TG is
a 68 y.o. patient admitted to the hospital after complaining of a “severe cold
with difficulty breathing”. A brief note
accompanies the patient to the floor, where he is examined by the medical
intern who writes the following note:
CC: “chest pain, cough, difficulty breathing”
PMH: HTN x 5 years
Gout
Sinusitis
(last episode 3 weeks ago)
Medications
prior to admission: Enalapril 10mg po QD
Multiple
vitamin + iron 1 tab po QD
Current
medications: Ceftriaxone 1g IV q24h
Erythromycin 1g IV q6h
Enalapril 10mg po QD
APAP
325-650mg po q4-6h PRN
PE:
Gen: Ill-appearing male, somewhat
undernourished appearing
VS: BP 110/85, HR 88, RR 18, Tcurrent
39°C (102.2°F), Wt 60 kg, Ht 166 cm
HEENT: Purulent white sputum x 2 days
COR: WNL
CHEST: Rales and crackles L base
LLL dull to percussion
Å Egophony
Abd: WNL, positive bowel sounds
EXT: WNL, no complaints
NEURO: Oriented to time, person, and place
Labs:
Na 138
|
Cl 100
|
BUN 15
|
Glu 144
|
Hg 12.5
|
||
K 4.3
|
HCO3 26
|
SCr 1.1
|
Plt
125
|
WBC 12.2
|
||
HCT 34%
|
||||||
AST 18
|
ALT 24
|
Alb 3.4
|
WBC Differential:
80% Neutrophils / 18% Bands / 2%
lymphs
Pulse
ox: 97% on 2L NC
CXR: LLL infiltrates
Blood
cx: Pending
Sputum
cx: Pending
A: 68 y/o M in his current state of health until 2 days ago
when he developed fever, cough, SOB. Signs
and symptoms consistent with CAP.
P: 1) CAP: continue
current antibiotic regimen. F/U on cx
results, clinical exam. Check VS q4h.
2) HTN: continue enalapril at current dose. Monitor BP.
1.What
are the options, including pro/cons, for antibiotic therapy in TG?
As an inpatient with CAP, empiric treatment should
consist of either Macrolides + Beta Lactam or a fluoroquinolone. Both the Macrolide/Cephalosporin combination
and fluoroquinolone combinations have similar spectrums. Erythromycin tends to be more toxic than
other macrolides, with higher incidence of side effects. Ceftriaxone
is not available PO , so the patient would need
to remain as an inpatient for the entire antibiotic course. A fluoroquinolone, such as levofloxacin has
similar coverage, and is available PO , and
would be allow the patient to complete the course at home. Both macrolides and fluoroquinolones have
some cardiac risk associated with QT prolongation. Although the patient has no history of
arrhythmias, he should be monitored.
2. You
are asked whether TG’s ceftriaxone dose should be increased to 2 grams IV q24h
“because that is the dose listed in the Sanford
guide.” Using the paper written by Frei
and Burgess as support, discuss whether 2 grams IV q24h is necessary in TG.
Two grams Q24 provides only marginal increases in
killing activity for S. pneumonia in monotherapy. If the strain were identified as PCN
resistant, then 2g might be warranted. Additionally,
erythromycin covers S. pneumonia, and should provide sufficient coverage for
the organism.
3.
Medline
Search: Please bring in original
research journal articles (not abstracts) that provide the following
information. You should be able to get this
info from 1-2 papers.
What are the national resistance rates for the
following:
Penicillin-susceptible Streptococcus pneumoniae
_______________%
Penicillin-intermediate Streptococcus pneumoniae _______________%
Penicillin-resistant Streptococcus pneumoniae _______________%
Erythromycin-resistant Streptococcus pneumoniae _______________%
b-lactamase-producing Haemophilus influenzae _______________%
b-lactamase-producing Moraxella catarrhalis _______________%
4.
Medline
Search: Bring one original research
article (not abstract) supporting the clinical use of IV to PO
conversion of antibiotics in CAP.
Chart
note:
HD #2.
Pt is doing well. No change in cough, slight decrease in sputum
production. Lungs still w/ crackles at L
base.
On HD
#3 TG is feeling even better and his cough has largely subsided. His chest examination still reveals slight
crackles, but is improved over admission.
TG is afebrile with a Tmax of 99.2°F (at 9AM today).
Both blood and sputum cultures remain negative. The medical intern believes that the patient
could be discharged today. Prior to
rounds, she asks your opinion regarding antibiotic therapy. Specifically, she wonders if home IV
antibiotics would be appropriate, and if there is a single drug that might be
used?
5. Can
antibiotic therapy be discontinued with the negative blood and sputum cultures?
Blood
cultures have low sensitivity and sputum cutures are notoriously difficult to
get. Patient should complete abx course.
6. What
are the options for oral therapy?
Fluoroquinolones are an option. Erythromycin PO
is possible, as are alternative cephalosporins, but Ceftriaxone is not available
orally.
7. How
is duration of therapy decided?
Empirically, based on the latest football scores.