1. Patient Case/ Antibiotic Stewardship Presentation
Shashank Sridhara
University of Florida
College of Pharmacy
Doctor of Pharmacy Candidate 2014

2. Our Patient 33 y.o Caucasian Female
PMH- Type 2 Diabetes* & Hypertension
S Hx- Stopped smoking a few months ago and no EtOH use
F Hx- Noncontributory
CC- Pulmonary Sx, Productive cough, SOB, fever and subjective chills.
2-3 weeks before being admitted Pt’s mother had a Sinus infection or a URTI.
2 weeks prior Pt was in ED and was treated for Pneumonia.
Patient received Amoxicillin as an inpatient and completed a course of Ciprofloxacin along with steroids as an outpatient.
Pt remains symptomatic and is now admitted
It is impt to note that in patients with comorbid conditions such as diabetes infections tend to be more complicated and more difficult to treat.
The focus of this presentation will be mostly on the topic of Infectious disease.

3. Our Patient Physical examination
VITAL SIGNS: She did have a temperature of 100.1, currently afebrile.
She is 93% on room air.
HEENT: Oral cavity clear.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: S1 and S2 heard. Regular rate and rhythm.
ABDOMEN: Soft, nontender.
EXTREMITIES: No edema.
MUSCULOSKELETAL: No joint swelling.
SKIN: No obvious rashes.

4. Our Patient Lab Data 1
Her D-dimer (to rule out thrombosis) was negative at 0.47.
Na is 132 ( mEq/L )
K is 4.1 ( mEq/L )
BUN of 10 ( mg/dl)
Creatinine- 0.6 ( mg/dl)
Lactic acid is 2.8 ( meq/L)
White count is 9 ( x10^3)
Hematocrit is 42.9 (41-50%)
Platelets of 312,000. (100,000 to 450,000)
Her chest x-ray shows a worsening right-sided and also now left-sided infiltrate.
A CT scan has been ordered
Blood cultures are pending

5. Patient Meds Pre Admission
Talk about interactions here- run an interaction checker and screen shot that shit with all the potential interactions w/ Abx.
Glipizide 5 mg BID
Metoprolol 100mg BID
Lisinopril/Hctz 40/12.5 BID
Clonidine 0.1mg BID
Metformin 500mg BID
Ibuprofen 800mg PRN/TID

6. Potential Interactions with Abx & Home meds
Ran an interaction check with Home meds & Possible Tx options (Levaquin, Avelox, Cipro, Amoxicillin and Azithromycin)
Many PD and PK interactions
Most of the interactions were minor and none of them were major or contraindicated.
Increased effects of metformin and glipizide were the most concerning of the minor interactions.
Azithromycin and moxifloxacin both increase the QTc interval. Significant - Monitor Closely.

7. CAP- community acquired pneumonia
Common Typical Pathogens
S.pneumoniae
H.influenzaei
Viral
Oral anaerobes (Aspiration)
Possible pathogens
And treatment options
Moraxella catarrhalis not added here is very rare and usually not seen in patients w/ pneumonia
Strep Pneumo most common type of typical bacteria pneumo

8. CAP Treatment Options

9. Complicated (Atypical) Pneumonia
Atypical pneumonia aka walking pneumonia
Not caused by traditional pathogens
Clinical presentation contrasts typical
These atypical organisms include special bacteria, viruses, fungi, and protozoa
Usually will not respond to Beta Lactams and Sulfonamide class of Abx
Need to go over the basics, Signs & Sx

10. Complicated (Atypical) Pneumonia Signs/Sx
No signs and symptoms of lobar consolidation,[ meaning that the infection is restricted to small areas, rather than involving a whole lobe. As the disease progresses, however, the look can tend to lobar pneumonia (noted in our patient)
Absence of leukocytosis (noted in our patient)
Moderate amount of sputum, or no sputum at all (i.e. non-productive).
Lack of alveolar exudate.
Despite general Sx and problems with the URT (such as high fever, headache, a dry irritating cough followed later by a productive cough with radiographs showing consolidation), there are in general few physical signs. The patient looks better than the symptoms suggest.
Alveolar exudate- The surrounding alveolar walls have capillaries that are dilated and filled with RBC's. Such an exudative process is typical for bacterial infection. This exudate gives rise to the productive cough of purulent yellow sputum seen with bacterial pneumonias.

11. Complicated Pneumonia Pathogens
Most common causative organisms are (often intracellular living) bacteria.
Chlamydophilia Pnemoniae
Legionella Pneumphila
Mycoplasma Pneumoniae
Viral causes
Respiratory Synctial Virus(RSV), 
Influenza A and B
If you look at your 4 page Abx spectrum that I have printed out for you, it will list the most common atypical pathogens.
Mycoplasma is a type of bacteria without a cell wall
Mycoplasma is found more often in younger than in older people Older people are more often infected by Legionella.

12. Diagnosis Chest X-rays are gold standard for diagnosis.
They show a pulmonary infection before physical signs of atypical pneumonia are observable at all.
Infiltration commonly occurs near the where the bronchus begins and tends to be more bilateral .The process most often involves the lower lobe, but may affect any lobe or combination of lobes.

13. Chest X-Rays of Atypical vs Typical
Strep (typical) is more unilateral
Atypical is more bilateral

14. SPECTRUM OF ACTIVITY
Describe what’s on it and go through some examples
For example- we can start to look at some treatment options for Atypical pathogens….on page 4 it should show you what they are and we can now choose some Abx based off of this chart.

15. Assessment and Plan 1
1. Complicated pneumonia potentially atypical. We will admit for Brevard
Pulmonary consultation. We will check blood cultures and other cultures.
Zosyn and Azithromycin initiated.
Rule out for influenza with nasal swab.
Check a CT scan just to rule out any more complicated infection.
2. Diabetes.
Continue her on sliding scale insulin and carb-controlleddiet.
3. Hypertension.
Continue on her home medications and follow her course expectantly.

16. Global Rph Empiric Tx Abx site
Walk them through this website….different disease states and treatment options.

17. Lab data 2 White count is 9.79 Platelets 275,000 Neutrophils 64.1.
Blood cultures are negative so far.
Her chest x-ray does show pneumonia of the right lung, which apparently has worsened from previous x-ray.
She did have a CT chest, which showed right upper and middle lobe pneumonia 2 days ago. Her last x-ray was 13 days ago at that point, she had right lower lobe infiltrate and the current CT chest, actually showing right upper and middle lobe infiltrates.
Indicating a progress of the disease.

18. Assessment and plan 2
This is a very young woman who has now presented with pneumonia.
Concerned about an immunocompromising condition given her age and the fact that she has presented with pneumonia.
We will get immunoglobulin levels and HIV serology to rule in a immunocompromised state.
We will obtain sputum Gram stain, culture and sensitivity
Legionella and pneumococcal urine antigen.
Looking at the x-ray done 11 days ago, this was a right lower lobe pneumonia and now we have a middle and upper lobe pneumonia. This speaks to a new process rather than a continuation of her prior pneumonia.
In terms of the antibiotic regimen, I think a respiratory fluoroquinolone would have been
adequate, ciprofloxacin would not cover any of the respiratory flora, maybe this is why she progressed despite the use of Cipro.
Respiratory Fluoroquinolones are Moxifloxacin (Avelox) and Levofloxacin (Levaquin)
However, she has been on steroids and has been on antibiotics.
Steroids put a patient in a immunocompromised state .
She is bringing up sputum so we can get a Gram stain, culture and sensitivity to taper the antibiotic regimen.

19. Discharge summary
Hospitalist team was called to admit for failed outpatient treatment for complicated pneumonia.
Blood cultures were ordered. She was ruled out for influenza with a nasal swab.
CT of the chest was ordered.
CT of the chest without contrast showed right upper lobe and middle lobe pneumonia.
The pulmonologist who evaluated the patient. His impression was community-acquired pneumonia
with adequate outpatient therapy.
Consult was placed with infectious disease due to the failed outpatient therapy.
ID doctor continued to make recommendations for antibiotics throughout her stay.
Her sputum grew normal respiratory flora after 48 hours.
HIV antibodies came back nonreactive.
She was found to be positive for IgM immunoglobulin.
Consult was placed with Hematology/Oncology. He recommended conservative therapy with the current antibiotics and close monitoring
The patient was discharged in stable condition.
IgM antibodies appear early in the course of an infection and usually reappear, to a lesser extent, after further exposure. IgM antibodies do not pass across the human placenta. These two biological properties of IgM make it useful in the diagnosis of infectious diseases. Demonstrating IgM antibodies in a patient's serum indicates recent infection
Need to find out what her final outpatient medications r still

20. Electronic copy of the Spectrum
Please write your addresses down if you would like to receive an electronic copy of this Abx spectrum chart on your so it can be easily accessed via your phone or computer.
Spectrum double sided x 4
Screen shots of the website (screen with dx state and detailed dose screen x4)
Find out her final plan and outpatient meds that she was sent home on.
How long was she in hospital for total?