jung Lee, … Meng-Chih Lin. (2019). Recommendations and guidelines for the treatment of pneumonia in Taiwan. Journal of Microbiology, Immunology and Infection, 52(1), 172–199. https://doi.org/10.1016/j.jmii.2018.11.004

Rosenthal, L.D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutic for advanced practice nurses and physician assistants (2^nd ed.) St. Louis, MO: Elsevier.

Case Study

• HH is a 68-year-old male who has been admitted to the medical ward with community-acquired pneumonia (CAP) for the past 3 days.
• His past medical history PMH is significant for:
• Chronic obstructive pulmonary disease (COPD)
• Hypertension (HTN)
• Hyperlipidemia
• Diabetes.
• He remains on empiric antibiotics, which include:
• Ceftriaxone 1 g IV everyday (day 3)
• Azithromycin 500 mg IV everyday (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.
• Height: 5’8” Weight: 89 kg (196 pounds)
• Allergies: Penicillin (delayed, rash)

Addressing Patient’s PMH

First, due to risk of bronchoconstriction resulting in chronic obstructive pulmonary disease (COPD) exacerbation, prescribing a thiazide diuretic or a potassium-sparing diuretic would be an appropriate first step in treating hypertension in the patient.  For the same reason, beta-blockers should be used with caution and reserved for patients diagnosed with cardiovascular disease (Finks et at., 2020).  Addressing hyperlipidemia, statins have been proven to be effective in preventing cardiac complications in patients also diagnosed with COPD (Lu et al., 2019).  Lastly, metformin (biguanide) has been proven to be the best treatment option in treating diabetes for patients who have also been diagnosed with COPD (Zhu et al., 2019).

CAP

Community acquired pneumonia (CAP), can be classified as either viral or bacterial.  Biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT) have been demonstrated to be beneficial in differentiating between bacterial and viral CAP (Ito & Ishida, 2020).  Along with good antibiotic stewardship, it is important to take into consideration comorbidities that may increase the risk of complications due to CAP.  Aside from treating with antibiotics for bacterial suspected CAP, anti-infective medications such as antivirals have been studied and have NOT been proven to be successful in reducing symptoms of CAP unless the patient is also suspected to be infected with influenza (Metlay et at., 2019).

Antivirals in CAP

Oseltamivir is one such antiviral prescribed within 48 hours of the onset of influenza-like symptoms.  This medication inhibits viral replication by impeding the enzyme neuraminidase preventing the new particles of the virus from budding off the cytoplasmic membrane of the host cells that have been infected by the virus.  Oseltamivir is considered a prophylactic treatment for the prevention of influenza A and B to help alleviate the severity and duration of symptoms.  This medication is typically well tolerated but can cause nausea, vomiting, and headache and is best taken with food.  This medication should NOT be administered within two weeks of a live attenuated influenza vaccine (LAIV) as this may cause a decreased immune response to the vaccine.  Oseltamivir is protein binding and is metabolized almost solely by the liver and excreted through the urine (Rosenthal & Burchum, 2021).  As the patient is now three days out, this medication would not be proven to be beneficial.

Empiric Therapy for CAP

In adhering to good antibiotic stewardship, empirical treatment of CAP is not always recommended.  However, as patient is currently being treated in an inpatient setting with oxygen supplementation, empirical treatment would be appropriate.  As the patient is allergic to penicillin other beta-lactam antibiotics should be avoided in those with immediate-type allergic reactions.  As the patient had a delayed allergic reaction, cefadroxil (a third generation cyclosporin/beta-lactam antibiotic) has not been noted to increase the rate of allergic reaction and may be used as an alternative to penicillin in these patients if culture is sensitive to this class.  This medication is often used in conjunction with azithromycin as an augmentation to help prevent more serious complications such as sepsis.  It is also not uncommon for a patient to experience nausea and vomiting from antibiotic therapy.  Ondansetron could be prescribed, and a probiotic could also be advised to be taken.  Careful monitoring of the patient is crucial and at some point a glucocorticoid such as prednisone may be considered with careful monitoring of blood pressure and blood glucose (Arumugham et at., 2021).

If the allergic reaction to penicillin was immediate, other classes of antibiotics could be prescribed as empirical treatment.  Fluoroquinolones such as levofloxacin and tetracyclines such as doxycycline have also been shown to be effective and approved for the empirical treatment of CAP.  Newer medications in the class of pleuromutilin (Lefamulin) has been shown to be highly effective as an empirical treatment for CAP and is well tolerated in those diagnosed with COPD.  This medication inhibits protein translation of the bacteria and interrupts the formation of the peptide bond.  This medication can increase the effectiveness of statins and is mainly eliminated in the gastrointestinal (GI) tract resulting in main symptoms being GI related (Russo, 2020).

References

Arumugham, V. B., Gujarathi, R., & Cascella, M. (2021). Third generation cephalosporins, In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK549881/

Finks, S. W., Rumbak, M. J., & Self, T. H. (2020). Treating Hypertension in Chronic Obstructive Pulmonary Disease. New England Journal of Medicine, 382, 353-363. doi: 10.1056/NEJMra1805377.

Ito, A. & Ishida, T. (2020). Diagnostic markers for community-acquired pneumonia. Annals of Translational Medicine, 8(9), 609. doi: 10.21037/atm.2020.02.182

Lu, Y., Chang, R., Xinni, J. Y., Teng, Y., & Cheng, N. (2019). Effectiveness of long-term using statins in copd-a network meta-analysis. Respiratory Research, 20(17), n. p. Retrieved from https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-019-0984-3

Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., Cooley, L. A., Dean, N. C., Fine, M. J., Flanders, S. A., Griffin, M. R., Metersky, M. L., Musher, D. M., Restrepo, M. I., & Whitney, C. G. (2019). Diagnosis and treatment of adults with community-acquired pneumonia. American Journal of Respiratory and Critical Care Medicine, 200(7), e45-e67. doi: 10.1164/rccm.201908-1581^ST

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2^nd ed.) St. Louis, MO: Elsevier

Russo, A., (2020). Spotlight on new antibiotics for the treatment of Pneumonia. Clinical Medicine Insights: Circulatory, Respiratory, and Pulmonary Medicine, 14, n. p. doi: 10.1177/1179548420982786

Zu, A., Teng, Y., Ge, D., Zhang, X., Hu, M., & Yao, X. (2019). Role of metformin in treatment of patients with chronic obstructive pulmonary disease. Journal of Thoracic Disease 11(10), 4371-4378. doi: 10.21037.jtd.2019.09.84

This is a detailed and outstanding post about the case study.

Indeed, community-acquired pneumonia remains the single most common cause of death from infectious diseases in the elderly population. Regarding the treatment, it is essential to determine the appropriate treatment option after conducting respiratory cultures and blood work to establish the agent that causes the current infections (Rothberg, 2022). This information will help in determining the precise antibiotic that should be given to the patient. When using IV antibiotics, it is important to administer them for five to seven days and reassess the patient to determine their efficacy before discontinuing them to avoid the development of resistance to certain antibiotics. The patient is not tolerating diet appropriately. As such, he needs nutrition therapy and IV hydration until vomiting and nausea are eliminated to avert electrolyte imbalance and dehydration during the existence of the reported symptoms. As you have correctly mentioned, it is important to ensure patient education is conducted by an interprofessional team to achieve optimum patient health outcomes (Munro et al., 2021).

References

Munro, S. C., Baker, D., Giuliano, K. K., Sullivan, S. C., Haber, J., Jones, B. E., … & Klompas, M. (2021). Nonventilator hospital-acquired pneumonia: a call to action: recommendations from the National Organization to Prevent Hospital-Acquired Pneumonia (NOHAP) among nonventilated patients. Infection Control & Hospital Epidemiology, 42(8), 991-996. https://doi.org/10.1017/ice.2021.239

Rothberg, M. B. (2022). Community-Acquired Pneumonia. Annals of Internal Medicine, 175(4), ITC49-ITC64. https://doi.org/10.7326/AITC202204190