Respiratory Tract Infections

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Respiratory Tract Infections

    • Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS,      Olsen LA, editors. The Healthcare Imperative: Lowering Costs and Improving Outcomes:
    • No drug interaction, or ADRs (adverse drug reactions), side effects includes diarrhea and headaches, which can easily be taking care of with over the counter medications (acetaminophen and anti-diarrhea) if severe. The other reasons will be the length of treatment (3days) and the cost of the drug ($30) for the 3 days treatment.  Both drugs have similar efficacy. The patient should be educated on the times of the day for the medication to be taking and whether the drug should be taking with food, or empty stomach. Encourage patient to drink plenty of fluids with medication if not contra-indicated. Respiratory Tract Infections

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    •  The main factor in determining the choice of microbial therapy was the type of previous antibiotic therapy, followed by interaction with other medicines the patient is using, and the results of the organism isolated in the culture and sensitivity of the sputum from laboratory Mahboub et al. (2015). Other factors that should be considered in the choice of antibiotics includes patient’s age, renal status, drug allergies, immune status (diabetes, neutropenia, or immunocompromised host) cardiopulmonary disease, pregnancy, medical insurance and prescription coverage, exposure to resistant organisms and prior antibiotic exposure(s) Chisholm-burns, Schwinghammer, Malone, Malone, Lee, & Bookstaver (2019).
    •             Community-acquired pneumonia (CAP) is common and serious acquired outside a hospital or long-term care facility or other recent contact with health care system
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    • Karen Halter posted Oct 14, 2020 9:34 PM
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    • Module 7 PharmSTEPSDrug 2 in our choice has no drug interactions or serious reactions, efficacy is not an issue, and cost is much less. The side effects are headaches and diarrhea, but drug 1 also carries the risk of diarrhea. A 3-day course of therapy even at twice a day is more likely to be completed against a 7-day course of therapy. As nurses, we all know someone who “saves” medications for when they need it again, so I have always felt a shorter course of therapy may be better.Knowing more about the history of our patient would be helpful, but based on the limited information given about medical history I would choose Levofloxacin as a monotherapy. Below is my STEPS analysis. Levofloxacin is a broad spectrum fluoroquinolone that is effective in the treatment of community pneumonia (CAP).(Levofloxacin in the Treatment of Community-acquired Pneumonia – Pubmed, 2010) The efficacy and tolerability is well documented and a dose of 750mg for 5 days has been approved in the USA.(Levofloxacin in the Treatment of Community-acquired Pneumonia – Pubmed, 2010)Tolerability-headache, insomniaPrice-lowAlthough there are newer drugs for the treatment of CAP the cost may be more and their efficacy has not been established historically. (Underhill, 2010)I believe that simplicity is still an important factor in treatment due to ½ to 1/3 of patients not taken prescribed medication as recommended. (Underhill, 2010)  Crosby, J., & Wormuth, L. (2016). A STEPS-Plus Approach to the Perfect Medicine List. Todays Geriatric Medicine, 9(1), 12.Underhill, S. P. (2010). Evaluating the safety and effectiveness of new drugs. American Family Physician. https://www.aafp.org/afp/2010/0701/p53.htmlless1 UnreadUnread10 ViewsViews Respiratory Tract Infections
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    • Levofloxacin in the treatment of community-acquired pneumonia – pubmed. (2010). PubMed. https://pubmed.ncbi.nlm.nih.gov/20455679/
  • References
    • Simplicity-one pill daily for 5 days (Levofloxacin in the Treatment of Community-acquired Pneumonia – Pubmed, 2010)
    • Efficacy-well established
    • Safety-interacts with insulin, steroids, NSAIDS (history would need to be determined)
    • CAP
    • Choosing the proper medication for any medical condition involves multiple considerations for the prescriber and things that should be considered are patient adherence to direction, poly pharmacy, interactions, other medical issues, safety and tolerance. It is indeed a huge responsibility especially with the ever-changing world of treatment choices. The STEPS approach has been considered the standard approach attempting to incorporate these important aspects, as well as delineate if the benefits outweigh the risk of treatments. (Crosby & Wormuth, 2016) It is up to the prescriber to determine the impact on treatment, determine the cost burden, and tailor any prescription to the individual patient. (Crosby & Wormuth, 2016) By utilizing the S (safety) T (tolerability) E(efficacy) P(price) and S(simplicity) approach for our example I believe I would choose the 3-day course. Respiratory Tract Infections
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    • Jessica Faltinowski posted Oct 15, 2020 1:06 AM
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    • Module 7:  Respiratory Tract InfectionsOne way to choose appropriate therapy is using the “STEPS” decision making analysis.  This tool enables a provider to consider the safety, tolerability, efficacy, price, and simplicity of more than one medication and make an informed choice (Pegler & Underhill, 2010).  In the case study, one must choose between 2 antibiotics for a patient.  Drug 1 and Drug 2 both have equal efficacy however, Drug 1 has more safety concerns, is more expensive, and requires a lengthier dosing schedule.  Conversely, Drug 2 has less tolerability and must be taken twice a day, however, only for 3 days. Considering these factors, drug 2 would be a better choice for the patient.  While there is a possibility of headache and diarrhea, the course of treatment is limited to 3 days versus 7 days with a possibility of diarrhea with the other medication.  Additionally, the medication is $70 cheaper, yet provides the same efficacy.
      Drug 1 Drug 2
      Safety Moderate Drug Interactions No serious interactions
      Tolerability Diarrhea Diarrhea, headaches
      Efficacy Similar Similar
      Price $100/7 day $30/3 days
      Simplicity 7 days, once daily dosing 3 days, twice daily dosing
      Levofloxacin 750 Mg/Day Amoxicillin/clavulanate AND Azithromycin 500 mg day 1 and 250 mg Day 2-5
      Safety Moderate drug reactions.  Black box warning. Respiratory Tract Infections Few drug interactions
      Tolerability Nausea, headache, diarrhea, tendon problems Nausea, headache, diarrhea
      Efficacy Similar Similar
      Price $6-$45/5 days $10/5 days/azithromycin

      $9-$20/5 days/amoxicillin/clavulanate
      Simplicity 750 mg/day for 5 days Amoxicillin/clavulanate 875mg/125 mg BID for 5 day AND Azithromycin 500 mg day 1 and 250 day 2-5 once daily

      ReferencesLeekha, S., Terrell, C. L., & Edson, R. S. (2011). General principles of antimicrobial therapy. Mayo Clinic Proceedings, 86(2), 156–167. https://doi.org/10.4065/mcp.2010.0639Pegler, S., & Underhill, J. (2010). Evaluating the safety and effectiveness of new drugs. American Family Physician, 82(1), 53–57.Uranga, A., España, P. P., Bilbao, A., Quintana, J., Arriaga, I., Intxausti, M., Lobo, J., Tomás, L., Camino, J., Nuñez, J., & Capelastegui, A. (2016). Duration of antibiotic treatment in community-acquired pneumonia. JAMA Internal Medicine, 176(9), 1257. https://doi.org/10.1001/jamainternmed.2016.3633less1 UnreadUnread12 ViewsViews

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  • Last post Oct 17, 2020 9:33 AM by Candace Whitman-Workman
  • Tanne, J. H. (2008). Fda adds “black box” warning label to fluoroquinolone antibiotics. BMJ, 337(jul15 1), a816–a816. https://doi.org/10.1136/bmj.a816
  • 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., Metersky, M. L., Musher, D. M., Restrepo, M. I., & Whitney, C. G. (2019). Diagnosis and treatment of adults with community-acquired pneumonia. an official clinical practice guideline of the american thoracic society and infectious diseases society of america. American Journal of Respiratory and Critical Care Medicine, 200(7), e45–e67. https://doi.org/10.1164/rccm.201908-1581st
  • Corrêa, R., Costa, A., Lundgren, F., Michelin, L., Figueiredo, M., Holanda, M., Gomes, M., Teixeira, P., Martins, R., Silva, R., Athanazio, R., Silva, R., & Pereira, M. (2018). 2018 recommendations for the management of community acquired pneumonia. Jornal Brasileiro de Pneumologia, 44(5), 405–423. https://doi.org/10.1590/s1806-37562018000000130  Respiratory Tract Infections
  • While levofloxacin is less expensive and simpler in dosing, it also carries a black box warning for tendon rupture, with an increased risk in patients over the age of 60 or cardiac comorbidities (Tanne, 2008).  Considering the comorbidities of the patient, starting with combination therapy of amoxicillin/clavulanate and azithromycin would be an effective, but safer solution.
  • Community acquired pneumonia (CAP) is an inflammation of the lungs caused by a microorganism that infects patients who are not hospitalized or patients in other health care setting such a care centers or dialysis clinics.  Diagnosis of CAP is based upon patient symptomology, physical examination, and chest x-ray (Corrêa et al., 2018).  While inpatient diagnosis is based upon blood cultures and sputum cultures whose results dictate the treatment protocol, outpatient treatment should be empirical and begin once pneumonia is confirmed radiographically (Metlay et al., 2019).  The most common microorganism in CAP is streptococcus pneumoniae, which is a gram-positive anaerobic bacterium (Leekha et al., 2011).  In the case study, the patient in question has community acquired pneumonia and other comorbidities.  As this patient is therefore more susceptible to poor outcomes and antibiotic resistance, a broad-spectrum antibiotic should be used (Metlay et al., 2019).  Since this patient has not received antibiotic therapy in the last 3 months, evidence-based research suggests that either a fluoroquinolone as monotherapy or a macrolide along with a beta-lactam agent should be used.   Recent evidence suggests that shorter duration of treatment can lead to a decrease in adverse effects, less treatment resistant microbial, and better patient outcomes (Uranga et al., 2016).  The chart below details the STEPS analysis of these medications.
  • Before beginning a patient on antibiotics, a provider must first establish the site of infection and the type of bacteria or fungi, or if unable to obtain, the most likely microbiological etiology  (Leekha et al., 2011).   Even after location and etiology are established, there are many different types of antibiotics that can treat the same microorganism, leaving a provider to make an educated decision as to the most effective and appropriate antibiotic for a patient. Respiratory Tract Infections
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  • Pawn Johnson-Hunter posted Oct 15, 2020 12:02 AM
  • Monotherapy

    Azithromycin

    		 Combination Therapy

    Amoxicillin-Clavulanate
    Safety Moderate drug interaction Moderate drug interaction
    Tolerability Abdominal pain, diarrhea, nausea diarrhea
    Efficiency similar similar
    Price/Preference $30.09/3 days $108.62/10 days
    Simplicity 3 days, once-daily dosing 7-10 days, every 12 hours

    Regimens recommended for patients with comorbidities include a β-lactam or cephalosporin in combination with either a macrolide or doxycycline. These combinations should effectively target macrolide- and doxycycline-resistant S. pneumoniae (as β-lactam resistance in S. pneumoniae remains less common), in addition to β-lactamase–producing strains of H. influenzae, many enteric gram-negative bacilli, most methicillin-susceptible S. aureus, and M. pneumoniae and C. pneumoniae. The monotherapies listed also are effective against most common bacterial pathogens (Metlay et al., 2019).  Chisholm-burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, K. C., & Bookstaver, P. B. (2019). Pharmacotherapy principles and practice, fifth edition (5th ed.). Mcgraw-hill Education / Medical. less0 UnreadUnread Respiratory Tract Infections

 

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  • Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., . . . Whitney, C. G. (2019). Diagnosis and treatment of adults with community-acquired pneumonia. an official clinical practice guideline of the american thoracic society and infectious diseases society of america. American Journal of Respiratory and Critical Care Medicine, 200(7), e45-e67. doi:10.1164/rccm.201908-1581st
  • References
  • Patients with comorbidities have higher mortality rates with combination therapy than single antibiotic alone.
  • The choice of treatment therapy depends on if the patient is in a community or inpatient hospital setting due to the severity of illness. For drug choice one, the treatment prescribed with consideration to therapy in a community home setting of an otherwise healthy patient who has not had any additional exposure to antibiotics in the last ninety days. In this case the most effective medication monotherapy would be a macrolide azithromycin has proved to be superior to other macrolide medication noting strong recommendation for treatment.  Another feature of azithromycin is its ability to achieve high concentrations in macrophages. The choice for drug two is for a patient who has a history of asthma. Respiratory Tract Infections
  • The management and treatment of a patient with community-acquired pneumonia (CAP) may differ depending on the patient’s medical history and present state of health. Like other illnesses, patient susceptibility to pneumonia depends on risk factors such as; toxins, existing respiratory disease, decreased immune system, and other comorbidities. The most common pathogens association with CAP are Streptococcus– S. pneumoniae, Mycoplasma- M. pneumoniae, Chlamydophila- C, pneumoniae and Haemophilus- H. influenzae (Chisholm-Burns, 2019). Clinical assessment for diagnosis of CAP may include patient symptomatic/compliant history, past medical history, complete blood count (CBC) to identify an increase/decrease in white blood count indicating infection,
  • Discussion 7: Respiratory Tract Infections Respiratory Tract Infections
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  • Dianne Cohen posted Oct 14, 2020 5:15 PM
  • Pneumonia is one of the leading causes of mortality in the United States (Chisholm-Burns, 2019). The cause of pneumonia can vary and depends on several factors prior to the onset of symptoms  Esden states, “According to the Infectious Diseases Society of America (IDSA), for a patient to qualify for community-acquired pneumonia (CAP) diagnosis, he or she must not have been hospitalized nor resided in a long-term care facility for, at minimum, 14 days prior to the onset of symptoms (2020, p.19). With this in mind, the primary health care provider uses empiric evidence along with a history and a careful exam to guide their diagnosis. (Chisholm-Burns, 2019). Diagnosis depends on the suspected causative bacteria and patient profile symptoms which may or may not include fever, chills, cough, headache, tachycardia, tachypnea, and malaise (Esden, 2020). If an X-ray is not possible, the practitioner relies on lung auscultation for proof of fluid in the lungs to diagnose CAP (Metlay et al., 2019). The selection of the proper antibiotic is key to successfully treating the patient and studies have shown that one treatment is not more effective than another (Metlay, 2019). Furthermore,  the STEP approach is an effective tool to minimize complications and ensure proper treatment. The following illustration is an example of utilizing the STEP method to treat a patient who has comorbidities with CAP.                                  Amoxicillin/Clavulanate, Respiratory Tract Infections
    Safety not recommended: penicillin hypersensitivity,  liver or kidney disease, if pregnant or breastfeeding, colitis, IBD,

    Diarrhea, mononucleosis, with ASA, Amiloride, acetaminophen, warfarin, use additional contraception

    		 Black Box Warning: tendonitis,  >age 60 increase risk tendon rupture, not recommended: Myasthenia Gravis, cardiac arrhythmias, CNS, corticosteroids, peripheral neuropathy, arteriosclerosis, pregnant/breastfeeding, can increase/decrease blood sugar in diabetes, possible interaction with antipsychotics
    Tolerability Possible GI, rash, urticaria Headache, dizziness, delirium, confusion, diarrhea, constipation, dysgeusia, visual impairment  not tolerated in children and elderly
    Efficacy Similar Similar
    Price/Preference Approximately $150 for 20 pills of each Approximately $325 for 20 pills
    Simplicity 500mg/125mg TID, and Clarithromycin 500mg BID, minimum of 5 days Respiratory Tract Infections 700mg QD

    minimum of 5 days

    Based on safety, tolerability, efficacy, and price, I would recommend the amoxicillin/clavulanate and clarithromycin combination. It has fewer contraindications, drug interactions,  and it is significantly cheaper than levofloxacin, Unfortunately, its administration is complicated, but patient teaching can remedy this problem. On the contrary, levofloxacin has several serious contraindications. However, if the patient can tolerate it and does not mind its expensive price then it is the preferred choice due to its easier administration.

  • References                                              https://www.cdc.gov/pneumonia/management-prevention-guidelines.htmlEsden, Jana, DNP, APRN & FNP-BC, CNE. (2020). Treatment update: Outpatient management of community-acquired pneumonia. Nurse Practitioner, 45, 16-25. https://doi.org/10.1097/01.NPR.0000653944.99226.25https://www.goodrx.com  https://doi.org/10.1164/rccm.201908-1581STPrescriber’s Digital Reference, 2020.https://docs.google.com/document/d/1NaAumFlmMQLBh4SZ1J7yrI8kJKfQuilS7amMoM30aHo/edit?usp=sharingless0 UnreadUnread
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  • Perri M, Martin BC, & Pritchard FL. (1995). Improving medication compliance: a practical intervention. Journal of Pharmacy Technology, 11(4), 167–172.
  • 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., Metersky, M. L., Musher, D. M., Restrepo, M. I., & Whitney, C. G. (2019). Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. American journal of respiratory and critical care medicine, 200(7), e45–e67.
  • Good Rx, Drug Prices, 2020.
  • Chisholm-Burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Bookstaver, P. B., & Lee, K. C. (2019). Pharmacotherapy principles & practice. McGraw-Hill Education. Respiratory Tract Infections
  • Centers for Disease Control and Prevention. Pneumonia Management and Prevention Guidelines.
  • In conclusion, selecting the proper antibiotic therapy to treat CAP is a complicated process. “Several factors to consider include cost, convenience of the regimen, medication allergies, recent usage of one class of antibiotics, and comorbidities or other risk factors that increase the possibility of adverse reactions with particular antibiotic choices” (Esden, 2020, p.22). However, with thoughtful consideration, positive outcomes result when patients are properly educated and involved in the decision process (Perri, 1995).
  • Data from Prescriber’s Digital Reference, 2020, and Good Rx
  •    Clarithromycin  Levofloxacin  Respiratory Tract Infections