Download Case Study 17 - Caangay Family Site

Case Study 17
Yoontaek Lim (Clark)
Patient History

MC., a 60 y/o male, has already
experiencing nausea, vomiting and
diarrhea aside from having developed
Pneumonia while in the hospital. Lab
exams and his other manifestations
revealed that the patient is already
suffering from sepsis
Definition


Swelling of the lungs of that can be caused by
many different organisms. The symptoms can
vary considerably, depending on the cause.
Incidence


In the United States
 Over 2 million people are found to have pneumonia
 Over 50,000 of those individuals die
 The sixth leading cause of death in the United States
In developing countries, pneumonia is either the first or
second leading cause of death.
Causes



Pneumonia is caused by bacteria, viruses, fungi, or
parasites.
Predisposing factors

Viral respiratory infections, alcoholism, smoking, age
extremes, debility, dysphagia, altered consciousness,
therapies that depress the immune system, and underlying
disease states such as heart failure, chronic obstructive
pulmonary disease, or immunosuppressive disorders.

Individuals in hospitals for other disorders are also at high risk.
The most common types, which are bacterial, are
Pneumococcus, Staphylococcus, Streptococcus,
Klebsiella, and Haemophi-lus pneumonia.
Symptoms

Bacterial


Viral


Malaise, sore throat, dry cough with rapid progression to productive
cough with mucoid, purulent, and blood-streaked sputum
Fungal


Headache, fever, myalgia, cough with mucopurulent sputum
Mycoplasmal


Abrupt onset with shaking chills, cough, dyspnea, sputum
production (often rust or salmon colored), pleurisy; nausea,
vomiting, malaise, and myalgia also may be present
Fever, dyspnea, and a dry, nonproductive cough that evolves over
several days or weeks are the first symptoms. Increasing shortness
of breath usually prompts the individual to seek treatment. The
onset tends to be more acute in individuals who do not have AIDS.
Aspiration

Dyspnea, cyanosis, hypotension, tachycardia
Potential Complications

Septic shock, lung abscess, respiratory
failure, bacteremia, endocarditis, pericarditis,
and meningitis are possible complications.
Treatment

Treatment of pneumonia is bed rest, fluids,
antibiotics, painkillers, and if needed, oxygen. Ice
packs or cold, wet compresses may be needed to
lower the fever. Fever, loss of fluids and breathing
through the mouth result in a need for special care of
the mouth and nose. Mild pneumonia is often treated
at home
Antimicrobial therapy for Pneumonia
Common
Pathogen
Neonate
Group B streptococcus,
E coli, listeria
Child
Pneumococcus, S
Adult
(community acquired)
st
Drugs of 1 choice
Alternative drugs
Ampicillin-sulbactam
aureus, H influenza
Cefriaxone, cefuroxime,
cefotaxime
Pneumococcus,
mycoplasma, legionella,
Outpatien: erythromycin,
amoxicillin, doxycycline
H influenzae, S aureus,
C pneumonia, doliform
Inpatient: macrolide +
cefotaxime, cefriaxone
Outpatien:
azithromycin,
claruthromycin,
quinolone
Inpatient: macrolide +
pipercillin-tazobactam,
ticarcillin-clavulanate,
or
cefuroxime;quinolone
Antimicrobial combination for this
case
Macrolide (Erythromycin)
+
Cefotaxime, Cefriaxone
Macrolide (Erythromycin)

Drug of choice for community-acquired
pneumonia that does not require hospitalization

Covers streptococcus pneumoniae, mycoplasma
pneumoniae, chylamydia trachomatis

One of the safest antibiotics

New agent

Extended coverage includes S aureus & H influenza

Clarithromycin : mycobacterium avium

Azithromycin : chlamydia
Cephalosporin;
rd
3
generation

Cefotaxime, Cefriaxone

Used for the multi-drug resistant aerobic
gram(-) organism that cause nosocomial
pneumonia, meningitis, sepsis, and urinary
tract infections
Dose
Antibiotics
Route
Adult
Erythromycin
OD
Base, Stearate,
Estolate
Pediatrics
Neonatal
0.25~0.5g q 6h 40㎎/㎏/day
Ethylsuccinate
0.4~0.6g q 6h
IV
Lactobionate
0.5~1.0g q 6h
20~40㎎/㎏/day
Cefotaxime
IV
1~2g q6~12h
50~200㎎/㎏
/day in 4~6
doses
100㎎/㎏/day
in 2 doses
Cefriaxone
IV
1~4g q24h
50~100㎎/㎏
/day in 1or 2
doses
50㎎/㎏/day
once a day
Mechanism of action

Erythromycin


Binds to 50S ribosomal subunits & inhibits protein
synthesis
Cefotaxime, Cefriaxone

Competitive inhibitor of the transpeptidase enzyme;
inhibits bactarial cell wall synthesis
Adverse effects

Erythromycin





Gastrointestinal
disturbance : most
common but not serious
Hypersensitivity reaction :
skin rashes, fever
Transient hearing
disturbance
Longer treatment
(>2weeks) : cholestic
jaundice
Oppotunistic infection of
the gastrointestinal tract
or vagina

Cefotaxime, Cefriaxone

Hypersensitivity
Pharmacokinetics of ribosomal
inhibitors
; Macrolides
Pharmacokinetics of macrolide

Administration : oral or IV
 Concentrate in the liver
 Elimination : mostly in the bile

Erythromycin : partly in the liver

Diffuse readily into most tissue bur cannot
cross the blood-brain barrier and poor
penetration into synovial fluid
 T1/2 : Erythrocyte 90min

Clarithromycin : 3 X, azithromycin : 8~16 X
When intra-abdominal source is
suspected,
what is the agent to be used?
Clarithromycin
; low gastrointestinal intolerance
References
1.
Rang H.P et al, Drugs used in the treatment of infections and
th
cancer : Pharmacology, 5 ed. Churchill Livingstone, 2003, pp
619-710
2.
Betram G. K, Chemotherapeutic agent : Basic&clinical
th
Pharmacology, 9 ed. Mcgraw-Hill edutation, 2004, pp 734763
3.
Mark G et al, Anti-bacterial Mediation : Clinical Microbiology
rd
mrs, 3 ed. Miami MedMaster Inc, 2004, pp 114-132
4.
Vinay K et al, The Lung : Robbins and Cotran Pathologic Basis
th
of Disease, 7 ed. Elsevier Inc, 2005, pp 711-773