Patient Case/ Antibiotic Stewardship Presentation

Shashank Sridhara

University of Florida

College of Pharmacy

Doctor of Pharmacy Candidate 2014

Our Patient 33 y.o Caucasian FemalePMH- Type 2 Diabetes* & HypertensionS Hx- Stopped smoking a few months ago and no EtOH useF Hx- NoncontributoryCC- Pulmonary Sx, Productive cough, SOB, fever and subjective

chills.2-3 weeks before being admitted Pt’s mother had a Sinus infection or a

URTI.2 weeks prior Pt was in ED and was treated for Pneumonia.Patient received Amoxicillin as an inpatient and completed a course of

Ciprofloxacin along with steroids as an outpatient. Pt remains symptomatic and is now admitted

Our Patient Physical examination

VITAL SIGNS: She did have a temperature of 100.1, currently afebrile.

She is 93% on room air.HEENT: Oral cavity clear.CHEST: Clear to auscultation bilaterally.CARDIOVASCULAR: S1 and S2 heard. Regular rate and rhythm.ABDOMEN: Soft, nontender.EXTREMITIES: No edema.MUSCULOSKELETAL: No joint swelling.SKIN: No obvious rashes.

Our Patient Lab Data 1Her D-dimer (to rule out thrombosis) was negative at 0.47. Na is 132 (135 - 147 mEq/L )K is 4.1 (3.5 - 5.2 mEq/L )BUN of 10 ( 7 - 20 mg/dl) Creatinine- 0.6 (0.5 - 1.4 mg/dl) Lactic acid is 2.8 (0.7 - 2.1 meq/L)White count is 9 (4.5-10 x10^3) Hematocrit is 42.9 (41-50%)Platelets of 312,000. (100,000 to 450,000) Her chest x-ray shows a worsening right-sided and also now left-sided

infiltrate. A CT scan has been orderedBlood cultures are pending

Patient Meds Pre Admission

•Glipizide 5 mg BID•Metoprolol 100mg BID•Lisinopril/Hctz 40/12.5 BID•Clonidine 0.1mg BID•Metformin 500mg BID•Ibuprofen 800mg PRN/TID

Potential Interactions with Abx & Home medsRan an interaction check with Home meds & Possible Tx

options (Levaquin, Avelox, Cipro, Amoxicillin and Azithromycin)

Many PD and PK interactionsMost of the interactions were minor and none of them

were major or contraindicated.Increased effects of metformin and glipizide were the

most concerning of the minor interactions.Azithromycin and moxifloxacin both increase the QTc

interval. Significant - Monitor Closely.

CAP- community acquired pneumoniaCommon Typical Pathogens

S.pneumoniaeH.influenzaei ViralOral anaerobes (Aspiration)

CAP Treatment Options

Complicated (Atypical) PneumoniaAtypical pneumonia aka walking pneumoniaNot caused by traditional pathogensClinical presentation contrasts typical These atypical organisms include special bacteria, viruses,

fungi, and protozoaUsually will not respond to Beta Lactams and

Sulfonamide class of Abx

Complicated (Atypical) Pneumonia Signs/SxNo signs and symptoms of lobar consolidation,[ meaning that the

infection is restricted to small areas, rather than involving a whole lobe. As the disease progresses, however, the look can tend to lobar pneumonia (noted in our patient)

Absence of leukocytosis (noted in our patient) Moderate amount of sputum, or no sputum at all (i.e. non-productive).Lack of alveolar exudate.Despite general Sx and problems with the URT (such as high fever,

headache, a dry irritating cough followed later by a productive cough with radiographs showing consolidation), there are in general few physical signs. The patient looks better than the symptoms suggest.

Complicated Pneumonia PathogensMost common causative organisms are

(often intracellular living) bacteria.Chlamydophilia PnemoniaeLegionella PneumphilaMycoplasma PneumoniaeViral causesRespiratory Synctial Virus(RSV), Influenza A and B

DiagnosisChest X-rays are gold standard for diagnosis.They show a pulmonary infection before physical signs of

atypical pneumonia are observable at all.Infiltration commonly occurs near the where the bronchus

begins and tends to be more bilateral .The process most often involves the lower lobe, but may affect any lobe or combination of lobes.

Chest X-Rays of Atypical vs Typical

Strep (typical) is more unilateralAtypical is more bilateral

SPECTRUM OF ACTIVITY

Assessment and Plan 11. Complicated pneumonia potentially atypical. We will admit for BrevardPulmonary consultation. We will check blood cultures and other

cultures. Zosyn and Azithromycin initiated.Rule out for influenza with nasal swab.Check a CT scan just to rule out any more complicated infection.

2. Diabetes.

Continue her on sliding scale insulin and carb-controlleddiet.

3. Hypertension.

Continue on her home medications and follow her course expectantly.

Global Rph Empiric Tx Abx sitehttp://www.globalrph.com/antibiotic.htm

Lab data 2White count is 9.79Platelets 275,000 Neutrophils 64.1.Blood cultures are negative so far. Her chest x-ray does show pneumonia of the right lung, which

apparently has worsened from previous x-ray. She did have a CT chest, which showed right upper and

middle lobe pneumonia 2 days ago. Her last x-ray was 13 days ago at that point, she had right lower lobe infiltrate and the current CT chest, actually showing right upper and middle lobe infiltrates.

Assessment and plan 2 This is a very young woman who has now presented with pneumonia. Concerned about an immunocompromising condition given her age and the fact that she has

presented with pneumonia. We will get immunoglobulin levels and HIV serology to rule in a immunocompromised state. We will obtain sputum Gram stain, culture and sensitivity Legionella and pneumococcal urine antigen. Looking at the x-ray done 11 days ago, this was a right lower lobe pneumonia and now we

have a middle and upper lobe pneumonia. This speaks to a new process rather than a continuation of her prior pneumonia.

In terms of the antibiotic regimen, I think a respiratory fluoroquinolone would have been adequate, ciprofloxacin would not cover any of the respiratory flora, maybe this is why she

progressed despite the use of Cipro. Respiratory Fluoroquinolones are Moxifloxacin (Avelox) and Levofloxacin (Levaquin) However, she has been on steroids and has been on antibiotics. Steroids put a patient in a immunocompromised state . She is bringing up sputum so we can get a Gram stain, culture and sensitivity to taper the

antibiotic regimen.

Discharge summary Hospitalist team was called to admit for failed outpatient treatment for complicated

pneumonia. Blood cultures were ordered. She was ruled out for influenza with a nasal swab. CT of the chest was ordered. CT of the chest without contrast showed right upper lobe and middle lobe pneumonia. The pulmonologist who evaluated the patient. His impression was community-acquired

pneumonia with adequate outpatient therapy. Consult was placed with infectious disease due to the failed outpatient therapy. ID doctor continued to make recommendations for antibiotics throughout her stay. Her sputum grew normal respiratory flora after 48 hours. HIV antibodies came back nonreactive. She was found to be positive for IgM immunoglobulin. Consult was placed with Hematology/Oncology. He recommended conservative therapy

with the current antibiotics and close monitoring The patient was discharged in stable condition.

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