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)


RESPOND TO YOUR COLLEAGES POST TO THE CASE STUDY BELOW WITH FEEDBACK ON ADDITIONAL ALTERNATIVE DRUG TREATMENT Case Study 1 HH is a 68 yo M who has been admitted to the medical ward with community-
Read a selection of your colleagues’ responses from Week 9 case study and respond to your colleagues and provide feedback with recommendations for alternative drug treatments to address the patient’s pathophysiology. Be specific and provide examples.    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)  POST A My patient is a 68 year old male diagnosed with community-acquired pneumonia (CAP), and past medical history of COPD, HTN, HLD, and diabetes, who is on a empiric antibiotics, ceftriaxone 1g IV qday and azithromycin 500 mg IV q day to treat the pneumonia. A patient with COPD may be complicated with pneumonia exhibiting some minor criteria like cough, respiratory rate more than or equal to 30bpm, uremia, (blood urine nitrogen level more than or equal to 20mg/dl, sometimes confusion /disorientation, and dyspnea (metlay et al., 2019), sometimes severe  respiratory  distress and sounds like wheezing. Major criteria are septic shock requiring vasopressors and respiratory failure that may be needing immediate fluid resuscitation (Metlay et al., 2019). Pneumonia is a lung infection, with Community Acquired Pneumonia as a type of pneumonia in patients who have not recently be hospitalized, thus, they develop it from the community they live in, just as the name goes. CAP is further diagnosed by imaging, a chest x-ray. The pathogens of CAP are Streptococcus pneumoniae, influenza A, Mycoplasma pneumoniae and Chlamydophila pneumoniae (Brown, 2012), Haemophilus influenzae, Mycoplasma pneumoniae, Staphylococcus aureus and Legionella species (Metlay et al., 2019). Most common risk factors are age, smoking and comorbidities (Brown, 2012) as seen in my patient.  The scenario did not mention if the patient was on inhaler, as such recommendations are that this patient would be needing an inhaler even while on admission, possibly an inhaled glucocorticoids (Budesonides-Symbicort) to prevent inflammation of any sort (Rosenthal & Burchen, 2021). Corticosteroids (dexamethasone) will help with inflammation but may be used in patients with refractory septic shock (Metlay et al., 2019). Administration of Macrolides such as azithromycin is in order, as they have anti-inflammatory components to help to control inflammation that could cause hypoxia, acute respiratory diseases syndrome (ARDS), including septic shock associated with pneumonia (Brown, 2012). Other macrolides include erythromycin and clarithromycin. I will recommend albuterol and/or duo-nebs as nebulizer treatments prn as rescue medicines and bronchodilators to relieve bronchospasms (Depending on the severity of any cough, patient will be on guaifenesin prn every 4 hours or it may form part of the scheduled meds every 4 hours. Since the patient is a diabetic patient, caution should be taken while getting steroids because steroids increase blood sugar naturally, so order fingerstick check every four hours (q4) or at hours of meal and bed time (ACHS) and prepare to administer a sliding scale insulin short acting. The patient will require statin considering his history of hyperlipidemia. Recommended also to reverse treatment are a combination of ß-lactam and macrolide Empiric antibiotics are given to a person before any test to know what type of bacteria caused the infection so as to treat with the right antibiotics, so it is important to do a sputum stain culture or sputum gram stain (will tell the organism causing the infection), urinary antigen test (will tell the exact antibiotics to treat), and Polymerase Chain Reaction (PCR), and a blood culture is required (Metlay et al., 2019). Educate the patient about practices to avoid spreading the diseases, like cough etiquette, hand washing,  smoking cessation if the person is a smoker as it affects the respiratory system, foods rich in vitamin C and zinc to help, also give ascorbic acid (vitamin C) to help with immunity. POST B In case study 1 HH a 68-year-old male is currently admitted to the hospital and admitted for community-acquired pneumonia for the past 3 days. Community-acquired pneumonia (CAP) is defined as an acute lung infection involving the alveoli that occurs in a patient without recent healthcare exposure (Rider & Frazee, 2018). Other than the continuation of IV antibiotics which patient has been responding very well with improvements. The patient’s current health needs entail dietary/ nutrition due to his intolerance to food and complaints of nausea and vomiting. Further workup and assessment would be needed for the prevention of malnutrition and dehydration. Chances of the intolerant diet being related to community-acquired pneumonia are unlikely. Although there may be a chance that it can be an adverse effect from the antibiotics. Blood and sputum cultures would have to be collected and resulted before changing antibiotics. Further imaging may also be found useful including an x-ray or CT abdominal/Kub. IV antiemetics and maintenance fluids should be started for hydration until the patient is able to tolerate oral intake. The patient’s treatment regimen would include IV antiemetics, IV fluids, and the change or continuation of IV antibiotics. IV antiemetics would include 1st line IV 4mg Zofran Q6H and 2nd line Reglan 10mg IV Q6H. Ondansetron has excellent utility as an antiemetic drug, and it is effective against nausea and vomiting of various etiologies (Griddine & Bush, 2022). Maintenance IV fluids for hydration D5 0.45 NS at 75/ml/hr after calculations (20 ml/kg/24 hours). This will help with the prevention of dehydration and keep patients’ glucose levels controlled and safe. There are three main indications: resuscitation, replacement, and maintenance (Malbrain et al., 2020). Continuation of patient’s antibiotics as he has shown improvement and great results with fewer oxygenation requirements. Unless cultures grow back stating otherwise. Patient education strategy should include incentive spirometer use and the importance for lung health, maintenance, and expansion. Incentive spirometry (IS) is commonly prescribed to reduce pulmonary complications (Eltorai et al., 2018). If requiring home oxygen patient should also be educated on oxygen monitoring and use. The patient may also benefit from education on diet and exercise as the patient is considered almost borderline obese. Which would help him with his hypertension and hyperlipidemia.   POST C As HH is admitted to the medical ward with community-acquired pneumonia (CAP), the first mode of treatment is going to be finding the proper antibiotics to fight this bacterial infection. The health needs of this patient on admission will include limiting the decline of their respiratory status and finding the correct antibiotic medication that will not interfere with the patient’s other medical history. As he is considered part of the elderly community of over 65, streptococcus pneumoniae continues to be seen as the main pathogen in this population of patients with CAP and this can be ensured by microbiology tests narrowing the pathogen (Jiang et al., 2022). In this population, it is important to monitor the organ function during treatment and choose the appropriate medication that coincides with the kidney and liver function of the patient (Jiang et al., 2022).  What is chosen for this patient is IV empiric antibiotics of cephalosporins and macrolides. Penicillins are usually the first-line choice for fighting this bacteria, but because this patient has an allergy, that family of medication was discarded as a choice therefore cephalosporins are considered as they are broad spectrum with similar actions to penicillin (Rosenthal & Burchum, 2021, p. 669).  Studies showed that combination therapy of beta-lactam antibiotics (cephalosporins) with an added macrolide significantly reduced mortality in CAP patients (Ito et al., 2019). After three days of dual IV therapy, this patient is showing clinical improvement with a now decreased oxygen requirement. This improvement comes at the cost of the patient now experiencing nausea, vomiting, and an essentially non-existent diet.              For my recommended treatment, I would continue with the IV antibiotic regimen as it appears to be improving the patient’s status with a resolution of some signs and symptoms related to the condition (Rosenthal & Burchum, 2021, p. 661).  The next step from the IV antibiotics would be switching to oral antibiotics.  This would reduce the hospital stay of the patient while also continuing the efficacy of the drugs prescribed (Kimura et al., 2020).  Now as we think about the appropriate time to switch to oral antibiotics from IV, not only will this patient have to show clinical improvements, but obvious toleration of oral intake is also necessary (McCarthy & Avent, 2020).  As this patient is experiencing GI symptoms and an absence of diet, oral intake is not currently tolerated.  This patient’s health needs will require a reduction in side effects while continuing with the improvements that the antibiotic therapy is producing.  My recommendation would be to continue IV therapy until oral intake is tolerated and we will do that by prescribing medication to treat the symptoms and improve nausea and vomiting, such as ondansetron.  This will hopefully allow this patient to begin tolerating orally and can begin oral antibiotics soon.  As soon as the patient can tolerate oral intake and their status continues to improve, we can switch them to a suitable oral medication with a similar spectrum or an oral form of what IV antibiotics have been given, which in this case will be a cephalosporin and a macrolide (McCarthy & Avent, 2020).  A patient education strategy I would recommend to assist this patient with their current health need would be focused on recovery at home.  This patient will be encouraged to have clinical follow-ups at close intervals to assess for possible decompensation or complications from their pneumonia (Kolditz & Ewig, 2017).  The importance of following their outpatient antibiotic regimen needs to be stressed heavily to aid in future infections not being resistant to certain antibiotics.  Education including smoking cessation, optimal oral hygiene, and infection control must also be stressed to ensure the patient does not become infected again.  The last education point I would give would be to be aware of the transmission of the illness and to limit face-to-face contact until antibiotics are completed. POST D   The case study provided mentions a patient that is a 68yo male that has been admitted to the hospital for community-acquired pneumonia (CAP). He has been treated with Ceftriaxone 1g IV qday and azithromycin 500mg IV qday for the last 3 days. This treatment has provided moderate improvement and has decreased the need for oxygen. He is tolerating a diet but is experiencing nausea and vomiting. He has a medical history of CPD, HTN, HLD, and DMII. His height is 5’8,” and his weight is 89 kg. He is allergic to Penicillin with the reaction of a rash.             This patient will need his vitals, focusing on blood pressure and pulse ox. He will also need his blood sugar checked. He may continue the current antibiotic treatment until a culture is obtained to identify the specific bacteria present. According to Cedars, “Streptococcus pneumoniae is a bacteria that is most often responsible for CAP in adults.” He would also benefit from IV fluids to provide hydration. The patient may be given an antiemetic medication, such as Phenergan or Zofran, to alleviate nausea and vomiting. Once nausea and vomiting are controlled, the patient should be encouraged to increase nutritional intake.              The education for the patient should be focused on the importance of monitoring the patient’s pulse ox due to the CAP, Blood pressure due to the HTN, and blood sugar. The patient should also be educated on maintaining a healthy diet and an active lifestyle. This will aid in the prevention of getting CAP again, as well as benefit the patient regarding his HTN, HLD, and DMII diagnoses. The patient should also be educated on the importance of vaccinations for both the Flu and Pneumonia. According Rosenthal and Burchum (2021) state that those that need a Pneumonia vaccine are those under the age of 2, those between 2-5 that have not completed the vaccine series, or those who are at high risk for pneumococcal disease.

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