NUR 635 Topic 9 DQ 2

Sample Answer for NUR 635 Topic 9 DQ 2 Included After Question

John, a 65-year-old male, presents with fever, productive cough with purulent sputum, and pleuritic chest pain. He appears to be confused, BUN 23, respiratory rate 31, and SBP 100. Lower lobe infiltrates were detected on chest x-ray.

He has no recent illness or antibiotic use. His COVID-19 test was confirmed negative. After a thorough evaluation, John is diagnosed with community acquired pneumonia. His patient history indicates that he has an allergy to penicillin. As a child he developed a rash when penicillin was administered. Use the guidelines and relevant literature in your topic Resources to discuss the following:

  • Briefly compare the pneumonia severity index and CURB-65.
  • Based on John’s presentation, what can you determine using the CURB-65 scoring system?
  • What bacteria are associated with CAP? How are these bacteria classified? (e.g. gram-positive, gram-negative, atypical, etc.).
  • Determine an empiric antibiotic treatment regimen for John. In your treatment regimen be sure to include the medication(s), dose, frequency, and intended duration of therapy.
  • Based on the treatment you prescribed, explain your rational for selecting the antibiotics (e.g., bug-drug coverage).
  • What are the key adverse effects associated with the medication(s)?
  • In the event a cephalosporin was included as part of John’s CAP regimen, is his childhood allergy to penicillin relevant? Could there be a problem with cross-sensitivity?

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 1.2, 2.2, 2.5. 4.2, 6.4, 9.2

A Sample Answer For the Assignment: NUR 635 Topic 9 DQ 2

Title: NUR 635 Topic 9 DQ 2

The CURB-65 is a commonly used severity scoring system utilized for the purpose of predicting fatality rates associated with community acquired pneumonia. Its primary function is to assist in the identification of patients who are suitable for outpatient treatment (Nguyen, et.al. 2020).

CURB-65 severity score according to Lim, et. al (2003)

Method:  Score 1 point for eachof following features that are present:

Confusion (mental testscore 8 new disorientation in person, place or time)

BUN > 20 mg/dL

Respiratory rate 30 breaths/min

Blood pressure (systolic<90 mm Hg, or diastolic 60 mm Hg)

Age 65 years
 

Interpretationof CURB-65 score:

0-1: Probably suitable for home treatment;low risk of death
 

2: Consider hospital supervised treatment
 

3:Manage in hospital as severe pneumonia; high risk of death

2. Johnny presented with signs and symptoms that met the criteria for the CURB-65. Based on these factors, Johnny received a score of 3, indicating that he may need hospitalization due to severe pneumonia and a potential risk of mortality.

3. One of the main causes of hospitalization, fatality, and substantial medical expenses is community-acquired pneumonia. Regunath H, Oba Y. (2023) classify the microorganisms that cause pneumonia acquired in the community into two categories: (1) Atypical agents including Legionella, Mycoplasma, Chlamydia pneumoniae, and C. psittaci; and (2) Typical agents like Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, Group A Streptococci, anaerobes, and gram-negative organisms. Based on genetic identification techniques, influenza, SARS-CoV-2 (severe acute respiratory syndrome coronavirus), and other respiratory viruses have been identified as pathogens more often. H. influenzae and S. pneumoniae are the most common causes of acute bacterial pneumonia globally. Streptococcus pneumoniae, influenza virus, and human rhinovirus were the most frequently found pathogens in the United States during the most current population-based active monitoring.

4. With a CURB 65 score of 3, inpatient care is advised for Johnny. For non-intensive care settings, monotherapy with a respiratory fluoroquinolone is recommended since Jonny is allergic to penicillin. Levofloxacin 750 mg per day or Macrolide alternatives: 500 mg IV or po daily, 500 mg po bid, or 500 mg of Clarithromycin for severe (ICU) hospitalization The following are macrolide options: 500 mg of azithromycin IV or po daily, 500 mg of clarithromycin po bid, and Levofloxacin 750 mg IV mg daily or moxifloxacin 400 mg daily are the available fluoroquinolone alternatives. 

Patterson, C. M., & Loebinger, M. R. (2012) state that in cases with low-to-moderate and high severity CAP, respectively, the administration of an antibiotic dosage should begin as soon as possible (preferably within four hours) and continue for a total of seven and seven-ten days. As soon as a patient shows clinical improvement after receiving parenteral antibiotics, they should switch to oral medicine.

5. The following side effects are reported by The Medical Letter (2021) after using antibiotics for community-acquired pneumonia: Penicillins and cephalosporins, which are beta-lactam antibiotics, may induce hemolytic anemia, neutropenia, cholestatic hepatitis, rash, diarrhea, nausea, vomiting, allergic reactions, and seizures.

Doxycycline may result in photosensitivity and gastrointestinal issues. When used in children under the age of eight, it may stunt their development in bone, darken their teeth permanently, and induce hypoplasia of the enamel.

The side effects of azithromycin and clarithromycin include headache, dizziness, vaginitis, and lengthening of the QT interval. Hepatic enzyme increases and dysgeusia are additional side effects of clarithromycin. The FDA has alerted people with heart disease to the possibility that using clarithromycin might raise their risk of cardiovascular morbidity and death. 

Fluoroquinolones may result in peripheral neuropathy, elevated aminotransferase and serum creatinine levels, eosinophilia, neutropenia, leukopenia, tremors, rash, gastrointestinal problems, and photosensitivity responses. Additionally, they have been linked to both extreme hypoglycemia and hyperglycemia, particularly in diabetic patients and elderly persons. There have been effects on the central nervous system, such as delirium, agitation, anxiety, seizures, and problems with concentration, memory, and direction. Additional severe side effects include aortic aneurysm, tendinitis, tendon rupture, diarrhea linked to Clostridium difficile, worsening of myasthenia gravis, QT-interval prolongation, and torsades de pointes (apart from delafloxacin). 

6. Elijaaly, K. & Steven, R. (2017) state that structurally identical side chains, as opposed to the beta-lactam ring itself, are more likely to be linked to cross-reactivity between penicillins and cephalosporins. As an example, the side chains of ampicillin and amoxicillin are the same as those of the first-generation cephalosporins cephalexin and cephradine as well as the second-generation cephalosporin cefaclor. In contrast, the side chains of ampicillin and cefadroxil and cefprozil are different. This stands in stark contrast to the side chain similarity that exists, if any, between later-generation cephalosporins and those found in the penicillin class. It is wise to avoid other beta-lactams in patients with a history of severe non-IgE-mediated or IgE-mediated reactions to penicillins due to the possibility of cross-reactivity even in cases where the side chains are dissimilar. This is especially true if there is no skin testing record or proof that the patient has successfully received other beta-lactams.

References:

Eljaaly, K. & Stevens, R. (2017). Penicillin Allergies and cross reactivity with other Beta-Lactams. Pharmacy Times. 6(3). 

Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI. (2003). Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 58:377-82.

Nguyen, Y., Corre, F., Honsel, V., Curac, S., Zarrouk, V., Fantin, B., & Galy, A. (2020). Applicability of the CURB-65 pneumonia severity score for outpatient treatment of COVID-19. The Journal of infection81(3), e96–e98. https://doi.org/10.1016/j.jinf.2020.05.049

Patterson, C. M., & Loebinger, M. R. (2012). Community acquired pneumonia: assessment and treatment. Clinical medicine (London, England)12(3), 283–286. https://doi.org/10.7861/clinmedicine.12-3-283

Regunath H, Oba Y. (2023). Community-Acquired Pneumonia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.  https://www.ncbi.nlm.nih.gov/books/NBK430749/

The Medical Letter. (2021). Antibacterial drugs for community acquired pneumonia. Meds Lett Drugs Ther.63(1616). 

A Sample Answer For the Assignment: NUR 635 Topic 9 DQ 2

Title: NUR 635 Topic 9 DQ 2

Briefly compare the pneumonia severity index and CURB-65.

The CURB-65 score (confusion, uremia, respiratory rate, blood pressure, age ≥ 65 years) and the pneumonia severity index (PSI) are two tools used to efficiently determine the need for intensive care in patients with community-acquired pneumonia (CAP). The PSI tool determines a risk category (I-V) by using a 20-point scoring system to determine the percentage risk of passing away within 30 days (Zeki et al., 2023). The CURB-65 includes only five variables, and one point is given for each; this score is much simpler to understand and apply than the PSI. In a comprehensive meta-analysis comparing the two tools, both severity scores have identical sensitivity, but the CURB-65 score was more specific than the PSI (Zeki et al., 2023). In other words, the CURB-65 score was more accurate in detecting high-risk patients and is often preferred due to its simpler implementation.

Based on John’s presentation, what can you determine using the CURB-65 scoring system?

The CURB-65 variables are confusion, urea, respiratory rate, blood pressure, and age. John scored 1 point each for confusion, urea, respiratory rate, and age. The CURB-65 score of 4 determines that John is at high right for critical care admission due to his CAP.

What bacteria are associated with CAP? How are these bacteria classified? (e.g. gram-positive, gram-negative, atypical, etc.).

      Gram-positive cocci

  • Streptococcus pneumoniae (second most common)
  • Staphylococcus aureus (25-50% mortality)
  •  

Gram-negative Bacilli

  • Haemophilus influenzae (common in smokers)
  • Legionella pneumophila

Mycoplasma

  • Mycoplasma pneumoniae (most common)


Enteric Gram-Negative Bacilli

  • Klebsiella pneumoniae
  • Anaerobic bacteria (common with aspiration)
  • Chlamydia pneumoniae

Determine an empiric antibiotic treatment regimen for John. In your treatment regimen be sure to include the medication(s), dose, frequency, and intended duration of therapy.

The American Thoracic Society (ATS) recommends that empiric antibiotic therapy should be initiated in adults with clinically suspected and confirmed CAP regardless. Considering John’s penicillin allergy, he should receive combination therapy with a third-generation cephalosporin and a macrolide (Metlay et al., 2019). Given his CURB-65 scores and need for acute care, intravenous antibiotics are indicated. First, Ceftriaxone (Rocephin) 1g IV Q 24 hours for not less than five days and Azithromycin (Zithromax) 500 mg IV Q 24 hours for not less than five days is an appropriate regimen for John (Metlay et al., 2019). If respiratory cultures offer more specific pathogens, antibiotics can be changed or modified.

Based on the treatment you prescribed, explain your rational for selecting the antibiotics (e.g., bug-drug coverage).

Cephalosporins are active against many species of Streptococcus pneumoniae, including cases associated with concurrent bacteremia, Pseudomonas aeruginosaKlebsiella pneumoniae, or Enterobacter species. Ceftriaxone will cover for gram-positive, gram-negative, and anaerobic bacteria.  

Azithromycin, macrolide, is particularly effective against atypical organisms (Chlamydia pneumoniae, Mycoplasma pneumoniae, Legionella species).

What are the key adverse effects associated with the medication(s)?

Azithromycin: for oral route, avoid concomitant use of aluminum- or magnesium-containing antacids due to reduced absorption. Caution in renal and liver impairment. Hypersensitivity is possible at each administration (Rosenthal & Burchum, 2020).

Ceftriaxone: Nausea, vomiting, and abdominal cramps are side effects. Renal dosing may be necessary for dialysis patients and should be administered after dialysis.

In the event a cephalosporin was included as part of John’s CAP regimen, is his childhood allergy to penicillin relevant? Could there be a problem with cross-sensitivity?

When a penicillin allergy is present, it is vital to choose the safest and most effective drug. Penicillin and cephalosporins both contain a ß-lactam ring (CDC, 2022). However, a third-generation cephalosporin has the least chance of cross-sensitivity reactions compared with first- and second-generation cephalosporins.

References

Centers for Disease Control and Prevention. (2022, September 21). Penicillin allergy – STI

treatment guidelines. Centers for Disease Control and Prevention.

https://www.cdc.gov/std/treatment-guidelines/penicillin-allergy.htm

Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., Cooley, L. A.,

Dean, N. C., Fine, M. J., Flanders, S. A., Griffin, M. R., Metersky, M. L., Musher, D. M., Restrepo, M. I., & Whitney, C. G. (2019). Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med, 200(7), e45-e67. https://doi.org/10.1164/rccm.201908-1581ST

Rosenthal, L. D., & Burchum, J. R. (2020). Lehne’s pharmacotherapeutics for advanced practice

nurses and physician assistants – e-book (2nd ed.). Elsevier Health Sciences.

Zaki, H. A., Hamdi Alkahlout, B., Shaban, E., Mohamed, E. H., Basharat, K., Elsayed, W. A. E.,

& Azad, A. (2023). The battle of the pneumonia predictors: A Comprehensive Meta-Analysis Comparing the Pneumonia Severity Index (PSI) and the CURB-65 Score in Predicting Mortality and the Need for ICU Support. Cureus15(7), e42672. https://doi-org.lopes.idm.oclc.org/10.7759/cureus.42672