Pneumonia is infection that affects either one or both of the lungs. It is not a single disease and it may have more than 30 types of different causes, including bacteria, fungi and viruses. In young children with the age of less than 5 years old, viral pneumonia is the most common type of pneumonia, with its most common cause being the flu virus. There are many other viruses that can cause pneumonia as well, such as respiratory syncytial virus, herpes simplex virus, rhinovirus and severe acute respiratory syndrome (SARS).
Community-acquired pneumonia is the most common type of pneumonia which is acquired in public areas like the school, grocery store or working place. It might be caused by either bacteria, fungi, virus or the irritants present in the air, with the most common cause being the bacteria Streptococcus pneumoniae. Its development can also occur following a flu or cold [1].
Hospital-acquired penumonia which is also known as institution-acquired pneumonia is acquired in the hospital, particularly while staying and under treatment in the intensive care unit (ICU) or utilizing a ventilator to assist in breathing. It usually also develops following a major surgery including chest surgery or during dialysis in kidney dialysis centers or staying in chronic care centers. It has the potential to be very dangerous, particularly to those who are young, elderly or immune-compromised [1].
List the clinical symptoms (systemic versus respiratory) associated with pneumonia.
Systemic symptoms [2]:
- Mild or high fever
- Shaking chills
- Headache
- Loss of appetite
- Fatigue, low energy
- Increased sweating and clammy skin
- Confusion (particularly in the elderly)
Respiratory symptoms [2]:
- Cough (may includes production of greenish or yellow mucus, even
blood mucus in certain types of pneumonias)
- Shortness of breath (might only occur while climbing up stairs)
- Stabbing or sharp chest pain which can worsen with deep breath or
cough
Using the SMART-COP tool and the information provided above calculate MR Barnes' SMART-COP score and determine if Mr Barnes has mild, moderate or severe CAP.
Mr Barnes' SMART-COP score is 6, which mean he has severe CAP and has a high risk (33%) of requiring intensive respiratory or vasopressor support (IRVS) [3]. The score might be lower than his actual score though due to the lack of information regarding Mr Barnes' albumin concentration in plasma, heart rate, mental status and blood pH.
Complete the following treatment plan for the management of Mr Barnes' CAP, as would be outlined in the patient's admission notes, using the table provided.
Treatment plan
Explain the reason:
- for your recommendation/response
when filling in the blanks.
- the doctor has ordered certain tests and
observations etc
to commence the following IV empirical antibiotics (include dose):
moxifloxacin 400mg IV, daily & azithromycin 500mg IV, daily.
Broad-spectrum antibiotics are required initially for the treatment of Streptococcus pneumoniae, Legionella penumophila, and enteric Gram-negative bacilli. Since Mr Barnes is allergic to penicillin, moxifloxacin is used in place of penicillin.
for paracetamol 0.5 to 1g orally or aspirin 600mg orally for pleuritic chest pain.
To provide sufficient analgesia to enable adequate respiratory movements in addition to reducing the risk of atelectasis and pneumonia.
for supplemental oxygen via nasal prongs.
Because Mr Barnes' oxygen saturation is 89% which is quite low.
for salbutamol 5mg q4h prn via nebuliser.
For the treatment of airflow limitation or for the improvement in mucociliary clearance.
for repeat chest x-ray in next 2 days.
To make sure that the treatment is effective for the pneumonia infection [1].
withhold ramipril tablets.
To prevent further reduction in Mr Barnes' blood pressure as he is already in hypotensive state.
for daily full blood examination (FBE), U & E's, Creatinine.
To check the white blood cells count and type, and also to determine the severity of Mr Barnes's pneumonia infection.
for QID observations ( BP, Resp Rate, Temp, O2 saturation).
To determine whether Mr Barnes is recovering well from the pneumonia infection.
follow up blood and sputum cultures.
To monitor the eradication of the specific causative agents of Mr Barnes' pneumonia.
What changes to test results, observations and patient symptoms would the medical staff and you as pharmacist monitor, to indicate that the antibiotic therapy is effective?
I will monitor Mr Barnes' x-ray result, if the x-ray result showed that the pneumonia infection area is reducing then that means the antibiotic therapy is effective. Furthermore, I will also monitor the pulse oximetry or blood gases test result, if the oxygen saturation goes up closer to ~95% then the antibiotic therapy is most likely effective. Besides this, I will also monitor the daily full blood examination result, the antibiotic therapy is effective if the white blood cells count is returning to the normal level. I would also monitor the result of his blood and sputum cultures. If the number of the causative agents of his pneumonia is continuously reducing, that indicates that the antibiotic therapy is effective.
Besides this, I will also monitor Mr Barnes' temperature, blood pressure and respiratory rate as well. If all of them gradually returned to their respective normal levels then the antibiotic therapy is effective. Not only this, I will also observe and ask whether does Mr Barnes' initial presenting symptoms such as coughing that produces sputum, pleuritic chest pain and feeling of malaise are improving. If they are improving, then the antibiotic is most likely effective.
(i) What oral antibiotic would you recommend for Mr Barnes given all afore mentioned
information?
I would recommend moxifloxacin, 400mg orally, daily for Mr Barnes [3].
(ii) What would be the recommended duration of antibiotic treatment?
The recommended duration of antibiotic treatment is 7 days.
(iii) In point form list the counseling points you would provide to Mr Barnes for this
antibiotic.
Take moxifloxacin together with meals.
Avoid taking antacids, iron and zinc supplements within 2 hours of taking moxifloxacin as they might interfere with the absorption of moxifloxacin.
Be sure to take moxifloxacin until finish.
Moxifloxacin can result in dizziness, confusion or faintness, which may then leads to reduced ability to drive and/or operate machinery. These effects can be exacerbated by alcohol consumption.
If experience any soreness of inflammation of tendon, discontinue moxifloxacin, don't exercise, and consult the doctor in the shortest time as possible.
It is common to experience nausea, gastric upset and diarrhoea while taking moxifloxacin.
Ensure plenty of fluids intake (1.5-2L per day) while taking moxifloxacin.
Avoid from using urinary alkalinisers together with moxifloxacin as there is the risk of cystalluria.
Moxifloxacin might increase the caffeine's effects in certain people by inhibiting its metabolism, hence reduction in caffeine intake might be required.
For the pneumonia caused by the following pathogens, list the antibiotic(s) you would recommend for "directed therapy". Complete the table below.
Pathogen causing the pneumonia
Description of the pathogen
is it gram negative or gram positive bacteria?
is it aerobic or anaerobic?
is it a fungus or virus?
Antibiotic recommendation
Non-MRSA staphylococcal pneumonia
It is a gram-positive aerobic bacteria. (facultative anaerobe if is aureus)
Di/flucloxacillin 2g IV, 4 to 6 hourly.
- With penicillin
hypersensitivity (excluding
immediate
hypersensitivity):
Cefalotin 2g IV, 4 hourly.
Cephazolin 2g IV, 8 hourly.
- With immediate penicillin
hypersensitivity:
Vancomycin 1.5g IV, 12 hourly.
Legionella species
It is a gram-negative aerobic bacteria.
- With mild disease:
Azithromycin 500mg orally, daily for 5 days
OR
Doxycycline 100mg orally, 12 hoursly for 10 to 14 days.
- With severe disease:
Azithromycin 500mg IV or orally, daily.
PLUS
Ciprofloxacin 400mg IV, 12-hourly.
Pseudomonas aeruginosa
It is a gram-negative aerobic bacteria.
Gentamycin 4 to 6 mg/kg for 1 dose, then dosing interval is determined by renal function for a maximum of either 1 or 2 additional doses.
PLUS EITHER
Ceftazidime 2g IV, 8-hourly.
OR
Meropenem 500mg to 1g IV, 8-hourly.
Mycoplasma pneumoniae
It is a gram-negative facultative anaerobic bacteria.
Doxycycline 200mg orally, for the first dose, followed by 100mg orally, daily.
References:
FamilyDoctor.org [homepage on the Internet]. Leawood, KS: American Acedemy of Family Physicians; c2012 [cited 2012 Sept 20]. Pneumonia; [about 9 screens]. Available from: http://familydoctor.org/familydoctor/en/diseases-conditions/pneumonia.printerview.all.html
American Lung Association [homepage on the Internet]. Washington, DC: American Lung Association; c2012 [cited 2012 Sept 20]. Symptoms, Diagnosis and Treatment; [about 4 screens]. Available from: http://www.lung.org/lung-disease/pneumonia/symptoms-diagnosis-and.html.
eTG complete [homepage on the Internet]. Victoria, Australia: Therapeutic Guidelines Limited; c2012 [updated 2012 Jul; cited 2012 Sept 20]. Available from: http://etg.tg.com.au.ezproxy.lib.monash.edu.au/conc/tgc.htm?id=27b1fc15b4331af2841f02ef96ddc67b
Lab Tests Online [homepage on the Internet]. Washington, DC: American Association for Clinical Chemistry; c2001-2012 [cited 2012 Sept 20]. Pneumonia; [about 4 screens]. Available from: http://www.labtestsonline.org.uk/understanding/conditions/pneumonia/start/3
Monash University Studies Online [homepage on the Internet]. Victoria, Australia: Monash University; c2012 [updated n.d.; cited 2012 Sept 20]. Available from: http://muso.monash.edu.au/webct/urw/lc19907.tp0/cobaltMainFrame.dowebct
The Ohio State University at Mansfield [homepage on the Internet]. Mansfield, OHIO: The Ohio State University at Mansfield; c2012 [cited 2012 Sept 20]. Bacteria Binomials; [about 32 screens]. Available from: http://www.mansfield.ohio-state.edu/~sabedon/biol4045.htm
Rowlinson M. C, LeBourgeois P, Ward K, Song Y, Finegold S. M, Bruckner D. A. Isolation of a Strictly Anaerobic Strain of Staphylococcus epidermidis. J Clin Microbiol [serial on the Internet]. 2006 March; [cited 2012 September 20]; 44(3): [about 12 screens]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1393158/
Case Study 2:
A definition of Epididymo-orchitis (EO)
Epididymo-orchitis is painful inflammation that involves either the epididymis (epididymitis) or the testicles (orchitis) or both together (epididymo-orchitis) [1,2]. Due to the fact that epididymis and testicles locate next to each other, differentiating whether the inflammation only affects one of these or both together can often be difficult and hence, epididymo-orchitis is the commonly used term.
Sexually transmitted infection such as gonorrhoea or chlamydia is the most common cause of EO in younger men with the age of <35 years old [1]. On the other hand, non sexually transmitted infection such as urinary tract infection is the main cause of EO in older men aged 35 years old and above.
It can usually be treated by antibiotics with full recovery in most cases without any complications [2].
(i) Epididymo-orchitis can be acquired sexually or non-sexually; provide a detailed
explanation of this statement.
Epididymo-orchitis (EO) has both types of main causes, namely sexual causes and non-sexual causes.
Sexual causes include sexually-transmitted infections, with chlamydial and gonorrhoeal infections being the most common ones [2]. This is the most usual cause of EO in younger men although this can also be the cause of EO in any men who are sexually active. In most cases of EO caused by sexually-transmitted infections, the urethra is commonly affected and resulting in urethritis, followed by the infections occasionally spreading down the vas deferens and further more to the testis and epididymis, causing EO.
Non-sexual causes include urinary tract infections, mumps virus, medication, operations that involve the urethra or prostate, scrotum injury and other viral infections, with urinary tract infection being the most common cause among thsee [2]. Urinary tract infections are commonly caused by gram-negative enteric bacteria like E. coli which may occasionally spread to the testis and epididymis via the vas deferens [2,3]. This affects all men at any age and is the most usual cause of EO in older men with the age of 35 years and above. The reason behind this is that urine flow is usually being partially blocked with increasing age as a result of enlarged prostate or urethra narrowing, leading to higher risk of developing urinary tract infection and hence EO as complication.
Mumps virus as well as other viruses causing viral infections may be able to reach the testes through the bloodstream occasionally, and hence, resulting in epididymo-orchitis (EO) [2]. Medication such as amiodarone may also have the side effect of causing EO which usually occurs with the dose of more than 200mg. Operation which involves the prostate or urethra may introduce bacteria into those sites from which the bacteria can spread to the testes and causing EO, although this cause is rare nowadays thanks to better surgical techniques.
(ii) a list of the likely causative pathogens of EO (sexually and non-sexually
acquired) and complete the following table [3,4,5,6,7,8,9,10]:
Name of likely pathogen
Description of the pathogen
is it gram negative or gram positive bacteria?
is it aerobic or anaerobic?
is it a fungus or virus?
Which antibiotic(s) is this pathogen usually susceptible to?
Sexually acquired:
Chlamydia trachomatis
It is a gram negative, aerobic, intracellular bacteria.
Cefriaxone
Azithromycin
Doxycycline
Neisseria gonorrhoeae
It is a gram negative, aerobic bacteria.
Cefriaxone
Azithromycin
Doxycycline
NON-sexually acquired:
Escherichia coli
It is a gram negative, facultative anaerobic bacteria.
Aztreonam
Imipenem
Mump virus
It is a virus.
-
Haemophilus influenzae
It is a gram negative, facultative anaerobic bacteria.
Chloramphenicol
Doxycycline
Ceftriaxone
Moxifloxacin
Neisseria meningitidis
It is a gram negative, aerobic bacteria.
Ciprofloxacin
Ceftriaxone
Penicillin
Rifampin
Mycobacterium tuberculosis
It is a gram positive (phylogenetically), stains acid fast, aerobic bacteria.
Isoniazid
Rifampin
Pyrazinamide
A list of the likely signs and symptoms of Epididymo-orchitis
The signs of epididymo-orchitis (EO) are [11]:
Fever.
Scrotal swelling.
Penile discharge.
Groin pain.
Bloody semen.
Pain during ejaculation or intercourse.
Tenderness and swelling of the affected side's groin area.
Tenderness and swelling of the testicle associated with heavy feeling inside it.
Pain in the testicle exacerbated by straining or bowel movement.
Pain associated with urination.
The symptoms of EO which may be seen upon physical examination are [11]:
Enlarged and tender testicle on the side affected.
Enlarged or tender prostate gland.
Groin area of the affected side having enlarged and tender lymph nodes.
What other diagnostic tests would you expect to be have been done or ordered for Mr Thompson to aid in the diagnosis of EO?
Other diagnostic tests which I expect to be have been done or ordered are [11]:
Testicular ultrasound
Urinalysis
Urine culture (clean catch) which more than one sample might be required, inclusive of initial stream, midstream as well as following prostate massage.
Screening test for gonorrhea and chlamydia via urethral smear
Susceptibility test of the causative agents (in the case of bacterial cause).
(i) Which intravenous (IV) antibiotics would you recommend for empirical
treatment of Mr Thompson's Epididymo-orchitis and state the reason(s) for your choice?
I would recommend the following IV antibiotics for empirical treatment [12]:
Gentamicin 4 to 6mg/kg IV, for 1 dose, maximum of 1 to 2 further doses' dosing interval is then determined based on renal function.
PLUS
Amoxycillin / ampicillin 2g IV, 6 hourly.
The reason of choosing these antibiotics is that Mr Thompson is most likely to get Epididymo-orchitis (EO) from a non-sexual cause and his EO is severe, hence the recommended choices of antibiotics are short-term gentamicin and amoxycillin / ampicillin according to the eTG website. However, as ampicillin can interact with warfarin, potentially increasing the risk of bleeding, amoxycillin which might only slightly increase the risk of bleeding may be used in place of it with monitoring [12, 13]. Besides this, he is also not having hypersensitivity to penicillin and hence, antibiotics belonging to this drug class can be used.
(ii) Which test results should be followed up in order to "direct" antimicrobial
therapy?
The test results that should be followed up are [3,12]:
Urine culture
Screening test for gonorrhea and chlamydia
Susceptibility test
Testicular ultrasound of resolution of epididymo-orchitis is slow.
(iii) If Mr Thompson's clinical condition improved and the doctors wanted to change his IV antibiotics to an oral antibiotic, which one do you think would be appropriate? List the counseling points you would provide for this antibiotic.
I think cephalexin 500mg orally, 12 hoursly for the duration of 14 days would be appropriate because the first-line antibiotic trimethoprim is not effective [12].
The counseling points which I will provide are [14,15]:
Try to take cephalexin without food, around 1 hour prior to meal or 2 hours after a meal.
Take cephalexin together with a full glass of water.
It is quite common to experience nausea, vomiting or diarrhoea during treatment with cephalexin.
Be sure to take the full course of cephalexin until finish even when feeling better.
If still experience diarrhoea (watery and bloody stools) 2 months or more after the last dose of cephalexin, contact doctor in the shortest time possible.
(iv) What would be the total duration of treatment with antibiotics for Mr Thompson's EO?
Mr Thompson's EO treatment with antibiotic will last for the total duration of 17 days [12].
(v) Besides antimicrobial therapy what other therapy (pharmacological and non- pharmacological) should be part of Mr Thompson's treatment plan?
- Non-pharmacological therapy:
Allow Mr Thompson to rest on bed with his scrotum elevated.
Apply ice packs to the affected scrotum area.
What process would you undertake to confirm that Mr Thompson's usual medications are accurately prescribed on the admission drug chart [16]?
I will carry out a Medicine Management Review.
I will make confirmation with Mr Thompson regarding to his medication history which is obtained during his admission to the hospital, as well as with his community health care provider where appropriate.
If possible, I will try to confirm each and every of Mr Thompson's medication history with a second source following the following hierarchy of:
Carer > Family > nursing home > own medications > community pharmacist > general practitioner (GP).
Beside this, I will fax the admission drug chart for the purpose of confirmation to Mr Thompson's GP or community pharmacist if necessary.
Moreover, I will record down what the doctor planned for every listed medications.
I will also make sure that all the listed medications matches the medications that are prescribed on the medication chart and at the same time, taking the doctor's plan into account.
Further information
Name of drug
Explanation of why you require this information
For example:
INR test result
Warfarin
To check if INR is within therapeutic range; monitor for warfarin toxicity; to determine warfarin dose
Blood pressure [17]
Ramipril
To ensure that blood pressure is well-controlled within the normal range.
Serum digoxin level, signs and symptoms of digoxin toxicity[17]
Digoxin
To ensure that serum digoxin level is within therapeutic range and to avoid digoxin toxicity.
Heart rate [17]
Amiodarone
To monitor for any new signs of arrhythmia.
Urine culture / Susceptibility test result [12]
Gentamicin
Amoxycillin / ampicillin
Cephalexin
To ensure that the causative agents for the epididymo-orchitis is susceptible to these antibiotics and that they are suitable antibiotic choices.
Body weight, serum electrolytes [12]
Frusemide
To check whether frusemide dose titration is required or not.
There are numerous potential drug related problems in this case (>10). List of three (3) potential drug-related problems associated with Mr Thompson's medication you, as the pharmacist, would anticipate and outline how you would manage them and/or monitor for them [13].
Digoxin and amiodarone:
Problem: May lead to digoxin toxicity (such as nausea, cardiac
arrhythmias and vomiting).
Management: Reduce digoxin dose by around 50% and monitor the serum digoxin level as well as look out for signs and symptoms of digoxin toxicity. If discontinuation of digoxin is possible then discontinue digoxin.
Amiodarone and warfarin:
Problem: May increase the risk of serious or even fatal bleeding.
Management: Reduce the dose of warfarin by around 1/3 or 1/2 and monitor the prothrombin time as well as INR value
Amiodarone and ibuprofen:
Problem: May increase ibuprofen's plasma level.
Management: Caution with the concurrent use of amiodarone and ibuprofen. Monitor frequently for NSAID-related adverse effects and consider adjusting the dose of ibuprofen.
References:
Sexual Health [homepage on the Internet]. Kingston upon Thames, Surrey: Sexual Health; c2012 [cited 2012 Sept 21]. Epididymo-orchitis; [about 4 screens]. Available from: http://www.sexualhealthkingston.co.uk/sexual-health-information/stis/men/epididymo-orchitis
Health Information and Advice [homepage on the Internet]. England: Egton Medical Information Systems Limited; c2012 [cited 2012 Sept 21]. Epididymo-orchitis; [about 9 screens]. Available from: http://www.patient.co.uk/health/Epididymo-orchitis.htm
NZSHS [homepage on the Internet]. New Zealand: The New Zealand Sexual Health Society Incorporated; c2012 [cited 2012 Sept 21]. Epididymo-orchitis_2009; [about 3 pages]. Available from: http://www.nzshs.org/treatment_guidelines/Epididyomo-orchitis_2009.pdf
European Bioinformatics Institute [homepage on the Internet]. Cambridge, UK; c2012 [cited 2012 Sept 21]. Chlamydia trachomatis; [about 2 screens]. Available from: http://www.ebi.ac.uk/2can/genomes/bacteria/Chlamydia_trachomatis.html
The Ohio State University at Mansfield [homepage on the Internet]. Mansfield, OHIO: The Ohio State University at Mansfield; c2012 [cited 2012 Sept 20]. Bacteria Binomials; [about 32 screens]. Available from: http://www.mansfield.ohio-state.edu/~sabedon/biol4045.htm
NHS Clinical Knowledge Summaries [homepage on the Internet]. High Holborn, London: National Institute for Health and Clinical Excellence; c2011 [cited 2012 Sept 20]. CKS Clinical Knowledge Summaries; [about 3 screens]. Available from: http://www.cks.nhs.uk/scrotal_swellings/background_information/causes/epididymo_orchitis
Chamberland S, L'Eeuyer J, Lessard C, Bernier M, Provencher P, Bergeron M. G, The Canadian Study Group. Antibiotic Susceptibility Profiles of 941 Gram-Negative Bacteria Isolated from Septicemic Patients throughout Canada. Clin Infect Dis [serial on the Internet]. 1992 Oct; [cited 2012 September 21]; 15(4): [about 15 pages]. Available from: http://www.jstor.org.ezproxy.lib.monash.edu.au/stable/pdfplus/4456676.pdf?acceptTC=true
Sill M. L, Tsang R. S. W. Antibiotic Susceptibility of Invasive Haemophilus influenzae Strains in Canada. Antimicrob Agents Chemother [serial on the Internet]. 2008 April; [cited 2012 September 21]; 52(4): [about 7 screens]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292521/
Cochrane Summaries [homepage on the Internet]. Oxford, UK: The Cochrane Collaboration; c2012 [cited 2012 Sept 21]. Antibiotics for preventing meningococcal infections; [about 2 screens]. Available from: http://summaries.cochrane.org/CD004785/antibiotics-for-preventing-meningococcal-infections
DUJS Online [homepage on the Internet]. NH: Dartmouth College Hanover; c2008 [cited 2012 Sept 21]. Antibiotic Resistance of Tuberculosis; [about 6 screens]. Available from: http://dujs.dartmouth.edu/winter-2009/new-trickes-for-an-old-foe-the-threat-of-antibiotic-resistant-tuberculosis
PubMed Health [homepage on the Internet]. Bethesda, MD: National Center for Biotechnology Information; c2012 [cited 2012 Sept 21]. Orchitis; [about 5 screens]. Available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002259/
eTG complete [homepage on the Internet]. Victoria, Australia: Therapeutic Guidelines Limited; c2012 [updated 2012 Jul; cited 2012 Sept 20]. Available from: http://etg.tg.com.au.ezproxy.lib.monash.edu.au/conc/tgc.htm?id=27b1fc15b4331af2841f02ef96ddc67b
Micromedex® 2.0 [homepage on the Internet]. U.S: Thomson Reuters; c1974-2012 [updated n.d.; cited 2012 Sept 21]. Available from: http://www.thomsonhc.com.ezproxy.lib.monash.edu.au/micromedex2/librarian/ND_T/evidencexpert/ND_PR/evidencexpert/CS/5A8A78/ND_AppProduct/evidencexpert/DUPLICATIONSHIELDSYNC/75C929/ND_PG/evidencexpert/ND_B/evidencexpert/ND_P/evidencexpert/PFActionId/pf.HomePage
University of Washington [homepage on the Internet]. Seattle, Washington: University of Washington; c2012 [cited 2012 Sept 21]. Most Commonly Prescribed Drugs Anti-Infectives [about 61 pages]. Available from: http://courses.washington.edu/pharm504/ABXPresentation.pdf
DailyMed [homepage on the Internet]. Bethesda, MD: U.S. National Library of Medicine; c2012 [cited 2012 Sept 21]. Keflex (Cephalexin) capsule [Advancis Pharmaceutical Corporation]; [about 14 screens]. Available from: http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=6490#nlm34076-0
Department of Health [homepage on the Internet]. Melbourne, Victoria: Department of Health; c2012 [cited 2012 Sept 21]. Medication Reconciliation - On Admission; [about 8 pages]. Available from: http://www.health.vic.gov.au/sssl/downloads/qld_tool.pdf
Medsafe Home Page [homepage on the Internet]. Wellington: New Zealand Medicines and Medical Devices Safety Authority; c2012 [cited 2012 Sept 21]. Keep an Eye on Amiodarone Patients; [about 4 screens]. Available from: http://www.medsafe.govt.nz/profs/puarticles/amiod.htm#Amiodarone
Case Study 3:
A brief description of Tuberculosis (TB) and how it is transmitted.
Tuberculosis (TB) is an infectious bacterial disease which most frequently affects the lungs [1]. However it is also able to affect other body parts like the spine, kidney and brain [2]. TB can be fatal if it is not being treated properly. Patients with active TB can be treated by antibiotics treatment with the duration of six months while patients with latent TB can also be treated so that active TB will not develop [1,3]. Those patients with latent TB have a lifetime risk of 10% to develop active TB disease and this risk is much higher for those with compromised immune systems such as diabetic patients or HIV patients [1].
TB is transmitted from human to human via the air [3]. The TB bacteria is propelled into the air whenever a person infected with active TB of the lungs or throat sneezes, speaks, coughs, spits or sings [1,3]. Only very few number of the TB bacteria is required to be inhaled by another person for that person to be infected with it [1]. However, a person who is infected with TB bacteria but not yet manifest the disease (latent TB) will not transmit the TB bacteria to other person.
The likely pathogen(s).
The likely pathogen causing tuberculosis is the bacteria Mycobacterium tuberculosis [1].
A list of those persons at the greatest risk for contracting TB; in particular in Mrs Rawat's case [1,2].
Young adults who are in their years of peak productivity, in this case, Mrs Rawat's only son - Neel.
Workers in facilities or institutions where they are working alongside with other people who have high risk of TB infection such as the nursing homes, correctional facilities and hospitals. In this case, Mrs Rawat herself and also her co-workers in the local hospital where she is working part-time.
Patients who are immuno-compromised, especially HIV patients. In this case, certain patients (those who have weakened immune system) in the local hospital where Mrs Rawat is working part-time.
Tobacco users.
Persons who are homeless.
Injection drug users.
The signs and symptoms of pulmonary TB [2].
Chest pain
Persistent bad cough that lasts more than 3 weeks, with blood or sputum.
Weight loss.
Chills.
Fatigue or weakness.
Loss of appetite.
Sweating at night.
The diagnostic tests (microbiological, radiological etc) and clinical information used to confirm the diagnosis of TB [2].
Tuberculin skin test (also known as the Mantoux tuberculin skin test):
It is carried out by injecting a small amount of tuberculin into the lower part of the arm's skin. After around 48 to 72 hours, qualified health care worker will look for area that is raised, hard or swollen. If such area is present, its size will be measured by using a ruler. The redness alone is not considered as part of the reaction. This test's result is dependent on the size of such area mentioned above as well as the risk of the person being tested to be infected with tuberculosis (TB) bacteria and if the person being tested is infected, the progression towards TB disease. A positive test result will mean that the person being tested is infected with TB bacteria. However, whether the infection is latent TB or active TB cannot be determine by this test. In addition, this test may give a false positive test result for some people who have received the bacille Calmette-Guérin (BCG) vaccine for TB disease before, hence additional tests may be needed in cases of positive test result for this test.
TB blood test (also known as the interferon-gamma release assays (IGRAs)):
This test mainly measure the reactivity of the immune system of the person being tested towards the causative bacteria for TB by doing blood testing in the laboratory. Currently there are two IGRAs that have been approved by the U.S. Food and Drug Administration (FDA) which are QuantiFERON®-TB Gold In-Tube test (QFT-GIT) and T-SPOT®.TB test (T-Spot). A positive test result will indicate that the person being tested is infected with TB bacteria. This test however, will not be able to determine the TB infection is active TB or latent TB. For people who have received the BCG vaccine for TB disease and those who can't find appropriate time for second appointment of tuberculin skin test, this test is the preferred test method.
Medical history:
Patient's TB exposure, disease, or infection history is obtained. Demographic factors such as age, origin country and occupation which may increase the exposure risk of the patient to TB are also considered. In addition, medical conditions of the patient which may also increase the risk of the development of latent TB infection to active TB disease are also determined.
Physical examination:
This might yield important information regarding the patient's overall condition as well as other factors which can change the TB treatment plan. For example, HIV infection status.
Chest radiograph:
This is for the detection of chest abnormalities. In cases of TB infection, lungs lesion may appears anywhere in different shape, size, density and cavitation. This is insufficient to definitively diagnose TB but can be used in a person who has had positive test result in the tuberculin skin test or TB blood test in order to rule out the possibility of that person having pulmonary TB.
Diagnostic Microbiology:
The presence of TB disease can be indicated by acid-fast-bacilli's (AFB) presence on a sputum smear or any other specimen. Confirmation of the TB diagnosis cannot be made based on acid-fast microscopy alone although it is quick and easy due to the fact that not all acid-fast-bacilli are M. tuberculosis. For this reason, culture of all the initial samples, regardless of their AFB smear results is needed to confirm the TB diagnosis. A positive M. tuberculosis culture confirms the TB disease diagnosis.
Drug resistance:
All the initial M. tuberculosis isolated from every patients is required to undergo drug resistant test as early as possible so as to ensure the most effective treatment for the patients. For those TB patients who do not shows sufficient response to treatment or those who still have positive culture results following treatment that lasted for three months or more, this test should be repeated.
Once the diagnosis of TB has been confirmed Mrs Rawat will be commenced on an anti-TB drug regimen. In your presentation address the following:
(i) What is the treating physician obligated to do by law?
The treating physician is obligated by law to report both clinically suspected and also confirmed tuberculosis cases to the designated department within the timeframe of 24 hours [2].
Depending on states, the treating physician might be also obligated to report non-adherent patients with TB, where non-adherent might include treatment cessation, leaving the hospital against medical advice or failure in following to treatment plan as well as other preventive measures to avoid TB transmission [2].
(ii) List the drugs (and the daily dose of each) that you think Mrs Rawat will be commenced on for standard short-course therapy of TB. Using the table below, for each of the four drugs used in the standard short-course therapy of TB outline the following:
Name of the drug & dosage [4]
List the common side effects [5,6]
Main counseling points you would provide to the patient about this drug- in point form [7,8,9].
Isoniazid 300mg orally, daily for 6 months.
Peripheral neuropathy, GI upset, metabolic changes, blood dyscrasias, hepatic changes, pyridoxine deficiency.
Be sure to take all the medication till finish.
Avoid consumption of alcohol to prevent further liver damage.
Take on an empty stomach, at least half an hour before meals and at bedtime.
Rifampicin 600mg orally, daily for 6 months.
Itching, headache, confusion, diarrhoea, vision changes, dizziness, flushing, drowsiness, behaviour changes, stomach cramps, urine, sweat, sputum, and tears red discolouration.
Be sure to take all the medication till finish.
If skin or eyes develop yellow discolouration or if urine discolours to cola colour, contact doctor as soon as possible.
May cause sweat, urine and tears to have orange discolouration which is not harmful.
Avoid wearing contact lenses because rifampicin can stain them permanently.
Avoid consumption of alcohol to prevent further liver damage.
Take on an empty stomach, at least half an hour before meals and at bedtime.
Ethambutol 750mg orally, daily for 2 months.
Appetite loss, stomach upset, vomiting, hands or feet numbness and tingling due to peripheral neuritis.
Be sure to take all the medication till finish.
Avoid consumption of alcohol to prevent further liver damage.
Avoid from taking antacids together with ethambutol, space more than 2 hours apart.
Pyrazinamide 1500mg orally, daily for 2 months.
Stomach upset, fatigue.
Be sure to take all the medication till finish.
Avoid consumption of alcohol to prevent further liver damage.
(iii) Which of the four anti-TB drugs in the standard short-course therapy causes peripheral neuritis? What additional supplement is prescribed concurrently to prevent/ minimise this adverse effect from occurring?
Isoniazid, ethambutol, rifampicin and pyrazinamide can cause peripheral neuritis [7, 10]. Pyridoxine (vitamin B6) can be prescribed concurrently to prevent/ minimise peripheral neuritis from occurring [11].
(iv) Prior to the first dose of the previously mentioned anti-TB drugs, Mrs Rawat will need to undergo a series of pre-therapy tests and baseline measurements; list these tests and briefly explain the reason for each.
Name of pre-therapy test [4]
Name of drug (where relevant)
Explanation of why this information/ test is required
Weight
Rifampicin, ethambitol, pyrazinamide [4]
To determine the appropriate antibiotics dosage to be use [4].
Liver function tests
Isoniazid + rifampicin, pyrazinamide [12]
To monitor for hepatotoxicity potentially caused by the TB drugs [12].
Renal function tests
Ethambutol [4]
To monitor renal clearance and prevent accumulation of ethambutol in the body if renal clearance declines [4].
Visual acuity
Ethambutol [4]
To monitor for signs of ocular toxicity [4].
Colour vision testing
Ethambutol [4]
To monitor for signs of ocular toxicity [4].
Full blood count
To monitor for anaemia, neutropenia and lymphopenia [13].
HIV testing after appropriate counseling
Rifampicin [4]
To determine the risk of rapid progression of TB disease / reinfection and also potential significant drug interactions with antiretroviral drugs in case of HIV-positive [4, 14].
Screening for chronic viral hepatitis (B and C)
Isoniazid + rifampicin, pyrazinamide [12]
To determine the risk of hepatotoxicity potentially caused by the TB drugs [12].
(v) Use the Cockcroft-Gault formula to calculate Mrs Rawat's Creatinine Clearance and state the dose(s) of the medication(s) you would give Mrs Rawat.
Ideal body weight = 57.2kg
Age = 60kg
Height = 165cm
Serum creatinine = 260 micromol / L
Creatinine clearance = 0.85
= 18.38 mL / min
- Ethambutol's dose needs to be changed to 600mg orally, daily for 2 months [4].
(vi)
Names of the interacting drugs [15]
Mechanism of the drug interaction & clinical effect [15]
Clinical management [15]
Rifampicin - Cardizem CD
Rifampicin may induce the metabolism of cardizem CD, causing loss of the effect of calcium channel blocker and hence, might result in clinical signs and symptoms of angina or hypertension.
Increases the dose of cardizem CD.
Rifampicin - Losec
Rifampicin might induce the CYP2C19 and CYP3A4-mediated metabolism of Losec, resulting in reduced Losec plasma concentrations.
Avoid from using Losec together with rifampicin.
(vii) If Mrs Rawat was 26 years old and on no regular medications what other factors do you need to consider when deciding on anti-TB therapy?
The other factors which I need to consider are whether [4]:
Are the causative organisms for the disease susceptible to rifampicin, isoniazid and pyrazinamide?
Is all drugs included in the regimen able to be tolerated by Mrs Rawat and that she is able to fully adhere to the treatment?
Is there evidence showing disseminated or central nervous system TB?
Is there presence of extensive cavitation on the initial chest X-ray?
Is there satisfactory response to the treatment?
Is Mrs Rawat is pregnant and/or breastfeeding?
*Why is it important to follow up these test result?
It is important to follow up these test result because of drug resistant concern. It is important at all time to use multidrug regimens to cover the likelihood of initial drug resistance as well as preventing resistant organisms from emerging [4].
*On obtaining these results, which of the four anti-TB therapy drugs could possibly
be ceased and under which circumstances?
Ethambutol can be possibly ceased if the lab test result showed an TB isolate which is susceptible to isoniazid and rifampicin [16].
As a pharmacist what could you do to encourage or aid Mrs Rawat's compliance with all her medications? How could you monitor patient compliance?
I will explain to Mrs Rawat about the purpose of each and every of her medications, as well as their name, dosing frequency, dosage, common side effects and also their timing of administration [17]. After that, I will have Mrs Rawat repeating back to me the information which I have told her and also ask her questions regarding what she is not able to understand. In addition, I will try to arrange follow-up with her and ask her about how is her medicine-taking going on. I will also assess her probability of non-adherence through the use of validated tools like the Morisky medication adherence questionnaire if the expected clinical effects of her medications do not seem to be there. Following this, I will address every of her concerns or problems which result in non-adherence and at the same time, normalize and empathize with her in order to encourage her responses. I will also provide her dose administration aids as appropriate so that it will be much easier for her to store and knowing when to take her medications as well as their dosage. I can also involve her family members such as her husband or her son in improving her medications adherence by reminding her to take her medications at the dosing time. Lastly, I will emphasize on the effects if she fails to take her medications as indicated, especially on health consequences and the ultimate impacts on her families.
I could monitor her compliance by questioning her regarding pill taking or through other methods for example, pill counting and urine drug testing if appropriate and available (urine should be discoloured to orange colour for the minimum duration of 6 hours since last rifampicin dose and may even present over 12 hours) [4]. Other than these, the Morisky medication adherence questionnaire can be used for this purpose [17].
Briefly list in point form the ongoing monitoring should be undertaken whilst Mrs Rawat is on anti-TB therapy drugs? (specific to TB drugs only, for the purpose of this case) [4].
Adherence to the anti-TB therapy drugs.
Sputum culture (if sputum is still being produced).
Visual acuity and colour vision monitoring as well as monitoring of visual symptoms (while she is still taking ethambutol).
Liver function tests.
Her body weight.
Renal function tests.
References:
World Health Organization [homepage on the Internet]. Geneva, Switzerland: World Health Organization; c2012 [cited 2012 Sept 22]. Tuberculosis; [about 3 screens]. Available from: http://www.who.int/topics/tuberculosis/en/
Centers for Disease Control and Prevention [homepage on the Internet]. Atlanta, GA: Centers for Disease Control and Prevention; c2012 [updated n.d.; cited 2012 Sept 22]. Available from: http://www.cdc.gov/
MedlinePlus [homepage on the Internet]. Bethesda, MD: U.S. National Library of Medicine; c2012 [cited 2012 Sept 22]. Tuberculosis: MedlinePlus; [about 6 screens]. Available from: http://www.nlm.nih.gov/medlineplus/tuberculosis.html
eTG complete [homepage on the Internet]. Victoria, Australia: Therapeutic Guidelines Limited; c2012 [updated 2012 Jul; cited 2012 Sept 20]. Available from: http://etg.tg.com.au.ezproxy.lib.monash.edu.au/conc/tgc.htm?id=27b1fc15b4331af2841f02ef96ddc67b
MIMS Online [homepage on the Internet]. London, England: UBM Medica Ltd; c2012 [updated Sept 2012; cited 2012 Sept 22]. Available from: https://www-mimsonline-com-au.ezproxy.lib.monash.edu.au/Search/Search.aspx
MedlinePlus [homepage on the Internet]. Bethesda, MD: U.S. National Library of Medicine; c2012 [cited 2012 Sept 22]. Rifampin: MedlinePlus Drug Information; [about 6 screens]. Available from: http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682403.html
HRSA HIV/AIDS Programs [homepage on the Internet]. U.S: U.S. Department of Health and Human Services; c2012 [cited 2012 Sept 22]. Mycobacterium tuberculosis; [about 19 screens]. Available from: http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/cg-623_mycobacterium_tb.html
Sansom L. N, editor. Australian pharmaceutical formulary and handbook. 21st ed. Canberra: Pharmaceutical Society of Australia; 2009.
BC Centre for Disease Control [homepage on the Internet]. British Columbia, Canada: BC Centre for Disease Contorl; c2012 [cited 2012 Sept 22]. Ethambutol [about 1 page]. Available from: http://www.bccdc.ca/NR/rdonlyres/F59D94C9-BDFC-4E2D-A8DB-C915F1FE8660/0/EthambutolCounsellingSheet_Field.pdf
World Health Organization [homepage on the Internet]. Geneva, Switzerland: World Health Organization; c2012 [cited 2012 Sept 22]. WHO Public Assessment Report; [about 2 pages]. Available from: http://apps.who.int/prequal/WHOPAR/WHOPARPRODUCTS/TB180part1v1.pdf
University of Pennsylvania Health System [homepage on the Internet]. Philadelphia, PA: Penn Medicine; c2012 [cited 2012 Sept 22]. Guidelines for the Management of Adverse Drug Effects of Antimycobacterial Agents; [about 60 pages]. Available from: http://www.uphs.upenn.edu/TBPA/treatment/managingsideeffects.pdf
Thompson N. P, Caplin M. E, Hamilton M. I, Gillespie S. H, Clarke S. W, Burroughs A. K, Mclntyre N. Anti-tuberculosis medication and the liver: dangers and recommendations in management. Eur Respir J [serial on the Internet]. 1995; [cited 2012 September 22]; 8: [about 5 pages]. Available from: http://erj.ersjournals.com/content/8/8/1384.full.pdf
Jemikalajah J. D, Okogun G. A. Hematological indices in human immunodeficiency virus and pulmonary tuberculosis infections in parts of Delta State, Nigeria. Saudi Med K [serial on the Internet]. 2009; [cited 2012 September 22]; 30(2): [about 4 pages]. Available from: http://www.smj.org.sa/PDFFiles/Feb09/13Hema20080806.pdf
HIV InSite Gateway to HIV and AIDS Knowledge [homepage on the Internet]. San Francisco: University of California; c2012 [cited 2012 Sept 22]. Tuberculosis and HIV; [about 30 screens]. Available from: http://hivinsite.ucsf.edu/InSite?page=kb-05-01-06#S3X
Micromedex® 2.0 [homepage on the Internet]. U.S: Thomson Reuters; c1974-2012 [updated n.d.; cited 2012 Sept 22]. Available from: http://www.thomsonhc.com.ezproxy.lib.monash.edu.au/micromedex2/librarian/PFDefaultActionId/evidencexpert.ShowDrugInteractionsResults
Heartland National TB Center [homepage on the Internet]. San Antonio, TX: Heartland National TB Center; c2012 [cited 2012 Sept 22]. Diagnosis & Medical Management of TB Disease; [about 76 pages]. Available from: http://www.heartlandntbc.org/training/archives/tbnucama_20120718_1040.pdf
American Medical Association [homepage on the Internet]. Chicago, IL: American Medical Association; c2012 [cited 2012 Sept 22]. Tactics to improve drug compliance; [about 13 screens]. Available from: http://www.ama-assn.org/amednews/2011/10/03/prsa1003.htm
Case study 4:
What is infective endocarditis? Explain the difference between complicated and uncomplicated.
Infective endocarditis (also known as bacterial endocarditis) is an infection which affects that heart's inner lining (endocardium) or the heart valves [1]. It happens at the damaged site of endocardium or heart valves where there is platelets and fibrin depositions. When certain microorganisms (most often bacteria, but also can be fungi or other microbes sometimes) gained entry into the blood stream and colonize on the platelet and fibrin deposition site, vegetation will be formed and this can lead to infective endocarditis [1,2]. The result from this is holes or growths on the heart valves or the valve tissue will have scarring, both of which will lead to a leaky heart valve [1]. If left untreated, it may result in death [2].
Complicated infective endocarditis is when large vegetation or multiple emboli are involved [2]. If the infective endocarditis patient has experienced the symptoms of infective endocarditis for over 3 months or has experienced secondary septic events, the infective endocarditis is also complicated. Otherwise, the infective endocarditis will be uncomplicated infective endocarditis.
In Simon's case what would you expect the likely pathogens to be?
I would expect the likely pathogens to be Staph. aureus, oral streptococci and entercococci, gram-negative (enteric) rods, fungi (mainly Candida) or coagulase-negative staphylococci [2].
List the signs (that may be seen on physical examination) and symptoms of infective endocarditis.
- The signs of infective endocarditis are [2]:
Heart murmur
Petechiae
Janeway lesions (red spots that are present on the palms of hands and feet's soles)
Osler's nodes (painful red sores that present on finger tips and toes)
- The symptoms of infective endocarditis are [2, 3]:
Fever
Unusual fatigue
Night sweats
Loss of weight
Muscle aches and pains (in acute infective endocarditis)
Flu-like symptoms (in acute infective endocarditis)
Heart failure symptoms (in chronic infective endocarditis)
Joint pain (in chronic infective endocarditis)
Outline the diagnostic tests, blood tests, microbiological tests etc that would be used to confirm the diagnosis of infective endocarditis and "direct" antibiotic therapy.
Patient's clinical physical examination and also presenting complaint's history [2].
- This helps with the diagnosis and also narrow down the scope of likely causative pathogen.
Using stethoscope to listen to heart [2, 3]:
- This is to enable doctor to listen to the patient's chest for distinct sound that indicates new heart murmur or sound change in old heart murmur.
The cause of heart murmurs are the faulty heart valves' sound and
certain heart defects.
Blood cultures [2, 3]:
- Different body area's blood samples are taken to determine the presence of any pathogen in the bloodstream. This is also done to determine the
exact causative pathogen and also the pathogen's sensitivity to different
antibiotics for treatment.
Echocardiography [3]:
- This is used to observe valve structure and function, as well as heart
wall motion and also the overall heart size. This test is the most reliable
diagnosis test so far for infective endocarditis.
Chest x-ray [2]:
- This is used to look out for any evidence that indicates cardiac failure.
Urine dipstick [2]:
- This is for the detection of any haematuria & proteinuria which are the
clinical features presenting in 60% to 70% of infective endocarditis
cases.
Temperature [1, 2]:
- This is to check for the presence of fever which is one of the main
symptoms of infective endocarditis.
Serum urea & electrolytes [2]:
- This is to check for any renal impairment.
What empirical intravenous (IV) antibiotic regimen would you expect Simon to be commenced while awaiting the microbiology results? Specify the doses for each of the antibiotics.
The empirical intravenous (IV) antibiotic regimen that I expect Simon to be commenced is [4]:
Benzylpenicillin 1.8g IV, 4 hourly.
PLUS
Di/flucloxacillin 2g IV, 4 hourly.
PLUS
Gentamicin 420mg IV, for 1 dose, followed by the determination of dosing interval for either 1 or 2 additional doses according to Simon's renal function.
At this point in time, which antibiotic would you expect Simon to be prescribed? What would be the expected duration of treatment?
I would expect Simon to be prescribed di/flucloxacillin 2g IV, 4 hourly [4]. The expected treatment duration is 4 weeks although in Simon's case, the duration may be shorten to 2 weeks if there is microbiological and clinical response in the time period of 72 to 96 hours since the commencement of the antibiotic treatment.
If methicillin-resistant staphylococcus aureus was the causative pathogen in Simon's case:
(i) Which IV antibiotic would you expect to be prescribed?
I would expect the IV antibiotic, vancomycin to be prescribed [2, 4].
(ii) Is this antibiotic primarily cleared by the kidneys or the liver?
This antibiotic is primarily cleared by the kidneys [4].
(iii) At what dose (given that Simon's creatinine clearance is 116ml/min)?
1.5g every twelve hours [4].
(iv) How would this drug be administered and why?
This drug would be administered intravenously because it has a very low oral bioavailability and hence, it must be given intravenously for the treatment of systemic infections such as infective endocarditis in order for it to be effective [5, 6].
(v) What therapeutic drug monitoring is involved when using this antibiotic? When should the first trough level be taken? What is the target trough level?
The therapeutic drug monitoring that is involved is vancomycin trough concentrations measurement [4]. The first trough level should be taken before the fourth or the fifth vancomycin dose and the target trough level is 15 3mg/L.
(vi) If the result of the trough level was 27mg/L, how would you interpret this result? Would you recommend a dosage adjustment? If yes, what would it be ?
This trough level result is higher than the recommended target trough concentrations for Simon [4]. I would recommend a dosage adjustment and adjust the vancomycin dose to:
= 0.83g
= ~0.8g
