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THE CASE OF MP

THE CASE OF MP. Jara -Medrano 22.July.2010. GENERAL DATA. MP 70-year-old male Car technician. HISTORY OF PRESENT ILLNESS. 3 days PTC. PAST MEDICAL HISTORY. Known diabetic since 5 years ago Maintained on Metformin with poor compliance (+) Adverse drug reactions/rashes Amoxicillin

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THE CASE OF MP

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  1. THE CASE OF MP Jara-Medrano 22.July.2010

  2. GENERAL DATA • MP • 70-year-old male • Car technician

  3. HISTORY OF PRESENT ILLNESS • 3 days PTC

  4. PAST MEDICAL HISTORY • Known diabetic since 5 years ago • Maintained on Metformin with poor compliance • (+) Adverse drug reactions/rashes • Amoxicillin • Penicillin • Cefuroxime • (–) Hypertension • (–) Travel history for the past 6 months

  5. PHYSICAL EXAMINATION • Awake, with occasional coughs. • Vital Signs • Pulse rate: 108 beats/min • Respiratory rate: 30 breaths/min • Temperature: 38oC • Blood pressure: 100/60

  6. DIAGNOSTICS • Chest radiograph (CXR) • Right lower lobe consolidation • Minimal pleural effusion • Complete Blood Count (CBC) • Results not yet available

  7. PRIMARY IMPRESSION • Sepsis secondary to moderate-risk community acquired pneumonia (MR-CAP)

  8. DIAGNOSIS of SEPSIS • Sepsis • Systemic inflammatory response syndrome (SIRS) • AND proven or suspected microbial etiology • SIRS (2 or more of the following conditions) • Fever (oral temperature > 38oC) or hypothermia • Tachypnea (RR>24 breaths/min) • Tachycardia (HR>90 beats/min) • Leukocytosis or leukopenia

  9. DIAGNOSIS of MR-CAP • Any of the following (Philippine CPG, 2010): • Unstable vital signs • Tachypnea, tachycardia, fever/hypothermia, SBP < 90 mmHg and DBP ≤ 60mmHg. • Altered mental status of acute onset • Suspected aspiration • Decompensated co-morbid condition • Chest X-ray • Multilobar infiltrates • Pleural effusion or abscess

  10. STEP 1. THE PATIENT’S PROBLEMS • Sepsis secondary to MR-CAP. • Uncontrolled blood sugar due to poorly maintained diabetes.

  11. to stabilize the patient to treat the focus of infection to provide symptomatic relief to prevent disease progression and possible complications to address the patient’s co-morbid condition (diabetes) to prevent development of antibiotic resistance to prevent disease recurrence to observe probable occurrence of adverse drug reactions STEP 2. Therapeutic Objectives

  12. STEP 3. VERIFY P-DRUG • The 2010 CPG on CAP recommends the use of the following for MR-CAP: • IV non-antipseudomonal β-lactam (BLIC, cephalosporin or carbapenem) + an extended macrolide OR • IV non-antipseudomonal β-lactam + fluoroquinolone

  13. STEP 3. VERIFY P-DRUG • Patient’s hypersensitivity to β-lactam antibiotics, however compels us to choose monotherapy using a respiratory fluoroquinolone such as levofloxacin or moxifloxacin

  14. STEP 3. VERIFY P-DRUG Decision to chose Fluoroquinolone over an Extended Macrolide • A respiratory fluoroquinolone as monotherapy was chosen over an extended macrolide due to the severity of the patient's situation. • Presence of sepsis and concomittant uncontrolled diabetes in the patient compels us to choose a respiratory fluoroquinolone due to its stronger activity against the suspected pathogens.

  15. STEP 3. VERIFY P-DRUG Decision to choose Levofloxacin over Moxifloxacin • Though Levofloxacin and Moxifloxacin shows equal efficacy in the treatment of CAP-MR, Levofloxacin is chosen due to its more affordable price.

  16. STEP 3. VERIFY P-DRUG • Dosage • Patient should be started with 750mg IV Levothyroxine q24 hour. • Assessment should be done after 3days so that parenteral therapy can be descalated to oral therapy once patient starts improving. • Nonresponse to therapy is an indication to examine Culture-Sensitivity of the etiologic agent and proper adminstration of adequate antimicrobial

  17. STEP 4. WRITE A PRESCRIPTION/ START TREATMENT Insert CJ’s file 

  18. STEP 5. GIVE INFORMATION, INSTRUCTIONS AND WARNINGS Effects of the Drugs • Levofloxacinis for the empiric treatment to cover potential pathogens of CAP-MR to eliminate infection • Expected symptoms to disappear: fever, generalized body weakness, productive cough and difficulty breathing • Most patients with uncomplicated bacterial pneumonia will respond to treatment within 24 to 72 hours • Antibiotics taken incorrectly or not at all may worsen the disease and may contribute to the development of antibiotic resistance

  19. STEP 5. GIVE INFORMATION, INSTRUCTIONS AND WARNINGS Side Effects • Levofloxacinis generally well tolerated • Mild nausea, vomiting, and/or abdominal discomfort • CNS side effects, predominately mild headache and dizziness

  20. STEP 5. GIVE INFORMATION, INSTRUCTIONS AND WARNINGS Instructions & Warnings • Temperature, RR, HR, BP, sensorium, O2 saturation and inspired oxygen concentration should be monitored to assess response to therapy. • A patient is considered to have responded to treatment if fever decreases within 72 hr, temperature normalizes within 5 days and respiratory signs, particularly tachypnea, return to normal

  21. STEP 5. GIVE INFORMATION, INSTRUCTIONS AND WARNINGS Instructions & Warnings • The patient should be afebrile for 48 to 72 hr with no signs of clinical instability before discontinuation of treatment • Patients who are not improving after 72 hr of empiric antibiotic therapy, the history, physical examination and the results of all available investigations should be reviewed.

  22. STEP 6. MONITOR • Duration of treatment for moderate-risk CAP: 14-21 days • Assess initial therapy by monitoring: • Temperature • respiratory rate • heart rate • blood pressure • sensorium • oxygen saturation • inspired oxygen concentration

  23. Indications for streamlining of antibiotic therapy: 1. Resolution of fever for > 24 hours 2. Less cough and resolution of respiratory distress (normalization of respiratory rate) 3. Improving white blood cell count, no bacteremia. 4. Etiologic agent is not a high-risk (virulent/resistant) pathogen e.g. Legionella, S. aureus or Gram- negative enteric bacilli 5. No unstable comorbid condition or life-threatening complication such as myocardial infarction, congestive heart failure, complete heart block, new atrial fibrillation, supraventricular tachycardia, etc. 6. No sign of organ dysfunction such as hypotension, acute mental changes, BUN to creatinine ratio of >10:1, hypoxemia, and metabolic acidosis 7. Patient is clinically hydrated, taking oral fl uids and is able to take oral medications

  24. Switch therapy from ParenteralAntibiotics The choice of oral antibiotics following initial parenteraltherapy is based on available culture results, antimicrobial spectrum, efficacy, safety and cost. In general, when switching to oral antibiotics, either the same agent as the parenteralantibiotic or an antibiotic from the same drug class should be used.

  25. Criteria for Discharge • During the 24 hours before discharge, the patient should have the following characteristics: 1. temperature of 36-37.5o C 2. pulse < 100/min 3. respiratory rate between 16-24/minute 4. systolic BP >90 mmHg 5. blood oxygen saturation >90% 6. functioning gastrointestinal tract

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