Antibiotic Prescriptions in the Ward- Sarah Low

MRA, 57 year old gentleman was admitted to the ward due to suspected lobar pneumonia, where he presented with fever for the past 1 week with cough and productive yellowish sputum. He is a non-smoker. Prior to his admission, he went to a clinic and was prescribed antibiotics but unsure what was it. And upon physical examination, there was crepitations heard over bilateral lungs more over the right middle zone. Chest X-Ray showed consolidation over the right lower lobe. He was prescribed IV Augmentin (Amoxicillin/Clavulanate) 1.2 g stat and tds with Azithromycin 500 mg OD for the next 3 days. When amoxicillin (susceptible to penicillases) combined with clavulanate (inhibitors of penicillase), their anti-bacterial activities are enhanced. It has a wider spectrum on infections, resulting from enterococci, Listeria monocytogenes, E. Coli, Proteus mirabilis, H. Influenzae, and Moraxella catarrhalis, although resistant strain occurs. Azithromycin, a macrolide antibiotic has a more active role against H influenza, Morazella catarrhalis, Neisseria. Because of its long half life, a single dose is effective in the treatment of urogenital infections caused by C. trachomatis, and a 4 day course of treatment has been effective in community acquired pneumonia.

TM, a 64 year old female known case of childhood bronchial asthma, presented to the ward with acute onset of shortness of breath on day of admission. She also had productive cough for the past 1 week prior to admission. Upon examination, there was occasional rhonci with prolonged expiration. Sputum FEME showed G+ cocci, G- bacilli and pus 5-10 HPF. She was given IV augmentin 1.2 g stat and tds with tablet erythromycin ethylsuccinate (EES) 800 mg BD. Erythromycin has activity against many species caused by M pneumonia, Corynebacterium, Campylobacter jejuni, gram positive cocci, and some gram-negative organisms. Azithromycin has a similar spectrum of activity but greater efficacy than erythromycin in therapeutic option for treatment of community acquired classic and atypical pneumonia

MJHN, a 64 year old gentleman known case of diabetes and hypertension for 10 years, was admitted to the ward after being noted in the Klinik Kesihatan for high urea and creatinine of 35.9 and 1027 respectively. He also had typical features of chronic renal failure such as generalised body weakness, with reduced oral intake and itchiness for past 2 weeks. He also had fever with cough and productive whitish sputum for the past 2 weeks, and was diagnosed of having community acquired pneumonia. His admission to the ward showed high spiking temperature, and he is currently on peritoneal dialysis. It is noted one of the top mortality cause in a dialysis patient is septicaemia, thus it is important to treat extensively with broad spectrum antibiotics which is IV Ceftriaxone for 3 days. Upon discharge, he was prescribed with oral tablet Augmentin 625 mg OD for the next 5 days. Ceftriaxone a third generation cephalosporin has increased activity against gram negative organisms resistant to other beta-lactam drugs and ability to penetrate the blood-brain barrier. It is active against producing strains of H influenza and Neisseria, and they are most active against penicillin-resistant pneumococci (PRSP strains). In populations of known/suspected pneumococcal resistance, a single dose of Ceftriaxone appears to be as effective as a 10 day course of Augmentin.

90 year old Malay gentleman presented with productive cough with whitish sputum. He was treated for community acquired pneumonia. IV Augmentin 1.2 g tds and EES 500 mg BD was prescribed in the beginning before changing it to IV Moxifloxacin (Avelox) 400 mg OD and Azithromycin 500 mg OD. Upon discharge, he was given tablet Moxifloxacin 400 mg OD. Based on the management above, the commonly preferred treatment for community acquired pneumonia is beta-lactamase inhibitors such as augmentin, however this patient was treated with  Moxifloxacin, which is a fourth generation fluoroquinolone. It is one of the broadest spectrum fluoroquinolones to date, with enhanced activity against gram positive and gram-negative organisms, atypical pneumonia agents, and some anaerobes. The conservative use of quinolone is recommended to minimise resistant pathogen. It is commonly used when failed first-line regimen or allergic to alternative.

AMY, a 61 year old gentleman presented with bilateral knee pain with consistently high spiking fever. Joint aspiration was done and noted there was 15-20 high. He was treated with IV Cloxacillin 1 g QID in view of septic arthritis and prevention of osteomyelitis. It is shown that cloxacillin is effective against organisms such as staphylococcal organisms, an etiological organism for septic arthritis. An inadequate dosage regimen (a single daily dose) prevented spread of bacteria but did not control abscesses. Delay in commencing treatment permitted persistence and spread of abscesses with destruction of the secondary (epiphyseal) ossification center and even transphyseal spread into metaphyseal bone. Repair by fibroblasts was mainly seen in articular and epiphyseal cartilage but was not seen in the epiphyseal ossification center (up to 18 days). Synovial fluid sampling with measurement of leukocyte and bacterial concentrations appears to be a useful guide to the effectiveness of treatment, because the numbers of cells correlate with the pathological process.

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ZD, a 51 year old Malay female presented with diarrhoea that has been ongoing for the past 5 days.  On the day of admission, she had high fever of 38.2 ⁰ C. She is a known case of hyperthyroidism, and has been compliant to her anti-thyroid medication, Carbimazole.  They were treating her for infective diarrhoea, thus tablet Ciprofloxacin was given. The most common approach in treatment of infectious diarrhoea would include supportive therapy- fluid and electrolyte replacement. There is a large body of evidence to show that antimicrobial agents can reduce the severity and duration of some intestinal infections, especially in those bacteria and infections that produce acute watery diarrhoea. As ZD has been having diarrhoea for past 5 days, antimicrobial agent was prescribed. Ciprofloxacin, second- generation fluoroquinolone have greater activity against gram-negative bacteria, especially enterotoxigenic E coli. Quinolone antibiotics are now the treatment of choice; standard doses for 3–5 days can reduce the severity and duration of illness by at least 50%