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COMMUNITY ACQUIRED PNEUMONIACLINICAL THERAPEUTICSProblem Based LearningJavid GhanchiStudent ID: 189013091Abbreviation:CAP: Community acquired pneumoniaIHD: Ischemic Heart DiseaseCOPD: Chronic Obstructive DiseaseHTN: HypertensionLTOT: Long Term Oxygen TherapyBTS: British Thoracic SocietyHAP: Hospital acquired pneumoniaBNF: British National FormularyNICE: National Institute of Health and Care Excellence IntroductionPneumonia:Pneumonia is an infection of alveolar sacs of one or both lungs caused by bacteria as a result; alveoli of lungs fill with fluid or pus. This can result lungs become solid. It is one of the leading causes of illness and death in children and elderly. Signs and symptoms include fever, chills, cough, difficult breathing, malaise and chest pain (McFerran, 2017).Types of pneumonia:There are two major types of pneumonia.Community acquired pneumonia:Community acquired pneumonia is lower respiratory tract infection develops outside hospitals and nursing homes. As its lower respiratory infection, typical signs and symptoms include high temperature 38°c chest pain, shortness of breath, sweating and chills dyspnoea, and expectoration (NICE, 2014). Elderly patient over 65 year show confusion as one of the most common symptoms (BTS, 2009).Hospital acquired pneumonia: Hospital acquired pneumonia (HAP) is a type of pneumonia which develops after 48 hours of hospitalization. HAP usually affects 0.5% to 1 % inpatient (NICE, 2014).Aetiology:Community acquired pneumonia mainly caused by bacteria and viruses. Most common pathogens responsible for CAP are as follows: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis. Other less common pathogens are Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella pneumopila. Among all the pathogen Streptococcus pneumonia are most common pathogens in smokers, and usually requires ICU admission immediately (Thorax, 2009, Vidal, 2017).Epidemiology and cost to Healthcare system:Due to high rate of admission and length of stay in hospital, pneumonia has significant impact on National healthcare system (NHS). In UK pneumonia is 6th most common cause of death and kills 29000 patients every year making it 3rd most common cause of death due to lung disease (Chalmers et al, 2017). In UK, 0.5% to 1% adults will have community acquired pneumonia every year, out of this 5-12% patient present to GPs with respiratory problems and from that 22- 42% of patient will be admitted to hospital. From these data Mortality rate for CAP is about 5-14%. (NICE, 2016). In UK NHS spent nearly £11billion on lung disease out of this CAP and COPD a cost NHS £ 1.9 billion each year and asthma cost £3 billion a year (BLF, 2018).Clinical Management of Community acquired pneumonia:Accurate diagnosis of any disease is depend on patient history and physical examination, following test and parameters are very important to diagnose CAP.Physical Examination: Fever more than 37.8C Productive cough Pleural pain Shortness of breath at restRadiology: Patient with below symptoms should perform chest radiography. Increase heart rate High respiratory rate High temperatureLaboratory test: Full blood count and glucose level Urea and electrolytes CRP level and procalcitonin.Microbiological test: Blood culture and sputum culture Urine antigen test for Streptococcus PneumoniaeSeverity assessment tools for CAP:Severity of CAP will be determined by calculating CURB65 score, by giving 1 score to every assessments.1. Confusion2. Blood urea level more than 7mmol/L3. Respiratory rate ≥ 30/min4. Age ≥ 65Depending upon score following judgment will be taken place:Score 0-1 low severity with risk of death ≤3% consider outpatient treatmentScore 2 with moderate risk of death consider inpatient treatmentScore 3-5 high severity of death consider urgent admission and under critical care unit (BTS, 2009).Risk Factor for CAP: Age over 65 years COPD and cigarette smoking Diabetes-mellitus  Chronic renal disease Chronic liver disease Alcohol abuse,  Working in health care system.CAP with co-morbidities:Patient with existing co-morbidities will not have only impact on disease progression but it can cause worst outcome. According to recent study, chances of patient with CAP mortality in hospital will be doubled by presence of one single co morbidity (JM Pereira, 2013).Pharmaceutical Care Plan:Patient Details:Name: Mr C Sex: Male Allergy: not specifiedAge: 76 years Weight: xxx Patient History:Presenting Complaint: Mr. C was admitted to A&E and found confused by his daughter. He has 2 days history of fever, chronic productive cough with thick yellow sputum which is getting worse. Pleuritic pain in the left axillary fossa. Chest x-ray shows an area of consolidation in the left lung.Past Medical/Surgical/Mental Health History: Hypertension (HTN), Ischemic heart disease (IHD), COPD but not on long-term oxygen therapy.Social History: Smoker: – Smokes 20 cigarettes a dayDiagnosis: Community acquired pneumoniaOn admission treatment plan: – Nebulised bronchodilator, steroids, IV antibioticsLaboratory esults: (Lab test online UK, 2018).Parameter Patients result Reference RangeTemperature 2 days history of fever 37.5 °cNa+ Not provided 133-146 mmol/LK+ Not provided 3.5-5.3 mmol/LUrea 9 mmol/L 2.5-7.8 mmolWCC 16.1 3.6-11.0x 109/LpO2 8.9kpa 11-13 kpapCO2 6.2kpa 4.7-6.0 kpaCRP 210mg/L 30 breaths/min) is one of the important factor From Mr C initial assessment history, respiratory rate data is missing, but CURB-65 score for Mr C falls under high CAP severity , so respiratory rate should be monitored at least twice a day and recorded more frequently (BTS, 2015).Blood Pressure Blood pressure is again important factor in determining CURB-65 score, so its monitoring is very important. Even with plan discharge home, patient should be monitor for blood pressure for 24 hours, if blood pressure is below 90mmhg then patient should not discharged. Looking at Mr C’s initial assessment history data on blood pressure is missing, but looking at his CURB-65 score he is falling under high severity of CAP, so blood pressure we assuming may be lower than normal. So it has to be monitored at least twice a day initially and recorded more frequently. Furthermore, Mr C should be on IV fluid treatment to maintain his blood pressure more 90/60mmhg and from his medicine history we can see that he is on Amlodipine tablet, that should be withheld until he is clinically suitable to be discharged, then upon review decision can be made (NICE, 2014).Oxygen Saturation Oxygen therapy is very important in high CAP severity to maintain adequate level of arterial blood gases. Considering Mr C blood result data, level of arterial blood gases are out of range, being COPD patient along with CAP and not being on LTOT therapy disturbed arterial blood gases. Mr C has been started with Oxygen therapy with saturation aiming 92% using 28% venture mask. According to BTS high concentration therapy can reduce hypoxic drive causing risk of hypercapnic respiratory failure in COPD patient. So the aim should be start oxygen therapy with low concentration (24-28%) to maintain oxygen saturation 88-92% without further reduction in arterial pH. Oxygen saturation for CAP patient should be monitored at least twice a day initially (BTS, 2017).Arterial Blood Gases To check blood oxygen level in the body arterial blood gases measurement is most appropriate and accurate method. Level of arterial blood gases measure severity of respiratory failure. In any critically ill patient if, blood spO2 level falls below 94%, arterial blood gases should be measured (BTS bmj 13). Mr C also a COPD patient. His Blood data for arterial blood gases shows that he is hypoxic and the immediate oxygen saturation aiming to maintain spO2 92% should be considered immediately within 30-60 minutes as pCO2 level raised (hypercapnic). As Mr C is hypercapnic, risk of respiratory failure, arterial blood gases should be measured daily until his condition improved (Thorax, 2009).Sputum Culture To find out disease causing bacteria, and to rule out infection such as TB and also to find out how susceptible bacteria to offered antibiotics From clinical data provided for Mr C, sputum culture result is missing, sputum culture should be sent out to laboratory, to find out effectiveness offered treatment of antibiotics, if treatment fails and condition is not improving then we can find out bacterial susceptibility to antibiotics, and alternative treatment can be offered.CRP , WCC, and PCT infection markers To find out about severity of infection C-reactive protein (CRP) and procalcitonin are markers for inflammation and their level at initial stage remain low but rapidly increase in inflammatory disease. Increasing level of these markers in pneumonia shows the progression of disease and therefore they are important risk factor to check the effect of treatment, and their level should be monitor regularly (Menendez et al 2008). Also increased level of WCC (white cell count) shows sign of infection. Looking at Mr C blood result, CRP level and WCC is significantly raised and that shows that his infection severity is very high. Also His CURB-65 score is 3; treatments for infection should be initiated. According to NICE 2014 corticosteroid treatment should not be offered to patient with pneumonia unless they have another co-morbidity which indicates use of corticosteroids (NICE, 2014). However meta-analysis study suggests that use of corticosteroids treatment in CAP reduce the long hospital stay and reduce in hospital mortality rate significantly. Mr C bloods result shows high level of CRP, and also he suffers from COPD, so Corticosteroid treatment should be started (Wu WF, 2018).Chest Radiography To understand and identifying differential diagnosis of pneumonia and COPD. Mr C chest x-ray results suggest that he has consolidation in left lung, which is clear sign of infection. He should be started on antibiotic treatment as soon as possible within 4 hours of hospitalization, and the x- ray should be repeated 3 days later to see the improvement in his condition of lungs and to see effectiveness of treatment (Menendez et al 2008).Clinical Problems and Solution:Problem Problem Type Priority Problem management/SolutionsCommunity acquired pneumonia Potential High Looking at Mr C blood results, there is some information missing and history details not taken correctly. Not having a full picture of clinical data, it is very hard to interpret data efficiently. But as Mr C CURB-65 score falling under high severity CAP treatment should be started as soon as possible.Mr C should be started on nebuliser, IV antibiotics along with steroids. As we have no data on allergy, treatment plan for antibiotics should be considered with alternative option in case Mr C allergic to proposed antibiotics.1. If Mr C is not allergic to penicillin, he should be started on, IV Co-amoxiclav 1.2g three times a day along with macrolide clarithromycin 500mg twice day for 7-10 days, treatment can be extended to 14-21 days if legionella, or suspect Staphylococcus aureus or gram negative bacteria. Levofloxacin strongly recommended adding therapy to above if, legionella present ( Lim et al, 2009, NICE, 2014).2. If Mr C is allergic to penicillin, IV Cefuroxime 1.5g TDS and IV Clarithromycin 500mg Twice a day, consider adding Levofloxacin and extend therapy to 14-21 days as mentioned above.Once Mr C stable switch IV antibiotics to orally.Chronic Obstructive Pulmonary Disease(COPD) Actual High As Mr C has COPD, initially corticosteroids Hydrocortisone 100mg IV every 6 hours should be started and later once it’s possible converts it to prednisolone treatment. Also his pre-admission use of salbutamol inhaler should be withheld and should commenced treatment on salbutamol 5mg and ipratropium 500mcg nebuliser four times a day. pO2 saturation should be maintained between 88-92% using 28% venture mask (Wu WF, 2017).HypertensionDrug- drug interaction Actual Medium Since, incomplete history of medication Amlodipin dose has not been specified, accurate dose of Amlodipin is necessary. As he started on IV fluid, Amlodipine should be withheld and later dose to be reviewed on discharge.The fact is Mr C has been started with IV antibiotics clarithromycin for CAP, which accelerates the action of Amlodipin, Mr C blood pressure is low, so Amlodipine should be withheld to avoid risk of AKI and reviewed on discharge (Raj, 2015).Venous Thromboembolism Potential High For Mr C we need to do risk assessment for venous thromboembolism to evaluate if he is mobile or bed bound. Based on assessment consider low molecular heparin for prophylaxis of VTE (BTS, 2015).Ischemic Heart Disease And Statin Therapy Actual Medium Again, due to incomplete medical history, and the accurate dose of Isosorbide mononitrate, amlodipin, QRISK assessment should be done for IHD.Moreover, details are missing for Mr C statin therapy for IHD. According to recent studies, statin in CAP improve survival rate from infection (Grudzinsk et al. 2017).According to NICE guidelines atorvastatin 80mg should be considered as secondary prevention of cardiovascular disease unless presence of chronic kidney disease or any interactions.Smoking cessation Actual High As Mr C smokes 20 cigarettes a day, as missing details about whether he tried quitting smoking or considered any nicotine replacement therapy. To avoid exacerbation of COPD, Mr C should be advised to stop smoking and should be referred to stop smoking clinic once discharged from hospital.Inhaler Technique Actual Medium As due to not having detailed history of Mr C, we don’t know his adherence to correct inhaler technique. While he is in hospital review on his inhaler technique should be done by respiratory nurse to achieve better control on COPD.Drug Counselling/Medicine adherence :Drug/Medicine adherence issues Problem Priority Problem handling/SolutionsMedicine Adherence Actual High Due to lack of information from Mr C history, we don’t have enough information on his adherence to medication, whether he has carer or anyone who looks after him, also information missing on his doses of his medications. Before his discharge, detailed discussion or review on Mr C understands about medication, knowledge and his concerns should be identified and his full involvement in his treatment is necessary, and choice of his treatment should be respected (NICE 2009).Salbutaol Inhaler Actual High He should be advised to inhale 2 puffs four times a day when required, if he is not complying with direct use of inhaler then advise him to use spacer device (BNF 76).Seretide 500 accuhaler Actual High Steroid inhaler technique should be shown to Mr C, also advice to inhale Two Puffs twice a day, rinse mouth with water to prevent oral thrush (BNF 76).Tiotropium Handihaler Actual High Inhale content of one capsule once a day using provide Handihaler (BNF 76).Amlodipin Actual Medium As We do not have enough information on amlodipine dose from history, by referring BNF Mr C should be prescribed amlodipine 10mg tablet, and that’s one to be taken daily.Aspirin Actual Medium According to BNF Mr C should take One tablet 75mg daily with or after food, if any sign of gastric irritation, Lansoprazole should be considered to protect stomach.Isosorbide Mononitrate Actual Medium As from Mr C medicine history, he taking isosorbie mononitrate but we don’t have accurate dosage information, so as per BNF he should take 20mg isosorbide mononitrate tablet twice a day at 8am and 2pm. Review his dose on discharge.Statin Actual Medium From his history, he is not taking any Statin, as described earlier in clinical problem; he should take Atorvastatin 80mg tablet One daily (NICE 2009).Follow up plan:Follow up Parameters Action/Future PlanDischarge Plan Before discharging Mr C, review should be done within 24 hrs, if he has any of below findings, his discharge should be delayed and microbiologist consultant should re-assess his infection severity, antibiotics, and O2 saturation level and IV fluid (BTS, 2015).• Temperature >37.8C• Heart rate > 100 beat/min• Respiratory rate > 24breath/min• SpO2 level < 90%• Systolic blood pressure less than 90mmHg• Unable to maintain oral intake and mental status.Review Mr C should be called for review at his local GP or at hospital in around 6 weeks time. He should be provided with information leaflet on CAP and it is responsibility of hospital staff to arrange follow up with Mr C and his GP.Vaccination As Mr C is over 65 and suffering from COPD, every year influenza vaccine is recommended. If Mr C not had previous Pneumococcal vaccine, he should be given 23-valent pneumococcal polysaccharide vaccine as per Department of Health guidelines (Julia AE Walters, 2017, NICE, 2014).Smoking cessation Since Mr C is a heavy smoker, with COPD and recent episode of CAP, he should be strongly recommended and referred to local stop smoking clinic.Exercise and general wellbeing Mr C should be advised to do regular exercise and adhere to healthy diet.Conclusion: ????????????References: