1. GROUP CASE PRESENTATION SATELLITE PHARMACY CLERKSHIP 2010/2011 GROUP B CASE: UROSEPSIS

2. PATIENT’ S CMR

3. PATIENT PARTICULARS NAME: MISS ABC BED/WARD: C1/17 AGE: 70 DIAGNOSIS : UROSEPSIS DATE OF ADMISSION: 12/7/2010 DATE OF DISCHARGE : 8/8/2010

4. Brief overview : UROSEPSIS  Definition: sepsis (septicaemia syndrome) caused by urinary tract infection  Urosepsis in adults comprises approximately 25% of all sepsis cases and in most cases is due to complicated urinary tract infections (UTIs)  Classic presentation: fever, chills, hypotension in some patient  Patients who are more likely to develop urosepsis include: infant,elderly patients, diabetics, immunosuppressed patients (such as transplant recipients), patients receiving cancer chemotherapy or corticosteroids and patients with acquired immunodeficiency syndrome(HIV)

5. Clinical diagnostic criteria of sepsis  Associated with Systemic Inflammatory Response Syndrome(SIRS): i) Temperature > 38 C or < 36 C ii) Heart rate > 90 beats per minute iii)Respiratory rate > 20 breaths or PaC02 < 32 mmHg iv) White blood cells > 12 x 10^9/L

7.  For therapeutic purposes, the diagnostic criteria of sepsis should identify patients at an early stage of the syndrome, prompting urologists and intensive care specialists to search for and treat infection, initiate appropriate therapy, and monitor for organ failure and other complications  In the case of urosepsis the clinical evidence of UTI is based on symptoms, physical examination, sonographic and radiological features, and laboratory data, such as bacteriuria and leucocyturia.

8. Pathophysiology of urosepsis Micro-organisms reach the urinary tract by way of the ascending, haematogenous or lymphatic routes. For urosepsis to be established, from the urinary tract the pathogens have to reach the bloodstream. The risk of bacteraemia is increased in severe urogenital infections such as pyelonephritis and acute bacterial prostatitis, and is facilitated by obstruction.systemic inflammatory response syndrome (SIRS) is then triggered

9. General Management of Urosepsis Effective treatment eliminates the infectious sources, and improves organ perfusion. Treatment of urosepsis comprises four basic strategies: i) supportive therapy (fluid replacement therapy for stabilisation and maintaining blood pressure, manage fluid and electrolyte balance) ii) antimicrobial therapy (initiate with broad spectrum antibiotic within in the first hour) iii) control or manage of the complicating factor, & iv) specific sepsis therapy(eg.corticosteroid, insulin, etc) All four strategies need to be started as early as possible.

10. Appropriate and early diagnosis of sepsis is important to enable commencement of treatment without delay-if left untreated it can cause severe sepsis & septic shock According to Kumar et al.’s data [7],we have 1 h to administer broad-spectrum antibiotics. We have 6 h to stabilise haemodynamics according to early goal-directed therapy. We have 24 h to apply adjunctive therapy

11.  Severe Sepsis association with organ dysfunction, hypoperfusion or hypotension- may include but are not limited to lactic acidosis, oliguria or an acute alteration of mental status  Septic shock- Sepsis with hypotension despite adequate fluid resuscitation

12. DRUG THERAPY GIVEN(based on CMR) HYDROCHLOROTHIAZIDE NIFEDIPINE AMLODIPINE PCM LOVASTATION TAZOCIN OMEPRAZOLE UNASYN RANITIDINE MAXOLON( COLCHICINE TICLIDOPINE PREDNISOLONE METOPROLOL MIST KCL NEUPOGEN ALBUMIN SYPLACTULOSE

13. Hydrochlorothiazide( HCTZ) INDICATION: Management of mild to moderate hypertension, treatment of edema in congestive heart failure, corticosteroid therapy and nephrotic syndrome ACTION: Inhibits sodium reabsorption in the distal tubules causing increased excretion of sodium(&chloride) and water Half life: 5.6-14.8 hour Onset of action ~ 2hours (duration 6-12hours)

14. DOSAGE IN ADULT  EDEMA(25-100mg/day, max 200mg/day)  HTN(12.5-50mg/day) In elderly patient : 12.5-25 mg once daily (from the prescription dose given is 25mg po od)

15. Warning /Precaution Should avoid in renal disease(ineffective) Electrolyte disturbance(hypokalemia, hyponatremia etc) can occur May precipitate gout(cause hyperuricemia) Use in caution with diabetes patient(may alter glucose control) Use in caution in patient with high cholesterol ADR: 1-10% :orthostatic hypotension, photosensitivity, hypokalemia, hyponatremia, anorexia, epigastric distress Contraindications Hypersensitivity to thiazides, related diuretics, or sulfonamide-derived drugs; anuria; renal decompensation Hepatic impairment: Minor alterations of fluid and electrolyte balance may precipitate hepatic coma; use drug with caution

16. DRP detected: Drug-drug interactions 1) Hydrochlorothiazide + prednisolone Levels/effect of hydrochlorothiazide may be increased by corticosteroid (prednisolone) still can be used together 2) Hydrochlorothiazide + amlodipine The antihypertensive effect of amlodipine and thiazide diuretics may be additive. Management consists of monitoring blood pressure during coadministration, especially during the first 1 to 3 weeks of therapy.

17. PATIENT CARE CONSIDERATIONS Administration/Storage If drug is administered as single dose, give in morning. Administer drug with food or milk to minimize GI irritation. Store tablets in tightly closed container at room temperature

18. Assessment/Interventions Monitor patient's BP with patient lying down and standing. Monitor serum potassium, calcium, magnesium, sodium, ABGs, uric acid. Monitor renal ( BUN, creatinine) and liver (ALT, AST) function tests. Monitor blood glucose levels in diabetic patients. Observe closely for anaphylaxis (shortness of breath, rash, edema) after first dose. Report muscle weakness, cramps, nausea, blurred vision, or dizziness to health care provider Advise patient to limit sodium intake for optimal drug effect Caution patient to avoid sudden position changes to prevent orthostatic hypotension Advise patient that drug may cause drowsiness and to use caution while driving or performing other tasks requiring mental alertness