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

NURS 6512 Discussion: Women’s and Men’s Health, Infectious Disease, and Hematologic Disorders

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

Many patients who present for medical treatment of acute illness have multiple comorbidities that require consideration.  The focus of this post is a 68-year-old male patient who presents with acute community-acquired pneumonia (CAP).  Medical history includes Type II diabetes, hypertension (HTN), hyperlipidemia, and chronic obstructive pulmonary disease (COPD).

Current Drug Therapy

The patient’s current drug therapy includes Metformin 500 mg twice a day, glipizide 10 mg once daily, lisinopril 10 mg once a day, hydrochlorothiazide 20mg once a day, simvastatin 40mg once a day, albuterol inhaler two puffs every four to six hours as needed for wheezing or shortness of breath, tiotropium inhaler two puffs (18 mcg) once daily.  He is receiving ceftriaxone 1 Gm IV daily and azithromycin 500mg IV daily for the treatment of community-acquired pneumonia and is improving after three days of this therapy.

Metformin is an antihyperglycemic medication used in conjunction with diet and exercise to control blood glucose levels in diabetic patients.  This drug should be held for 48 hours when radioactive dye is used for diagnostic testing to prevent damage to the kidneys. Mechanisms of action include increased insulin sensitivity, decreased glucose secretion and decreased glucose absorption.  Metformin does not cause hypoglycemia.  Glipizide is a blood glucose lowering drug classified as a sulfonylurea drug used to control blood glucose levels in diabetic patients who do not achieve adequate control with diet, exercise, and metformin.  Glipizide works by stimulating insulin production and secretion in pancreatic beta cells and its action is dependent on functioning pancreatic beta cells.  Patients taking glipizide are at risk of hypoglycemia and should be educated on signs and symptoms of hypoglycemia.

The patient is taking lisinopril and hydrochlorothiazide for blood pressure control.  Lisinopril is an angiotensin converting enzyme

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

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

(ACE) inhibitor that works to lower blood pressure and protect diabetic patients from renal disease and is also cardio protective.  Hydrochlorothiazide is a diuretic and antihypertensive medication whose mechanism of action is not fully understood.  It works in the distal tubule to enhance the secretion of sodium and chloride.  It is not metabolized but is excreted by the kidneys and requires dosage adjustments in cases of renal impairment.  Patients taking hydrochlorothiazide should be monitored for fluid and electrolyte imbalances.

Simvastatin is a statin drug that acts to lower the risk of coronary heart disease by lowering cholesterol and triglyceride levels in high-risk patients.  Patient should avoid grapefruit while taking this medication.  Dosing adjustments should be considered in patients with decreased renal function.  Simvastatin interacts with several medications and prescribing providers must check drug-drug interactions when prescribing to avoid risk of rhabdomyolysis (Food and Drug Administration [FDA] & Merck Sharp & Dohme Corp [Merck & Co, Inc.], 2012).

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The patient is taking tiotropium inhaled powder which is a long-acting muscarinic antagonist (LAMA) that works to prevent bronchospasm in patients diagnosed with COPD.  This anticholinergic drug should not be used for rescue when the patient is experiencing shortness of breath.  This patient uses an albuterol inhaler as needed for rescue when he is experiencing shortness of breath or wheezing.  Albuterol is a short-acting beta agonist (SABA) that works immediately to relieve bronchospasm and is used only as needed.

Anti-infective Therapy for CAP

Ceftriaxone and azithromycin are being given intravenously to treat community acquired pneumonia (CAP).  Ceftriaxone is a broad spectrum, third generation cephalosporin antibiotic used to treat bacterial infections in the lower respiratory tract.  It works by inhibiting bacterial cell wall synthesis which results in a weak cell wall, bacterial cell lysis, and death.  Ceftriaxone is mixed in 50 ml of D5W and should be administered over 30 minutes for four to fourteen days.  Compatibility with other IV solutions is a concern, and this drug should be checked for compatibility if other IV solutions are being used particularly calcium which is not compatible with ceftriaxone.  Onset is immediate when ceftriaxone is administered IV and peak is within two hours.  The half-life of the drug is six to nine hours, and it is excreted primarily by the kidneys.  Altered dosing is required in patients with moderate to severe renal impairment.  Adverse reactions include life threatening anaphylaxis in patients with allergies to cephtriaxone.  Less severe reactions include rash, fever, nausea, pain at injection site.  Ceftriaxone is generally well tolerated.  Patients taking broad spectrum antibiotics may develop diarrhea related to clostridium difficile (Roche Pharmaceuticals, 1997).

Azithromycin is a broad-spectrum macrolide antibiotic and is indicated for treatment of CAP and prolonged, severe, exacerbation of COPD not responsive to LAMA, or LABA medications (Rosenthal & Burchum, 2019, p. 579).  It works by inhibiting bacterial protein synthesis and should be used for at least two to five days of therapy in treatment of CAP.  Absorption is primarily from the small intestine and azithromycin distributes readily into most body tissues and fluid.  It is primarily eliminated in bile.  The peak plasma concentration is within one hour of IV administration and the half life of the drug is approximately eight hours.  Adverse reactions include gastrointestinal (GI) upset, prolonged QT interval and risk of torsades de pointes, sudden cardiac death, anaphylaxis, hepatotoxicity, and clostridium difficile associated diarrhea.  Azithromycin should not be taken by patients taking class IA or class III antidysrhythmic drugs or CYP3A4 inhibitors.  Taking this medication with food has been shown to decrease GI upset (Rosenthal & Burchum, 2019, p. 679).

Current Therapy

The patient is experiencing nausea, vomiting, and is not tolerating his diet.  Glipizide should be discontinued, and capillary blood glucose testing ordered before meals and at bedtime.  Low dose sliding scale Humalog insulin will be used to control blood glucose levels until patient is eating well.  This will help protect the patient from hypoglycemic occurrences.  In making decisions about which antibiotic should be used to treat bacterial infections, Choosing Wisely guidelines provide expert recommendations (Choosing Wisely, 2021).  CAP is commonly caused by staphylococcus aureus, Mycoplasma, H. influenza and S. pneumoniae.  Recommended treatments include penicillin G, penicillin V and amoxicillin.  If the strain is determined to be resistant, cephalosporin or ampicillin is recommended.  Since this patient has an allergy to penicillin the recommended drug is azithromycin.  Cephalosporin drugs are safe to use in patients with penicillin allergies if the reaction is mild.  Ceftriaxone is used to treat gram negative bacteria.  This combination of antibiotics may have been chosen by the clinician because of the severity of the infection and the need to treat before the pathogen is identified in culture.  Once the culture and sensitivity results are back from the lab, decisions will need to be made as how therapy should be continued to produce the best patient outcome (Rosenthal & Burchum, 2019).  Since our patient is on day three of treatment, culture results should be available.

Conclusion

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

Clinical knowledge and guidance are imperative in preventing poor patient outcomes and bacterial resistance to drugs when treating infections.  Renal function, hepatic function, allergies and their severity, and patient comorbidities must be considered.  When selecting antibiotics, one must consider the infecting organism and host factors to ensure the best patient outcomes.

References

Choosing Wisely. (2021). Learning Resources. Retrieved April 29, 2022, from https://www.choosingwisely.org/choosing-wisely-learning-network/cwln-resources/

Food and Drug Administration & Bristol-Myers Squibb Co. (2011). Glucophage (metformin hydrochloride). Food and Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020357s037s039,021202s021s023lbl.pdf

Food and Drug Administration & Merck Sharp & Dohme Corp. (2012). Zocor (Simvastatin). Food and Drug Administration.

https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/019766s085lbl.pdf

Food and Drug Administration & Mylan Pharmaceuticals Inc. (2011). Hydrochlorothiazide. Food and Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/040735s004,040770s003lbl.pdf

Food and Drug Administration & Roerig Division of Pfizer. (2011). Glipizide. FDA. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/017783s021lbl.pdf

Roche Pharmaceuticals. (1997). Cephtriaxone. Food and Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/0550585s063lbl.pdf

Rosenthal, L. D., & Burchum, J. R. (2019). Lehneś Pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Elsevier.