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Respiratory Tract Infections Essays

Module VII: Respiratory Tract Infections

 

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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 interactions No drug interactions / 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

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. 

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    • Module 7
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    • Anna McMullen posted Oct 14, 2020 5:51 PM
    • The “STEPS” analysis for clinical decision making is a useful tool when trying to make a clinical decision based on important factors that will influence the patient and their ability to benefit from the treatment. I have often heard people say, “the most expensive drug is the one that does not work,” which refers to the fact that often times providers will prescribe a medication based on its cheap price over its efficacy, safety, and tolerability. The medications in the STEPS analysis provided both indicate similar efficacy. Tolerability for both drugs include side-effects which are not serious and can easily be managed with OTC medications should they become a problem. The main differentiating factor is safety; drug 1 indicates moderate drug interactions whereas drug 2 indicates no interactions. Differences exist between price and simplicity as well, though neither regimen is overly complicated or intrusive; drug 1 is only once a day but must be taken for 7 days whereas drug 2 is only 3 days but must be taken twice a day. For many patients, choice of therapy is ultimately dictated by out-of-pocket cost, and in this example, drug 1 is significantly more expensive for the treatment duration, $100/ treatment, whereas drug 2 is only $30/ treatment. With all of these factors considered, I would recommend drug 2, first and foremost due to its preferable safety profile, and secondly due to its considerably lower cost; all other factors between the two drugs are relatively comparable.
      Combination Therapy Amoxicillin/ Clavulanate AND a macrolide or doxycycline Monotherapy

      Respiratory Fluoroquinolone
      Safety Minimal drug interactions

      May interact with allopurinol, blood thinners, or other antibiotics (Cunha, 2020).

      		 Moderate drug interactions

      May interact with: tizanidine, clozapine, cyclosporine, glyburide, methotrexate, metoclopramide, phenytoin, probenecid, ropinirole, theophylline, NSAIDS, steroids (Cunha, 2020).
      Tolerability More medication classes to ensure there is no drug allergy.

      Overall, main side-effect is GI.

      		 Serious potential adverse reactions

      FDA issued a Boxed Warning and included in the Warnings and Precautions sections of medications in the fluoroquinolone drug class to describe the “serious risk of multiple disabling and potentially irreversible adverse reactions that can occur together”(FDA Updates Warnings for Oral and Injectable Fluoroquinolone, 2018)”
      Efficacy Similar

      Effective against most common bacterial pathogens (Metlay et al., 2019).

      		 Similar

      Effective against typical and atypical organisms (Metlay et al., 2019).
      Price/ Preference Augmentin (Amoxicillin/ Clavulanate) as low as $13.59 (875mg/125mg- 20 tabs) (Augmentin, 2020)

      Doxycycline as low as $11.34 (100 mg- 20 caps) (Doxycycline Hyclate, 2020)

      		 Levaquin (Levofloxacin) as low as $9.01 (Levofloxacin, 2020)
      Simplicity Combination therapy Monotherapy

      When treating a patient with CAP with comorbidities, standard of care is either combination therapy of amoxicillin/ clavulanate (Augmentin) with a macrolide or doxycline, or monotherapy with a respiratory fluroquinolone (Metlay et al., 2019).  Metlay et al. (2019) indicate that both sets of recommendations contain multiple antibiotic options and that there is no order of preference listed. Liu et al. (2019) performed a meta-analysis comparing respiratory fluroquinolones vs. B-lactams with or without macrolides for hospitalized CAP patients and concluded that for these patients, respiratory fluroquinolone monotherapy has similar efficacy and favorable safety profile compared to B-lactams with or without macrolides. Metlay et al. (2019) in their official clinical practice guidelines for the treatment of adults with CAP indicate that despite growing concern over adverse events associated with fluoroquinolones that this therapy is justified for adults with CAP and comorbidities for the following reasons: they have very low resistance rates in bacterial causes of CAP, cover both typical and atypical organisms, have the convenience of monotherapy, and have a relative rarity of serious adverse events related to their use. Antibiotic resistance is another factor that must be faced when prescribing treatment for CAP. In their meta-analysis, Liu et al. (2019) found that compared to fluroquinolones, drug resistance was more prominent in comparator antibiotics, particularly macrolides. Combination therapy also presents the risk of more drug-drug interactions, side-effects, and resistance.ReferencesCunha, J. (2020, April 21). Augmention vs. cipro. RxList. https://www.rxlist.com/augmentin_vs_cipro/drugs-condition.htmFDA updates warnings for oral and injectable fluoroquinolone. (2018, March 8). U.S. Food and Drug Administration. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-updates-warnings-oral-and-injectable-fluoroquinolone-antibioticsLiu, S., Tong, X., Ma, Y., Wang, D., Huang, J., Zhang, L., Wu, M., Wang, L., Liu, T., & Fan, H. (2019). Respiratory fluoroquinolones monotherapy vs. β-lactams with or without macrolides for hospitalized community-acquired pneumonia patients: A meta-analysis. Frontiers in Pharmacology, 10. https://doi.org/10.3389/fphar.2019.00489 less0 UnreadUnread

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    • View profile card for Anna McMullen
    • Last post Oct 19, 2020 2:11 PM by Anna McMullen
    • 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. American Journal of Respiratory and Critical Care Medicine, 200(7), e45–e67. https://doi.org/10.1164/rccm.201908-1581st
    • Levofloxacin. (2020). GoodRx. https://www.goodrx.com/levofloxacin
    • Doxycycline Hyclate. (2020). GoodRx. https://www.goodrx.com/doxycycline-hyclate
    • Augmentin. (2020). GoodRx. https://www.goodrx.com/augmentin
    • Overall, I think that either regimen would be okay for this patient, assuming that the patient has not used any of the above antibiotics in the past three months, does not have an allergy to any of the medications, and as long as the patient is not taking any medications which would interact with the medications prescribed. Based on the research presented, adverse events seen with respiratory fluroquinolones do not significantly outweigh those seen with combination therapy (Liu et al., 2019). However, if an adverse event does occur, it is likely to be more serious (FDA Updates Warnings for Oral and Injectable Fluoroquinolone, 2018). Though the simplicity of taking one antibiotic as opposed to two and paying for one antibiotic is overall more affordable, neither of these components are significant enough in my eyes to be a deal breaker between treatments (ex. if combination therapy was $200 and monotherapy $10, or vice versa, that might make more a difference in someone’s budget). Therefore, in regard to overall safety and tolerability profile, I would recommend combination therapy for this patient.
    •             STEPS analysis for CAP for an adult patient with comorbidities
    • Module VII – Candace Whitman-Workman
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    • Candace Whitman-Workman posted Oct 14, 2020 7:34 PM
    • Respiratory InfectionMy rationale for choosing Drug 2 is cost.  Drug 2 is significantly cheaper than Drug 1 and lesser cost would improve the likelihood of the patient actually purchasing and using it.  Another factor leading to my choice is the drug regimen.  Granted Drug 2 is to be taken twice per day, it is only taken for three (3) days which, in my opinion, would also enhance compliance with completing the entire drug course.  If this were an actual situation, we would know what medications the patient was on and could make a better informed choice where safety (S) is concerned as we would readily be able to identify if there are any drug to drug interactions to consider.  As far as tolerability (T) goes, both Drug 1 and 2 can cause diarrhea and Drug 2 can also cause headache, but it is far more tolerable when there are only three (3) days of negative side effects versus seven (7) days.  As previously mentioned, I am concerned regarding the serious adverse drug reaction listed, but without knowing what exactly this entails, I would continue to choose Drug 2.  If this were of greater potential for this particular patient, my decision would obviously be effected and changed.  Another factor in choosing Drug 2 is the reduction of risk in developing multi-drug resistant organisms (MDROs), a benefit of using antibiotics for only three (3) days.  In a study conducted by Bashir & Gray (2017), interventions were placed reducing the length of antibiotic usage.  In this study, despite the shortened time frame, infections improved and there was no negative patient outcome and drives home the judicious use of antibiotics improves patient outcomes.   Community Acquired Pneumonia (CAP) is commonly caused, according to Chisolm-Burns et al. (2019), by mixed viral and bacterial flora. Pneumonia resulting from mixed infections occurs in up to 56% of pneumonia cases with Streptococcus Pneumoniae being the primary pathogen.  We know this patient is outpatient with comorbidities, but the comorbidities are unknown.  We also do not know when this patient last used antibiotics.  If this particular patient has not used any antibiotics within the prior three (3) months, Chisolm-Burns et al. (2019) recommends starting a respiratory fluoroquinolone alone or a combination of an oral B-lactum agent plus a macrolide or azalide.  Personally, I would simply the regimen by using a respiratory fluoroquinolone alone.  Moxifloxacin and gemifloxacin are preferred over levofloxacin as, they have “added benefit of reducing resistance selection and enhancing bacterial eradication” (Wispelwey & Schafer, 2010).
      STEPS Moxifloxacin Amoxicillin
      Safety Potentially irreversible serious side effects, food/drug interactions, drug/drug interactions Drug/drug interactions
      Tolerability Well tolerated; diarrhea, ease in sun burning Many, diarrhea, pain, tarry stool, etc
      Efficacy similar Requires high dose and second antibiotic for treatment
      Price/Preference $20-$60 w/ coupon $5-$8 w/ coupon, plus cost of second antibiotic
      Simplicity Single daily (400mg) dosing for 7 days 500mg Q8 hours

      ReferenceChisolm-Burns, M. A., S, Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, J. M., & Bookstaver, P. B. (2019). Pharmacotherapy Principles & Practice (Fifth ed.). McGrraw-Hill Education.Wispelwey, B., & Schafer, K. (2010). MedScape. Retrieved from Fluoroquinolones in the management of community acquired pneumonia in primary care: https://www.medscape.com/viewarticle/736439less0 UnreadUnread

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    • View profile card for Kelly Miskovsky
    • Last post Oct 19, 2020 10:46 AM by Kelly Miskovsky
    • Pegler, S., & Underhill, J. (2010). Evaluating the safety and effectiveness of new drugs. American family physician, 82(1), 53–57.
    • Bashir, A., & Gray, J. (2017). Fight antibiotic resistance – it’s in your hands to improve antibiotic stewardship. Journal of Hospital Infection, 95(4), 361-362. doi:10.1016/j.jhin.2017.02.018
    • CAP
    • Even using a STEP analysis, this is a difficult decision.  There are so many unknown factors in this case study that could drastically impact my decision as a provider.  Pegler & Underhill (2010) describe the STEP analysis when considering newer medications.  However, from this situation, we do not know if these are tried and true drugs or newer to the market medications.  Another unknown factor that is particularly concerning and one that could definitely change my decision is the lack of information regarding the serious ADRs.  However, given the information available, I would tend to choose Drug 2.
    • Module VII Discussion Post
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    • Gisselle Mustiga posted Oct 14, 2020 11:53 PM
    •            Considering the STEPS analysis, I would prefer using Drug 2. Compared to drug 1, with moderate drug interaction with current medications, Drug 2 has no drug interaction issues; therefore, it’s safer. Based on their prices, the drug seems cheaper, $30/ 3 days than drug 1, which costs 100 dollars and is used for 7 days. It should be noted that most patients and clients prefer taking drugs for the shortest time possible. Adhering and taking drugs for a more extended period seems to be tiresome and challenging. Therefore, drug one seems to be more favorable as it involves taking 2 drugs per day for 3 days.
      Macrolides (level A) such as azithromycin Amoxicillin
      Safety Has significant interactions in patients with Colitis and QT prolongation. It has severe interactions with Advair Diskus. No severe interactions. Mild interactions with amiloride and clarithromycin
      Tolerability Mild diarrheas, rash, abdominal pain, vomiting, and nausea Mild Diarrhea, rash, vomiting, and nausea
      Efficacy 67/.1 % efficacy 98.6% efficacy (Beghi et al. 1995)
      Price/Preference Between $49 and $60 for oral doses. / 4 days $ 4/ 10 days
      Simplicity One day oral dose of 500 mg, then 250 mg once per day for four doses 500mg orally, every 8 hours

      Considering the Price, drug safety, efficacy percentage, and drug tolerability, Amoxicillin seems to be the best option for outpatient clients.AAFP (2020). Diagnosis and Treatment of Community-Acquired Pneumonia. American Family Physician. https://www.aafp.org/afp/2006/0201/p442.html#sec-4 less0 UnreadUnread

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    • View profile card for Kelly Miskovsky
    • Last post Oct 19, 2020 10:43 AM by Kelly Miskovsky
    •  
    • Beghi, G., Berni, F., Carratù, L., Casalini, A., Consigli, G., D’Antò, M., Gioia, V., Molino, A., Paizis, G., & Vaghi, A. (1995). Efficacy and tolerability of azithromycin versus amoxicillin/clavulanic acid in acute purulent exacerbation of chronic bronchitis. Journal of chemotherapy (Florence, Italy), 7(2), 146–152. https://doi.org/10.1179/joc.1995.7.2.146
    •  References
    •           CAP is a potentially severe illness that is associated with severe morbidity and mortality. Therefore, CAP should be treated and managed using appropriate medication and methods. Treatment of outpatient clients with moderate and low morbidities involves the use of antibiotics, including macrolides (level A) such as azithromycin and Amoxicillin (AAFP, 2020). The STEPS analysis can compare the two treatment methods to see the most effective in terms of cost, efficiency, and simplicity.
    • Module 7
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    • Carlita Lockett posted Oct 12, 2020 12:26 AM
    •            Both of the medications carry side effects which are not becoming.  In this case, I would be inclined to choose Drug 2.  I would choose this drug because it is the safest drug without any interactions or serious adverse drug reactions.  Drug 1 costs $14.29 per day to take whereas Drug 2 costs only $10 per day.  The costs of Drug 1 would save the patient $4.29 a day.  The simplicity of the dosage would be another reason why Drug 2 is the most appropriate choice.  Drug 1 is given once daily for 7 days. It is comparable to taking a medication twice a day for 3 days.  It is less likely that Drug 2 will have an issue with compliance due to the shortened period of prescribed days.   Although both drugs have diarrhea as a side effect, a prophylactic analgesic could be prescribed to offset the chance of experiencing a headache by taking Drug 2.                                   Drug 1 (amoxicillin/clavulanic acid)                    Drug 2 (levofloxacin)                                  with urine glucose test                                  skin rash, headache, stomach pain                insomnia, dizziness, nausea,                                                                                                           acute liver failurePrice/Preference     $0.56/tablet or $11.20/10 days                     $1.27/tablet or $6.35/5 days           Although both medications treat the CAP similarly, choosing levofloxacin could prove to be the wrong choice.  Outpatients are treated orally with penicillins, macrolides, tetracyclines, or fluoroquinolones with anti-pneumococcal activity (i.e. moxifloxacin or levofloxacin) (Kolditz et al., 2016).  The price of the levofloxacin is more cost-effective between the two drugs.  It also has the strongest likelihood of adherence with only having to be taken once for 5 days.  This drug has multiple side effects ranging from common, infrequent, to rare.  Based on the side effects and the many drug interactions I believe the best choice would be to take the amoxicillin/clavulanic acid.  The drug costs slightly more and requires to be taken more often, but the safety and tolerability of the amoxicillin/clavulanic acid make it the most appropriate drug of choice. Ewig, S. & Kolditz, M. (2017).  Community-acquired pneumonia in adults.  Deutscheshttps://doi.org/10.3238/arztebl.2017.0838management, and treatment of community-acquired pneumonia.  F1000 Research,https://doi.org//10.12688/f1000research.7657.1

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    • View profile card for Gisselle Mustiga
    • Last post Oct 18, 2020 10:37 PM by Gisselle Mustiga
    • 5(300), 1-11.
    • Kolditz, M., Ott, S., Pletz, M.W., Rohde, G.G., & Welte, T. (2016).  Advances in the prevention,
    • Arzteblatt International, 114(49), 838-848.
    •                                                     References:
    •           Patients with mild community-acquired pneumonia (CAP) who have chronic illness should be treated with a combination including a beta-lactamase inhibitor (amoxicillin/clavulanic acid), which widens the spectrum of efficacy to cover S. aureus, enterobacteria, and beta-lactamase-producing H. influenzae (Ewig & Kolditz, 2017).  If the adult outpatient did not have any comorbidities they would have only received a high dose of amoxicillin.  The use of Augmentin would come at a higher cost and would likely result in non-adherence due to the dosing times and length.  It could be difficult to take this medication as scheduled.  This drug has fewer adverse drug reactions and has manageable side effects.
    • Simplicity                  10 days, BID dosing                                         5 days, once-daily dosing
    • Efficacy                     Similar                                                              Similar
    •                                                                                                            rhabdomyolysis, jaundice,
    • Tolerability                Nausea, vomiting, diarrhea,                          Constipation, diarrhea, H/A,
    • Safety                        Singular drug ADR, may interfere                       Moderate drug interactions
    • Module V11 Discussion: Respiratory Tract InfectionsSubscribe
    • Augusta Ibeh posted Oct 14, 2020 10:46 PM
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    •             The goals for value-based payment are to give healthcare adequate resources to deliver efficient, quality care and to remove the penalties that exist today for improving quality and efficiency Institute of medicine (2010). Choosing the treatment(s) for patients with conditions with the use of “STEPS” will help to promote recovery, reduce complications, hospital days, readmissions and reduce cost. The clinical trials of drugs on human starts after the Investigational New Drug Application is reviewed by the Food and Drug Administration and local Institutional Review Board panels of scientists and non-scientists in hospitals and research institutions have overseen the clinical research. The clinical approval go through phases before drugs are put in the market to be used in the treatment of diseases Center for Drug Evaluation and Research. (n.d.).Mahboub, Al Zaabi, Ahmed, Niederman, & El-Bishbishi (2015). Treatments and improving patient’s health with CAP without complications has been the priorities of healthcare providers and as such guidelines had been developed to be followed when caring for patients with CAP.            Using the “STEPS” analysis I will choose the number drug and my reasons are:ReferenceCenter for Drug Evaluation and Research. (n.d.). The FDA’s Drug Review Process: Ensuring       Drugs Are Safe and Effective. Retrieved from https://www.fda.gov/drugs/drug-          information-consumers/fdas-drug-review-process-ensuring-drugs-are-safe-and-effectiveMahboub, B., Al Zaabi, A., Al Ali, O. M., Ahmed, R., Niederman, M. S., & El-Bishbishi, R. (2015). Real life management of community-acquired Pneumonia in adults in the Gulf region and comparison with          practice guidelines: a prospective study. BMC pulmonary medicine, 15, 112.    https://doi.org/10.1186/s12890-015-0108-x less1 UnreadUnread10 ViewsViews
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    • View profile card for Shante Hunt
    • Last post Oct 18, 2020 2:38 PM by Shante Hunt
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  • Module 7 Respiratory Tract Infections
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  • Robin Morgan posted Oct 12, 2020 5:33 PM
  • Discussion 7 Advanced PharmacologyIn reviewing our 2 drug choices in the table assignment; I would choose drug #2. My reasoning is STEPS. Safety, drug #1 interact with other medications, but no serious ADR’s listed. Drug #2 has no drug interactions, but a potential for ADR’s. Since I do not know the medication history of our patient, I don’t know what other drugs this medication may interfere with? I would go with drug #2 so as not to worry about the interactions, but monitor for ADR’s. Tolerability, as both drugs have the potential for diarrhea that is an even reaction, drug #2 does have the potential for a headache, but since its only taken for 3 days the diarrhea has less potential to disturb fluid and electrolytes in the long run. Efficacy is important, but both these drugs work well. Price is much better for drug #2 at only $30 for three days, this is a big plus in my book. Simplicity, while drug #1 is only taken one time per day, it has to be taken for 7 days, and 7 days of diarrhea may cause many to stop taking the drug by at least day 5. Drug #2 is twice per day, but only for 3 days, I feel most people will be compliant for the first 3 days, and understand that any side effects will soon be gone.When reviewing the choices for monotherapy with fluroquinolones the main drug choices are; levofloxacin, Gemifloxacin, moxifloxacin.If after assessing this patient I found his CAP to be mild, I would start with monotherapy. As any of the Fluroquinolones seem to have a good efficacy and are generally well tolerated. I would prescribe Gemifloxacin for its short duration of 5 days, I would then reevaluate my patients’ condition. If within the 5 days he continues to worsen, I would change to a dual therapy, and even evaluate the need for hospitalization.Beta-lactams; Amoxicillin or amoxicillin-clavulanate (Augmentin). Amoxicillin and Augmentin have the similar side effects mostly with the GI tract, while Augmentin has a few more such as headache and bloating. There is the potential for several drug interactions with either of these two drugs, both may make birth control inactive. These drugs are very effective antibiotics, as Augmentin could be prescribed if an infection is antibiotic resistant or amoxicillin alone does not work. The dosage of both Amoxicillin and Augmentin is 500mg every 8 hours or 875 mg every 12 hours for 7-10 days.  Augmentin is available in extended release tablets and can be taken only one time per day for 7-10 days. These drugs are both available in generic forms and are relatively inexpensive. Other available Beta-lactam are cefpodoxime and cefuroxime, both of these drugs have high drug interactions, about the same side effects as other beta-lactams, are taken every twelve hours and have good efficacy against CAP, but both are tier 2 medications with a higher cost. As monotherapy for CAP beta-lactams would be used with macrolides; Clarithromycin, and Azithromycin. Clarithromycin 250mg every 12 hours for 5-7 days, side effects are minimal, interacts with many medications, efficacy very effective for upper and lower respiratory infections, this drug is a tier 2 and may be more expensive than others around $186 without insurance. Azithromycin 500 mg daily for three days, Azithromycin and Clarithromycin are both generally well tolerated and the efficacy of both these drugs is good.  Azithromycin interacts with less medication that Clarithromycin, Azithromycin is a tear 2 medication and is similar in cost to Clarithromycin.   ReferencesEdmunds, M. W. (2016). Escalating cost of medications may influence prescribing. The Journal for Nurse Practitioners, 12(3), A17–A18. https://doi.org/10.1016/j.nurpra.2016.01.002 less0 UnreadUnread
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  • View profile card for Karen Halter
  • Last post Oct 16, 2020 10:45 AM by Karen Halter
  • Leschenko, I. V. (2017). Community aquired pneumonia in adults: Possibilities of treatment in outpatient conditions. Medical Council, (18), 108–114. https://doi.org/10.21518/2079-701x-2017-18-108-114
  • Circh, R. (2016). Community-acquired pneumonia. Oxford University Press. https://doi.org/10.1093/med/9780199976805.003.0022
  •      If this patient has a further need for dual therapy antibiotics for CAP, I would order the combination of beta-lactide and a macrolide. I would prescribe the beta-lactide Augmentin as at this point the patient needs a more potent antibiotic, side effects and cost of both Amoxicillin and Augmentin are almost identical, and cost of both relatively low. The macrolide I would choose would be Azithromycin for a cost effectiveness and once daily dose.
  •      Beta-lactam plus a macrolide is the recommended dual therapy for CAP in the outpatient setting, Dual therapy is recommended in more serious cases of CAP or when monotherapy is not improving the pneumonia.  It is good to note that if this patient has been treated with antibiotics in the last 3 months, then doxycycline should be used as part of the dual therapy with Beta-lactam(Circh, 2016).
  • Levofloxacin-750 mg po daily for 10days, side effects usually mild, moderate amount of drug interactions, treatment would cost about $20 without insurance. Gemifloxacin- 320mg po for 5 days, side effects usually mild, moderate amount of drug interactions, the cost is around $50 without insurance. Moxifloxacin- 400mg daily for 7-10 days. Side affects generally mild, interacts with other medications, relative comparative in cost to Gemifloxacin as there is a generic available.
  •      When treating CAP outside a hospital setting in a patient with co morbidities the first recommendation for antibiotics is respiratory fluroquinolone, or an oral beta-lactam antibiotic plus a macrolide(Leschenko, 2017).
  • Medication can be very expensive, insurance companies often refuse to cover more expensive medications when more cost-effective medications are available, in order to obtain more expensive medications, the provider must show that less expensive drugs were ineffective or caused too many side effects. As healthcare prescribers we want to attempt to keep the cost down for the patient in order for them to be compliant with medications and continue with medication compliance(Edmunds, 2016).
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  • Kathryn Mosholder posted Oct 14, 2020 10:41 PM
  • In this case study, I would choose drug number one because of its convenience of once-daily dosing. Patients are more likely to be compliant with medication regimens taken once daily. Regarding safety, drug one does have more drug interactions than drug number two. Still, it is possible to decide the drug interactions with the current patient’s med list and either change the medication regimen or eliminate drugs it interacts with and starts the patient on substitutes. Tolerability is in drug one’s favor because it only has the side effect of diahrea and not diahrrea and headache. Many patients find that they can not tolerate headaches and seek other means of reducing them, such as narcotics, NSAIDs, and street drugs; a provider with Immodium and diet efficiently manage diarrhea (Andersson et al., 2017). Efficacy is the same for both drugs, so this does not affect the choice of one or the other.In the steps to decide on a medication, S stands for safety. For a patient with Community-Acquired Pneumonia, I would start with an MRSA coverage drugs such as Vancomycin, second a Gram-Negative B-Lactam Antibiotics with Antipseudonomal Activity such as Cefepime, and third a Gram-Negative Non-B Lactam Antibiotic with Antipseudomonal Activity such as Levofloxacin (Chisholm-Burns et al., 2019). Antibiotics should be used for only a short period. Long term antibiotics can cause C-Diff and overgrowth of yeast (Chisholm-Burns et al., 2019). The T in Step stands for tolerability (Chisholm-Burns et al., 2019). The Provider needs to check the allergies of patients before determining an antibiotic and the patient’s condition (Chisholm-Burns et al., 2019). A well-nourished patient with no comorbidities will tolerate antibiotics better than a compromised patient (Chisholm-Burns et al., 2019). Chisholm-Burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Bookstaver, P. B., & Lee, K. C. (2019). Pharmacotherapy principles & practice. McGraw-Hill Education. less0 UnreadUnread
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  • View profile card for Kelly Miskovsky
  • Last post Oct 15, 2020 9:21 AM by Kelly Miskovsky
  • Jensen, J. S., Ipsen, H. L., & Jørsboe, H. (2015). High use of antibiotics in elderly patients at discharge after hospitalization for acute abdominal pain. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 23(S1). https://doi.org/10.1186/1757-7241-23-s1-a25
  • Andersson, M., Persson, M., & Kjellgren, A. (2017). Psychoactive substances as a last resort-a qualitative study of self-treatment of migraine and cluster headaches. Harm Reduction Journal, 14(1), 60–10. https://doi.org/10.1186/s12954-017-0186-6
  • E is for Efficacy, and after the bacteria, the patient is carrying is determined. After blood and sputum cultures, the antibiotic regiment might need to be changed. P is for the price, which is always determined by the hospital’s contracts and medication availability (Chisholm-Burns et al., 2019). Price should not play a significant factor in treatment if the patient is hospitalized (Chisholm-Burns et al., 2019). S is for simplicity. It is not easy to run three IV drugs, and the patient’s veins do tire quickly of Vancomycin (Chisholm-Burns et al., 2019). It is essential to consider the patient’s condition before determining if a three IV antibiotic treatment is a good idea (Chisholm-Burns et al., 2019). In most cases, even getting one or two IV antibiotic treatments into a patient is more effective than no medication (Chisholm-Burns et al., 2019).  After the patient is stable, switching from IV to po would be more patient ideal and assist with continued medication compliance after discharge from the hospital (Chisholm-Burns et al., 2019). Elderly patients are especially at risk for poor medication compliance (Jensen et al., 2015) Hospital readmission rate is higher for elderly patients due to them not understanding their medication regiment and how to manage their acute condition with their chronic conditions (Jensen et al., 2015).
  • Regarding the two drugs’ prices, one is more expensive than drug two; however, I recommend the patient ask for the discounted drug price. Many times pharmacies can give coupons for drugs that have high costs. If this is not an option, I would see if the patient’s insurance will cover the script. Regarding simplicity, drug number one is more straightforward regarding the fact that medication is once daily. Patients remember to take medication more effectively when it is only once a day once-daily dosing increases medication compliance.
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  • Shante Hunt posted Oct 14, 2020 6:51 PM
  • Community acquired pneumonia (CAP) treatment in patients with co-morbidities should include combination therapy with Augmentin and a Z-pack, or monotherapy Levaquin (Metlay et al, 2019).  Practice guidelines also state that treatment should begin empirically and does not require culture to begin therapy (Haik, 2020) thus possibly improving patient outcomes by starting treatment immediately.  Using the STEPS procedure, I would compare a regimen of Augmentin 875/125 twice daily for five days, and Azithromycin (Z-pack) for five days versus Levofloxacin 750 mg daily for five days.  For pricing purposes, I have used prices available in my local area without insurance coverage using a discount card program which is free to obtain.Regimen #1Azithromycin 500 mg day one, then 250 mg for four remaining days- $13.55 Regimen #2
    Augmentin/Z-pack Levofloxacin
    S- prolonged bleeding time with Warfarin S- moderate interactions with aspirin and some bronchodilators; major interaction with Warfarin
    T- major side effects nausea, vomiting, diarrhea, dizziness, change in heart rate T- major side effects include headache, diarrhea, insomnia, constipation and dizziness
    E- similar E- similar
    P- $33.42 for five day regimen P- $45.79 for five day regimen
    S- requires twice daily dosing (BID for Augmentin; daily for Z-pack S- once daily dosing required
  • Metlay, J., Waterer, G., Long, A., Anzueto, A., Brozek, J., Crothers, K., Cooley, L., Dean, N., Fine, M., Flanders, S., Griffin, M., Metersky, M., Musher, D., Restrepo, M., & Whitney, C. (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. American Journal of Respiratory & Critical Care Medicine, 200(7), e45-e67. http://dx.doi.org.wilkes.idm.oclc.org/10.1164/rccm.201908-1581ST
  • Haik, W. (2020). Physicians: Review new community-acquired pneumonia guidelines for 2020. Briefings on Coding Compliance Strategies, 22(11), 1-3. http://web.b.ebscohost.com.wilkes.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=5&sid=8899d3a8-b6d3-43a2-b33b-374073880550%40pdc-v-sessmgr05
  • Drugs.com. Levofloxacin. Retrieved October 14, 2020, from https://www.drugs.com/mtm/levofloxacin.html
  • Drugs.com. Azithromycin. Retrieved October 14, 2020, from https://www.drugs.com/azithromycin.html
  • Drugs.com. Augmentin. Retrieved October 14, 2020, from https://www.drugs.com/augmentin.html
  • References:
  • In the first example provided above, I would recommend the $30/3 day regimen due to shorter duration of treatment, lack of major drug interactions and adverse effects, and cost-effectiveness of the regimen.
  • Based on the above information, I would recommend the combination treatment over monotherapy.  While the combination therapy requires one additional dose per day and two medications, the cost is lower for the patient and there are less major drug interactions than with monotherapy with Levofloxacin.
  • Levofloxacin 750 mg daily for 5 days- $45.79 (Drugs.com)
  • Total cost- $33.42 for five days of treatment (Drugs.com)
  • Augmentin 875/125 twice daily (5-day regimen)- $19.87
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