A Comparison of Available Treatment Regimes for Adult Outpatients with Comorbidities

Antimicrobial therapy is indicated when bacteria are present and causing harm in a patient (infection). Appropriate diagnosis is key to minimizing harm from unnecessary or inappropriate antimicrobial use and for antimicrobial stewardship (preventing the development of resistance). Normal flora should exist in various locations of the body and is necessary for normal functioning.
When choosing an empiric therapy, consider spectrum of activity, likely pathogens for location of infection, patient specific factors, adverse drug effects, drug interactions, pharmacokinetics and pharmacodynamics. De-escalation of therapy is essential if the causative organism is identified.
Please utilize the Pharm Text book I attached in the previous assignment.
Patient education should be provided regarding the benefits and risks of therapy, side effects, and importance of completing the course of therapy.
There are 4 classifications of pneumonia. It is essential to appropriate treatment to accurately determine which type is present.
Effective therapy used for the shortest duration possible should be the goal of pneumonia treatment.
Community acquired pneumonia is common for both outpatient and inpatient prescribers. Be familiar with the appropriate treatment (Table 71-2), common adverse effects, interactions and monitoring parameters.
Acute otitis media is very common, especially in young children. Table 72-2 describes possible agents as well as important considerations (comments section).
Treatment for Acute Bacterial Rhinosinusitis differs depending on the presence or absence of risk factors for resistance (Table 72-3), allergies, causative pathogens, safety and tolerability (Figure 72-3 and Table 72-4).
Pharyngitis is commonly associated with viral upper respiratory infections, however, the most common kind of bacterial pharyngitis is streptococcal (or "strep throat"). Table 72-5 describes treatment options and their uses.
This topic will consist of three components: an introduction to antibiotic regimen selection, lower respiratory tract infections (pneumonia) and upper respiratory tract infections (acute otitis media, bacterial rhinosinusitis, and pharyngitis). The introduction explains how to choose empiric antibiotics based on the location of the infection as well as patient and drug-specific factors. If the causative agent is later identified, de-escalation of antibiotics may be required. Choosing appropriate empiric therapy is essential to treatment success. One of the challenges with the treatment of infectious disease is that there are often multiple correct treatment options for an infection. Using your assessment skills and knowledge of medications, you should be able to choose an agent that is the better choice for a specific patient. We will utilize an approach called "steps" to help with this process during our discussion this week.
Upper respiratory tract infections (URI) include primarily acute otitis media, rhinosinusitis, the "common cold" and pharyngitis. Most URIs are viral, self limiting, and do not require antibiotic treatment. Understanding when to treat with antibiotics is essential to understanding this section. Again, taking into account patient specific factors, adverse effects, drug interactions, etc when choosing is vital to treatment success.
The chapter on lower respiratory tract infections focuses on pneumonia. There are 4 classifications of pneumonia: community acquired pneumonia (CAP), aspiration pneumonia, hospital acquired pneumonia (HAP) and ventilator associated pneumonia (VAP). Be sure to understand how to classify the various types of pneumonia as the treatment for each differs. The treatment choice, dosage, frequency, and duration could vary dependent on the type of pneumonia as well as patient specific factors (renal impairment, recent antibiotic use, allergies, IV/PO preference, etc). Also be sure to consider adverse effects (for example, some antibiotics can cause diarrhea, nausea and vomiting) and drug interactions that may be problematic for certain patients.
Update: HCAP referred to pneumonia acquired in health care facilities such as nursing homes, hemodialysis centers, outpatient clinics, or during a hospitalization within the past three months. This category was used to identify patients at risk for infection with multidrug-resistant (MDR) pathogens. This categorization may have been overly sensitive and may have led to increased, inappropriately broad antibiotic use. Although patients with recent contact with health care facilities are at increased risk for infection with MDR pathogens, this risk is small for most patients and the overall incidence is low. Thus, the category of HCAP was purposefully not included in the 2016 IDSA/ATS guidelines.
Objectives
At the completion of this module the student will be able to:
Antimicrobial Regimen Selection:
describe the role of a Gram stain in classification of bacteria.
understand how to differentiate between colonization and infection.
utilize major drug-specific and patient-specific considerations when selecting antimicrobial therapy.
Lower Respiratory Tract Infections:
recognize risk factors and common organisms for each type of pneumonia (CAP, aspiration, HAP, VAP).
formulate a empiric treatment regimen for patients with pneumonia.
identify essential monitoring parameters for antibiotics used for the treatment of pneumonia.
Upper Respiratory Tract Infections (URI):
differentiate between a viral and bacterial source of sinusitis.
create an empiric treatment regimen for patients with an upper respiratory tract infection.
identify essential monitoring parameters for antibiotic used for the treatment of URI's.
Readings
Pharmacotherapy Principles and Practice
Chapter 69: Antimicrobial Regimen Selection
Chapter 71: Lower Respiratory Tract Infections
Chapter 72: Upper Respiratory Tract Infections
Dynamed Summaries
Community acquired pneumonia in adults https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T115170/
Hospital acquired pneumonia https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T116938/
Upper respiratory infections in adults and adolescents https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T114537/
Acute Rhinosinusitis in Adults: https://wilkes(dot)idm(dot)oclc(dot)org/login?url=https://www-dynamed-com(dot)wilkes(dot)idm(dot)oclc(dot)org/condition/acute-rhinosinusitis-in-adults
Acute Otitis Media in Children: https://wilkes(dot)idm(dot)oclc(dot)org/login?url=https://www-dynamed-com(dot)wilkes(dot)idm(dot)oclc(dot)org/condition/acute-otitis-media-aom-in-children
Module VII Discussions & Assignments
Discussion
When faced with a choice between 2 or more possible answers, using a "STEPS" analysis may be a useful clinical decision making tool. The goal is to provide information for each agent and compare the results to aid in your decision.
S: safety - are there any serious drug interactions? Possible serious side effects or adverse drug reactions?
T - tolerability - consider any adverse drug effects or side effects that may be concerning to the patient such as: diarrhea, headaches, rash, etc.
E - efficacy - is one agent more efficacious than the other for the infection?
P - price - does the patient have insurance? will cost inhibit adherence or access to the medication?
S - simplicity - which regimen is simpler? Once a day dosing will likely have better adherence rates than three times a day dosing. Also, three days of an antibiotic may be preferable to 7-10 days. Depending on the drug you choose, the frequency and duration will vary.
Here's an example table
Drug 1 Drug 2
Safety moderate drug interaction with current medications no drug interactions or serious ADRs
Tolerability diarrhea diarrhea, headaches
Efficacy similar similar
Price/Preference $100/7 days $30/3 days
Simplicity 7 days, once daily dosing 3 days, BID dosing
1. Which one would you choose and why?
2. Identify the available treatment strategies for CAP in an adult outpatient with comorbidities. Create your own "steps" analysis comparing the use of the available treatment regimens. Be prepared to compare and contrast your ideas with your classmates.
Reference: Evaluating the safety and effectiveness of new drugs
Module VII: Respiratory Tract Infections
Assignments
None
Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight. Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.
Special Guidance on APA formatting in Discussion Posts
APA formatting is required in discussion posts with the following two exceptions (due to limitations with the text editor in LIVE): double line space and indent 1/2 inch from the left margin. Discussion posts will NOT be evaluated on those two formatting requirements. All other APA formatting guidelines should be followed. For example, in-text citations must be formatted with the appropriate information and in the correct sequence (Author, year), reference list entries must include all appropriate information following guidelines for capitalization, italics, and be in the correct sequence. Refer to the APA Publication Manual 7th ed. for each source type's specific requirements. Please let your instructor know if you have any questions.