Yetman

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Discussion: Community-Acquired Pneumonia

                                                                                                              Case  Study

HH is a 68-yr M who has been admitted to the medical ward with community-acquired pneumonia for the past three days. His PMH is

significant for COPD, HTN, hyperlipidemia, and diabetes. He remains on empiric antibiotics, including ceftriaxone 1 g IV q day (day 3) and

azithromycin 500 mg IV q day (day 3). Since admission, his clinical status has improved, with decreased oxygen requirements. He is not tolerating a

diet at this time, complaining of nausea and vomiting. Ht: 5’8″ Wt: 89 kg Allergies: Penicillin (rash).

Diagnosis: Community-Acquired Pneumonia (CAP)

CAP is the term used to describe an acute infection of the lungs that develops outside the hospital setting by an immune-competent

individual who has not been recently hospitalized (Shoar & Musher, 2020). Adults with CAP typically present with cough, fever, sputum production or

shortness of breath, oxygen desaturation, confusion, leukocytosis or leukopenia, and pleuritic chest pain, along with the presence of an acute

infiltrate on the chest radiograph (Shoar & Musher, 2020).

Antibiotic suggested for CAP’s empiric treatment is based on agents useful against CAP’s major treatable bacterial causes. The bacterial

pathogens responsible for CAP include Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae, Haemophilus

influenzae, Staphylococcus aureus, Legionella species, and Moraxella catarrhalis (Metlay et al., 2019).

The patient is on right treatment, his clinical status has improved, with decreased oxygen requirement. Recommended treatment plan for

patients with comorbidities such as alcoholism, COPD, post influenza, asplenia, diabetes mellitus, lung/liver/renal diseases include: Combination

of a beta-lactam (ceftriaxone 1 g IV q24h or cefotaxime 1 g IV q8h or ceftaroline 600 mg IV q12h) plus azithromycin 500 mg IV q24h (Donovan, 2019).

The therapy duration is a minimum of 5 days. The patient needs to be afebrile for 48-72 hours, controlled blood pressure, adequate oral intake, and

room air oxygen saturation of greater than 90% and treatment duration can be extended if symptoms are not recovered in some cases (Donovan,

2019).

             In this case, the patient symptoms are improving, his oxygen requirement is decreased, but he is not tolerating a diet at this time,

complaining of nausea and vomiting. The patient received antibiotics for three days, so antibiotics need to be continued. With appropriate antibiotic

therapy, some improvement in the patient’s clinical course is usually seen within 48 to 72 hours (File, 2020).

                                                                                     Health Needs and Treatment Regimen

The patient is not tolerating diet and complaining of nausea and vomiting. Gastrointestinal (GI) manifestations such as nausea, vomiting,

and diarrhea are considered possibly due to adverse drug (antibiotics) effects (Lin et al., 2009). Changing the antibiotic can help patients to avoid

these side effects. Levofloxacin 750 mg IV or PO q24h is a recommended dose to treat CAP patients (Donovan, 2019).

              Levofloxacin possesses greater bioavailability and a longer serum half-life that allows for rapid step-down from intravenous administration

to oral therapy, minimizing unnecessary hospitalization, which may decrease costs and improve patient quality of life (Lynch III et al., 2006). Several

randomized clinical trials to evaluate levofloxacin to treat CAP demonstrate that levofloxacin is effective and safe for CAP treatment, displaying

relatively mild adverse effects. Levofloxacin has much to offer in terms of bacterial eradication (Lynch III et al., 2006). The other studies also

concluded that monotherapy with oral levofloxacin is as effective as treatment with Ceftriaxone plus, Azithromycin combination in patients with CAP

who required hospitalization (Izadi et al., 2019).

             Probiotics can be added to the treatment plan. Probiotics replenish the natural GI flora with nonpathogenic organisms. Few studies found

probiotics to be useful for preventing and treating antibiotic-associated diarrhea related to antibiotic treatment (Rodgers et al., 2013).

An antiemetic medication such as ondansetron can be added. It is a selective 5-HT3 serotonin-receptor antagonist and acts on central and

peripheral areas to prevent and treat nausea and vomiting (Griddine & Bush, 2020).

As the patient is diabetic, his blood sugar needs to monitor carefully because of sickness, nausea, and vomiting. Sliding scale insulin (SSI) is

recommended. Both hyperglycemia and hypoglycemia in hospitalized patients result in adverse outcomes, including increased infection rates,

longer hospital length of stay, and even death. The use of oral antidiabetic treatments during hospitalization is generally not recommended because

of their safety and efficacy and their significant risk of hypoglycemia and contraindications (Marín-Peñalver et al., 2016).

                                                             Patient Education for the management of Their Health Needs

The patient needs to be educated and encouraged to use an incentive spirometer (IS). Incentive spirometry is commonly used to break up

fluid that builds up in the lungs in people with pneumonia. IS helps to open the airways and help manage COPD symptoms (Yetman, 2020).

The patient needs to be educated about importance of the pneumococcal conjugate vaccine (PCV) and influenza vaccines.

As per International Journal of Chronic Obstructive Pulmonary Disease study, these vaccines decrease the risk of exacerbations in patients with

chronic obstructive pulmonary disease (COPD) (Ely, 2018). Patients over 65 years of age are more susceptible to community-acquired pneumonia

(CAP), and COPD patients are 20 times more prone to develop CAP (Ely, 2018). The Community-Acquired Pneumonia Immunization Trial in Adults

(CAPITA) provided evidence of the benefits of vaccinating with PCV13, which protects against 13 pneumococcal bacteria types (Ely, 2018).

              At the time of discharge, the patient needs to be educated to continue his home medications and finish the prescription of antibiotics if

prescribed, even if he starts to feel better. Taking the entire course of antibiotics is one way to prevent recurring and more severe infections and

combat antibiotic resistance (Rosenthal & Burchum, 2020).

                                                                                                                Conclusion

              Community-acquired pneumonia (CAP) is one of the most common acute infections requiring hospital admission. Age is a dominant risk

factor, with CAP’s incidence increasing markedly in patients who are over 65 years of age. Aging increases the mucosal cell surface protein

expression that bacteria can adhere to, enabling potential pathogens to avoid normal clearance mechanisms better. There is evidence that age

directly affects innate and adaptive immunity, a process called immunosenescence, which weakens lung immunity to invading microbes (Brown,

2012). Few behavior changes like quitting smoking and alcohol abuse and administering the vaccine can prevent or decrease CAP’s severity.

References

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Donovan, F. M. (2019). Community-acquired pneumonia empiric therapy: Empiric therapy regimens. https://emedicine.medscape.com/article/2011819-

overview

Ely, K. (2018). Study Shows the Efficacy of Vaccination in Patients With COPD. https://www.ajmc.com/view/study-shows-the-efficacy-of-vaccination-in-

patients-with-copd

File, T. M. (2020). Treatment of community-acquired pneumonia in adults who require hospitalization. UpToDate.

https://www.uptodate.com/contents/treatment-of-community-acquired-pneumonia-in-adults-who-require-hospitalization

Griddine, A., & Bush, J. S. (2020). Ondansetron – statpearls – ncbi bookshelfhttps://www.ncbi.nlm.nih.gov/books/NBK499839/

Izadi, M., Dadsetan, B., Najafi, Z., Jafari, S., Mazaheri, E., Dadras, O., Heidari, H., SeyedAlinaghi, S., & Voltarelli, F. (2019). Levofloxacin versus

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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.,

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Rodgers, B., Kirley, K., & Mounsey, A. (2013). Prescribing an antibiotic? pair it with probiotics. PubMed Central (PMC).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3601687

Rosenthal, L. D., & Burchum, J. R. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Saunders.

Shoar, S., & Musher, D. M. (2020). Etiology of community-acquired pneumonia in adults: A systematic review. Pneumonia12(1).

https://doi.org/10.1186/s41479-020-00074-3

Yetman, D. (2020). Incentive spirometer: What it’s for and how to use it. Healthline. https://www.healthline.com/health/incentive-spirometer