Antibiotics- Tan Swee Vien

1.       89/Male/Malay with UL COAD X 1 year, chronic smoker
P/W progressively worsening shortness of breath X 3/7 and productive cough with purulent sputum X 3/7

PE: Afebrile. Signs of COAD with no crepitations.

Invx: Blood investigations within normal limits, Chest x-ray showed reticulonodular shadowing with air bronchogram on right lower zone.

Provisional Diagnosis: Acute exacerbation of COAD secondary to Community Acquired Pneumonia

Mx: treated with T. Augmentin 1.2g TDS and T. EES 800mg BD.

2.       83/Male/Malay with UL CVA X 5 years ago

P/W acute confused state which fluctuates X 1/52, no oral intake X2/7, low grade fever X1/52 and lumbar back painX 2/7

PE: Very agitated, afebrile

Invx: Urine FEME: urinary tract infection +ve

Provisional Diagnosis: Acute delirium with sepsis secondary to Urinary tract Infection

Mx: treated with IV Cefuroxime 750mg TDS and ·IV Ciprofloxacin 200mg BD

Note: Urinary tract infections occurring in men should not be regarded as uncomplicated. Administer antimicrobial therapy, initially given intravenously, such as a third-generation cephalosporin, a fluoroquinolone, or an aminoglycoside. In patients with risk factors associated with an unfavorable prognosis, such as old age, debility, renal calculi, recent hospitalization or instrumentation, diabetes, sickle cell anemia, underlying carcinoma, or intercurrent cancer chemotherapy, the antimicrobial coverage should be broadened and an antipseudomonal agent should be added.

They should receive a 10- to 14-day course of antibiotics.

3.       75/Male/Malay, NKMI

P/W progressively worsening shortness of breath X3/7 and non-productive cough X3/7, heart failure symptoms

PE: BP on admission: 196/109

Invx: ECG: T depression in avL, V6, LVH. CXR: Cardiomegaly,

Provisional Diagnosis:? See Mx below

Mx: treated for decompensated congestive cardiac failure with community acquired pneumonia on the 1^st day, IV Augmentin 1.2g TDS and T. EES 800mg BD given. However, on the 2^nd day of admission, another doctor noted that there were no pneumonic changes in chest x-ray, as well as blood investigations normal, therefore, AB was taken off. Patient was treated for decompensated congestive cardiac failure alone.

4.       71/Male/Indian UL COAD, HPT, ex-chronic smoker

P/W progressively worsening shortness of breath X2/7 and productive cough with purulent sputum X2/7. No fever. A/W orthopnea. Hx of admission to ICU and intubation X3 years ago.

PE: Respi rate: 26, SP02: 100% under Venti-mask, Signs of COAD, crepitations on left lower zone of lung

Invx: ABG: Respiratory acidosis with type 1 failure. WBC slightly raised. ECG: SR, poor R wave progression, tall P wave

Provisional Diagnosis: Acute exacerbation of COAD secondary to community acquired pneumonia with Cor pulmonale

Mx: treated with IV Augmentin 1.2g TDS and T. Azithromycin 50mg OD

Note: *Compared with erythromycin, azithromycin offer improved tolerability, however both are clinically effective for treatment of respiratory infections. Azithromycin retains the activity of erythromycin against gram-positive organisms but offers increased gram-negative coverage over erythromycin and clarithromycin.

5.       51/Female/Malay UL Hyperthyroidism x 10 years

P/W progressively worsening diarrhea X 6/7, >10times/day and high grade fever X 3/7. A/W generalised colicky abdominal pain and palpitations. History of taking outside food with husband but he is well

PE: Febrile, PR: 75beats, irregularly irregular. Abdo: soft, tender at lower abdomen, bowel hyperactivity.

Invx: WBC slightly raised. Stool C&S, ova and cyst results pending.

Provisional Diagnosis: Infective Acute Gastroenteritis

Mx: Treated with IV. Ceftriaxone 1g OD. Discharged with T. Ciprofloxacin 250mg BD X1/7

6.      90/Female/Malay UL Childhood Bronchial Asthma

P/W progressively worsening of breath X1/7 and productive cough with purulent sputum 3/7

PE:not done

Provisional Diagnosis: newly diagnosed COAD with cor pulmonale, community- acquired pneumonia

Mx: Initially treated with IV Augmentin 1.2g TDS and T.EES 800mg on Day 1. But was changed to IV Moxifloxacin 400mg OD, and  subsequently on Day 2 –added T. Azithromycin 500mg OD

7.       /Male/Malay UL gouty arthritis diagnosed few months ago

P/W progressively worsening pain and swelling on bilateral lower limbs, more severe on the joints and high grade fever.

PE: not done

Invx: WBC count raised.

Mx: Initially treated as acute exacerbation of gouty arthritis, but after joint aspiration was done, septic arthritis was noted. Treated with IV Cloxacillin 1g QID.

Note: Staphylococcus aureus is the most common pathogen in all age groups and should be treated with antimicrobial regimens similar to those recommended for osteomyelitis, although generally a 2 - 3-week treatment regimen is sufficient. However, depending on the patient’s age, other pathogens may need consideration.

8.       62/Male/Malay UL COAD X 3 years

P/W Progressively worsening shortness of breath X 2/7 and productive cough with purulent sputum x4/7.

PE: Respi rate: 20, febrile. Signs of COAD with right basal crepitations.

Invx: WBC raised. CXR: Opacities over right lower zone with air bronchogram

Provisional diagnosis: Acute exacerbation of COAD secondary to community-acquired pneumonia

Mx: was treated with T. Ciprofloxacin 500mg BD

9.       80/Male/Malay UL DM, HPT

P/W: Swelling of the right lower limb up to shin level. Hyperpigmentation

PE: not done

Ivx: Blood C&S done on multiple occasions

Provisional Diagnosis: Right leg cellulitis

Mx: IV Cefepime 2g BD

Note:The most common etiology of cellulitis with purulent drainage is S. aureus, although Group A streptococci and other streptococcal species can also present in this manner.

The appropriate antibiotics:

Mild:	Moderate/Severe
Augmentin 875 mg PO BID OR Ciprofloxacin 500 mg PO BID] PLUS Clindamycin 300 mg PO TID	Piperacillin/tazobactam 3.375 g IV q6h OR Meropenem 500 mg IV q8h. If concern for MRSA, add vancomycin -Severe PCN allergy: Ciprofloxacin + Clindamycin OR Aztreonam + Clindamycin. If concern for MRSA, use vancomycin instead of clindamycin and add anaerobic coverage with metronidazole.

10. 36/Female/Malay UL SLE with lupus nephritis, CVA right hemiparesis, DM, HPT
P/W non-productive cough X1/7 and shortness of breath on exertion, low grade fever X2/7, no heart failure symptoms.
Recently discharged on 19/3/2014 from Hosp Muar for SLE with anemia and recurrent ascites. Peritoneal tapping was done but no growth was found.
PE: Respi: bronchial breathing, course crepitations over bilateral lungs
Inx: WBC slightly raised, ESR and CRP raised, CXR: cardiomegaly with bilateral lung haziness up to mid-zone, Blood C&S showed no growth
Provisional Diagnosis: Healthcare associated pneumonia
Mx: Aside fr treating patient's SLE condition, she was treated with IV Cefepime 2g TDS.(initially started on Augmentin and EES but was then off and changed).
Note: *what is healthcare associated pneumonia?

• Residence in a nursing home or other long-term care facility
• Hospitalization in an acute care hospital for two or more days within the prior 90 days
• Attendance at a hospital or hemodialysis clinic within the prior 30 days
• Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days

Since patient has no known multi-drug resistance risk factors, therefore it is appropriate to give this antibiotics as it can cover gram-neg bacilli resistant.

Questions

1. Why are different types of antibiotics prescribed for community-acquired pneumonia and COAD?

Bacterial infections appear to trigger one-third to one-half of COAD exacerbations. Nontypeable Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae are the bacteria most frequently isolated bronchoscopically from patients having an exacerbation of COAD. Pseudomonas aeruginosa and Enterobacteriaceae are also commonly isolated, particularly from patients with severe COPD.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline, recommends antibiotic therapy for patients who have the following features: a severe exacerbation requiring mechanical ventilation (noninvasive or invasive) or an exacerbation with increased sputum purulence plus either increased dyspnea or increased sputum volume

Historically favored (ie, first-line) antibiotics based upon randomized trials include doxycycline, trimethoprim-sulfamethoxazole, and amoxicillin. However, amoxicillin is no longer considered a first-line agent because it is inactive against most nontypeable H. influenzae and M. catarrhalis.

Other (ie, second-line) antibiotics are also logical choices for outpatients based upon in vitro activity and trials showing efficacy that is comparable, but usually not superior, to doxycycline and trimethoprim-sulfamethoxazole. Antibiotics in this category include amoxicillin-clavulanate, azithromycin, cefpodoxime, cefprozil, cefuroxime, loracarbef, and the fluoroquinolones. In patients with complicated COPD and risk factors for Pseudomonas who do not have indications for hospitalization, ciprofloxacin is a good choice.

Risk for developing Pseudomonas includes

- Frequent administration of antibiotics (4 or more courses over the past year)

  - Recent hospitalization (2 or more days' duration in the past 90 days)

  - Isolation of Pseudomonas during a previous hospitalization

  - Severe underlying COPD (FEV1 <50 percent predicted)

In-Patients with risk factors should be given IV/PO Levofloxacin 750mg OD OR IV Cefipime/Ceftazidime OR IV Unasyn 4.5g

In-Patients without risk factors should be treated with IV/PO Levofloxacin 750mg OD OR IV/PO Moxifloxacin.

2. Ciprofloxacin vs Moxifloxacin in treating CAP?

Compared with other quinolones, moxifloxacin and gatifloxacin have been shown to have superior in vitro activity against pneumococci. Although this activity may make moxifloxacin or gatifloxacin an attractive choice for pneumococcal infections, these agents should probably be reserved for treatment of infections with atypical pathogens or for life-threatening pneumonias.

The activity of newer generation fluoroquinolones against gram-negative microorganisms is preserved, but they are less active against gram-negative bacteria than is ciprofloxacin. Specifically, these agents are not as active against Pseudomonas aeruginosa as is ciprofloxacin. For other respiratory pathogens, including Moraxella catarrhalis, Haemophilus influenzae, and Legionella pneumophila, both older and newer fluoroquinolones demonstrate excellent activity. For Chlamydia pneumoniae and Mycoplasma pneumoniae, gatifloxacin, gemifloxacin, and moxifloxacin appear to be comparable to one another and superior to ciprofloxacin.

3. Should patients having diarrhea X6/7 be started on antibiotics?

The management of patients with acute diarrhea begins with general measures such as hydration and alteration of diet. Antibiotic therapy is not required in most cases since the illness is usually self-limited. Nevertheless, empiric and specific antibiotic therapy can be considered in certain situations.

Patients with fever or bloody diarrhea, patients with >8stools/day, dehydration, symptoms>1/52, immunocompromised should be considered empiric antibiotics while awaiting culture results.

Empiric therapy with an oral fluoroquinolone (ciprofloxacin 500 mg twice daily, norfloxacin 400 mg twice daily, or levofloxacin 500 mg once daily) for three to five days in the absence of suspected EHEC or fluoroquinolone-resistant campylobacter infection. Azithromycin (500 mg PO once daily for three days) or erythromycin (500 mg PO twice daily for five days) are alternative agents, particularly if fluoroquinolone resistance is suspected.