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 Abrupt onset with shaking chills, cough, dyspnea, sputum production (often rust or salmon colored), pleurisy; nausea, vomiting, malaise, and myalgia also may be present Viral Headache, fever, myalgia, cough with mucopurulent sputum Mycoplasmal Malaise, sore throat, dry cough with rapid progression to productive cough with mucoid, purulent, and blood-streaked sputum Fungal 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 Drugs of 1 st choiceAlternative drugs Neonate Group B streptococcus, E coli, listeria Child Pneumococcus, S aureus, H influenza Cefriaxone, cefuroxime, cefotaxime Ampicillin-sulbactam Adult (community - acquired) Pneumococcus, mycoplasma, legionella, H influenzae, S aureus, C pneumonia, doliform Outpatien: erythromycin, amoxicillin, doxycycline 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; 3 rd generation Cefotaxime, Cefriaxone Used for the multi-drug resistant aerobic gram(-) organism that cause nosocomial pneumonia, meningitis, sepsis, and urinary tract infections

Dose AntibioticsRouteAdultPediatricsNeonatal Erythromycin ODBase, Stearate, Estolate 0.25~0.5g q 6h Ethylsuccinate 0.4~0.6g q 6h 40 ㎎ / ㎏ /day IVLactobionate 0.5~1.0g q 6h 20~40 ㎎ / ㎏ /day Cefotaxime IV1~2g q6~12h 50~200 ㎎ / ㎏ /day in 4~6 doses 100 ㎎ / ㎏ /day in 2 doses Cefriaxone IV1~4g 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  Rang H.P et al, Drugs used in the treatment of infections and cancer : Pharmacology, 5 th ed. Churchill Livingstone, 2003, pp  Betram G. K, Chemotherapeutic agent : Basic&clinical Pharmacology, 9 th ed. Mcgraw-Hill edutation, 2004, pp  Mark G et al, Anti-bacterial Mediation : Clinical Microbiology mrs, 3 rd ed. Miami MedMaster Inc, 2004, pp  Vinay K et al, The Lung : Robbins and Cotran Pathologic Basis of Disease, 7 th ed. Elsevier Inc, 2005, pp