Allergic Drug Reaction Amanda, Becca, Greg, Robby, Sam Patient - PowerPoint PPT Presentation

Allergic Drug Reaction Amanda, Becca, Greg, Robby, Sam

Patient Presentation Chief Complaint: "My cough is back and I feel like I did when I was admitted two weeks ago."

Problem List 1. Hospital acquired pneumonia 2. Problem: COPD 3. Problem: CVD: S/P MI and HTN

Subjective Data ● Chief Complaint: "My cough is back and I feel like I did when I was admitted two weeks ago." ● AA is a 55-year-old man ● Two weeks ago, he presented to the ER with a 3-day history of tiredness, cough and productive greenish sputum. Sputum cultures at that time revealed Pseudomonas aeruginosa ○ ○ Sensitive to aztreonam and cefepime Intermediate sensitivity to piperacillin–tazobactam and tobramycin. ○ ○ Desensitized to cefepime He was treated for 7 days with IV cefepime without incident. He was discharged ○ from the hospital to his home 2 weeks ago. ● He has had four admissions this year for COPD and pneumonia.

Subjective Data PMH: ● COPD x 17 years ● Chronic empyema secondary to bronchopleural fistulae with chest tube placement 7 months ago ● Right upper lobe abscess secondary to Candida and Aspergillus ; S/P upper lobe lobectomy 11 years ago ● HTN x 10 years ● S/P MI 15 years ago SH: ● Lives with his mother; he is unemployed. He has a 40 pack-year smoking history. Admits to occasional alcohol use; denies use of recreational drugs. ROS ● (+) Fatigue, fever, sore throat, shortness of breath, and cough with thick sputum; (–) nausea,vomiting, diarrhea, chills, or chest pain

ALLERGIES! ● Ampicillin–sulbactam: facial edema, tongue swelling, periorbital edema ● Ceftazidime: urticarial rash on chest and face with shortness of breath ● Codeine: nausea, pruritus

Objective Data Meds ● Albuterol MDI two puffs Q 6 h PRN ● Ipratropium MDI two puffs Q 6 h ● Aspirin 325 mg po once daily ● Amlodipine 10 mg po once daily ● Prednisone 20 mg po daily (initiated as 60 mg po daily during previous hospital admission; plan was to taper the dose and discontinue therapy within 2 weeks of hospital discharge)

Objective Physical Examination: ● Gen: A 55-year-old Caucasian man appearing older than his stated age in moderate respiratory distress. He is lethargic and hard of hearing. ● VS:100/60|85|16|39°C|52 kg|5'5″ ● Skin: Dry scaly skin; no tenting ● HEENT: PERRLA, EOM intact, dry mucous membranes ● Neck/Lymph Nodes: (–) Bruits, (–) lymphadenopathy ● Lungs/Thorax: (+) Diffuse crackles at the left base; wheezes throughout with poor breath sounds ● CV: Normal S 1 and S 2 , RRR, (–) MRG ● Abd: Distended with (+) bowel sounds; (–) hepatosplenomegaly ● Genit/Rect: Deferred ● Ext: (+) Clubbing; (–) cyanosis or edema; poor muscle tone

Objective ABG : pH 7.44, pO 2 55 mm Hg, pCO 2 38 mm Hg, O 2 sat 90% Chest X-Ray : Haziness in the left lower lobe S/P right upper lobe resection Sputum Gram Stain : Pending Sputum Cultures : Pending Blood Cultures : Pending

Labs

Assessment: Pneumonia ● Patient presenting with Hospital Acquired Pneumonia, due to a relapse of recent infection or new infection ● signs and symptoms: PMH, productive sputum, WBC, Neutrophils ● Goals: ○ Initiate antibiotic therapy within 4 hours of arrival at hospital ○ Reduce fever and other symptoms of infection ○ Limit the side effects and avoid allergic reactions Prevent future infection ○ ○ Counsel on side effects

Assessment: Pneumonia ● Treatment options, dosing ranges: Recurrent infection: Gram negative P. aeruginosa ○ ■ Aztreonam (2 g IV every 6-8 hours, Max 8g/day) Cefepime (1 to 2 g IV every 8-12 hours) ■ ○ New infection: MRSA Vancomycin (patient based to Desired peak 20-40 mg/L, ■ Desired trough 10-20 mg/L) ■ Linezolid (600 mg IV every 12 hours) ○ New infection Double coverage : aminoglycoside Gentamicin (3mg/kg/d IV in divided doses every 8 hours) ■ ● Studies: ○ Variability in Antibiotic Prescribing Patterns and Outcomes in Patients With Clinically Suspected Ventilator-Associated Pneumonia ○ Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults

Assessment: Pneumonia ● Patient education/Monitoring consider allergies, ○ ○ skin test ○ possible desensitization ● Non-pharmacological recommendations

Assessment: COPD AA presents with COPD and likely an exacerbation brought on by a pulmonary infection. His staging (according to GOLD Guidelines) needs more information (FEV1/FVC)

Assessment COPD Goals ● relieve symptoms, prevent disease progression, improve health status, treat complications and exacerbations , reduce mortality and quit smoking !

Assessment COPD COPD is evident by PMH (COPD x17 years), clubbing of fingers, multiple recurrent bacterial infections, smoking history and risk factors (smoking, infections/inflammation in airway, socioeconomic status, gender?) Important to treat fully as part of treatment for patient’s overall pneumonia treatment and CVD

Assessment: COPD Pharmacologic and nonpharmacologic therapy recommendations… ● obtain FEV1 to stage properly ● give LABA as needed ● ipratropium while inpatient ○ initiate tiotropium as outpatient better adherence ● give SABA as needed ● give PO corticosteroids for 10x day and taper starting at 40 mg prednisone for 2 days ○ after 10 days D/C SABA initate a combined LABA/corticosteroid ● evaluate vaccine history, once healthy give vaccines (especially influenza and pneumococcal vaccine

Assessment: COPD EDUCATE ON SMOKING CESSATION -Assess patient’s motivation to quit and provide with education on why and how to quit

Assessment: CVD Diagnosis: S/P MI 15 years ago, HTN x 10 years, HTN currently controlled using Amlodipine, reassess blood pressure after HCAP is resolved, (+) Clubbing, Infection may have role in current BP Risk factors: S/P MI 15 years ago, 40 pack year smoking history, HTN x 10 years Goals: Prevent recurrent MI, stroke, atherosclerosis, and control blood pressure below 140/80, Goal HR between 55-60 Secondary Prevention: According to 2013 ACCF/AHA STEMI Guidelines: D/C Amlodipine, Start a cardioselective beta- blocker such as metoprolol for secondary prevention of MI, switch to Aspirin 81 mg per day. Consider starting an ACE-I, such as lisinopril and a HMG CoA Reductase Inhibitor, such as atorvastatin. Blood pressure, fasting Lipid panel and baseline LFTs should be measured upon resolution of current infection. Education: Educate patient on the changes in the medication regimen, and decreasing sodium intake, and increasing exercise. Assess patient’s motivation for quitting smoking, and educate about the benefits of smoking cessation.

Plan: Nosocomial Pneumonia Perform allergic skin test for aztreonam Desensitization Protocol: ● If no reaction is triggered within an hour after the ● Start with 0. 0002 mg in 51ml over 20 minutes test: Watch/wait 10 minute between EVERY ○ ● Initiate aztreonam 2 grams intravenously infusion over 20 minutes every 6 hours for 7 days ● Start with 0. 002 mg in 51ml over 20 minutes ● If a reaction is triggered, initiate desensitization ● Start with 0. 02 mg in 51ml over 20 minutes protocol and titrate up to 2 grams intravenously ● Start with 0. 2 mg in 51ml over 20 minutes over 20 minutes every 6 hours for 7 days. ● Desensitization: (To the right) ● Start with 2 mg in 51ml over 20 minutes ● Start with 20 mg in 51ml over 20 minutes ● Monitor vitals, O2 saturation, breathing sounds, ● Start with 200 mg in 51ml over 20 minutes hypotension, dysrhythmias, hives, facial edema, ● Start with 2000 mg in 51ml over 20 minutes vomiting, sneezing, cough or flushing. ● Administer aztreonam 2g IV every 6 hours per pneumonia protocol

Plan: Nosocomial Pneumonia ● Initiate Gentamicin IV 50 mg every 8 hours Monitor and adjust dose accordingly ○ ■ obtain Peak 3o minutes after admin (4-12 mcg/L) ■ Obtain Trough 30 minutes before next dose (0.5 to 2 mcg/mL) ○ Monitor proteinuria ■ ■ serum calcium, magnesium, potassium and sodium ■ CBC, Fever, symptoms ○ Side effects Ototoxicity ■

Vancomycin Population Dosing Desired peak 20-40 mg/L Desired trough 10-20 mg/L (15-20 if severe) Ototoxicity occurs peak > 80 mg/L Nephrotoxicity occurs trough > 20 mg/L Red man syndrome occurs with infusion > 15 mg/min

Plan: Nosocomial Pneumonia Initiate vancomycin 500 mg intravenously over an hour every 12 hours for 7 days - Monitor peak and trough levels after the 4th dose. - Trough before infusion - Peak should be 2 hours after infusion - Monitor Chem 7, CBC, and auditory and renal function. All antibiotic measures are dependent upon pending cultures.