Respiratory Pharmacy Lecture – Zacharry Dougherty PharmD

Community Acquired Pneumonia (CAP)

• ATS/IDSA guidelines for treatment of adults with CAP
• Typical organisms include strep pneumoniae, H. Influenzae, M. pneumoniae
• Be aware if the patient has a history of MRSA / Pseudomonas colonization
• Risk stratify patients with a calculator such as Pneumonia Severity Index (PSI) to determine inpatient vs outpatient treatment.

Outpatient:

• With vs without comorbidities
• Without (Single agents): Amoxicillin 1000mg TID, Doxy 100mg BID, Azithromycin 500mg daily for 3 days.

Azithromycin monotherapy not recommended due to local S. pneumoniae resistance rates

• With: Augmentin 875mg BID plus doxy or azithromycin for 7 days
• Cefpodoxime 200mg BID or Cefuroxime 500mg BID plus doxy or azithromycin for 7 days
• Levofloxacin 750mg daily for 7 days

Clinical success is highest with cephalosporins.

Cefdinir technically has appropriate coverage, however some strains of these bacteria have resistance to this, and for this reason, it is not recommended by the ATS/IDSA

Multi Drug Resistant (MDR) Coverage:

• Doxycyline 100mg BID for MRSA coverage and Levofloxacin 750mg daily for p. aeruginosa

Always consult your hospital antibiogram

Inpatient (Nonsevere vs Severe CAP):

Nonsevere:

• Ceftriaxone 2g Daily + Azithromycin

If Prior culture, or recent hospitalization, add MRSA coverage with Vancomycin

If Prior culture, for pseudomonas change ceftriaxone to cefepime.

Severe:

• Cefepime 2g Q8 or Zosyn 4.5g Q6 (plus vancomycin and azithromycin)

Anaerobic Infections:

• Less common, however lung abscess, empyema, and necrotizing pneumonia make this more likely to occur.

Room 9 Follow-up – Madelyn Huttner MD

Age 60s F found down at home confused by family with black sputum. Hx of suspected IBS. Seen initially in room 9. HR 100, BP 100/60, 94% NRB, afebrile. GCS 14, pale, dried black emesis and stool covering her body.

Orders:

• CBC, CMP, Type and cross, Lipase, Coags, UA, CXR, ABG, Lactic Acid

Consider CTA A/P – was not obtained in this case

Medications:

• Protonix, Octreotide, Ceftriaxone, IV Fluids, Blood products

Consider reversal of anticoagulation

Procedures:

• Intubation, Central line, A line

Consider Minnesota tube

Anticipate significant blood in the airway

SALAD (Suction Assisted Laryngoscopy) Technique

ABG 7.3 / 29 / 45 / 14. Hgb 11.6

Na 130, K 3.2, Cl 96, BUN 46, Cr 2.2

Lactic 4.4

GI and MICU consulted from room 9. Patient found to have a history of excessive NSAID use.

Taken for emergent EGD with GI. Found to have significant esophagitis, diffusely ulcerated gastric mucosa and duodenitis.

Overview of Lithuanian Healthcare System – Simona and Deimante

Universal coverage throughout Lithuania. Patients can choose private insurance, however emergency care is fully covered. Private care is used for elective care, and faster access to care, but not common for emergency care. Can show your ID and have no-copay emergency care throughout Europe.

ED systems are based in public hospitals in major centers in Vilnius, Kaunas, and Klaipeda.

Country has a shortage of emergency medicine specialists. General practitioners are gatekeepers to other specialists.

Vilnius and Kaunas are tertiary care centers and trauma centers.

Gallbladder / Biliary Disease – Tim Price MD

30s Male with 4 days of abdominal pain. Pain is consistent and has been steadily worsening. Described as a dull pain. Located in the upper abdomen. If he lays on his back and holds his hands up, his pain is relieved. Has had regular bowel movements but has some nausea a small amount of emesis 3 days ago, as well as decreased appetite. Denies fevers or chills. Has taken hydrocodone which did help somewhat. Denies dysuria.

Differential: Cholecystitis, Choledocolithiasis, Biliary colic, Pancreatitis, Pyelonephritis, Nephrolithiasis, Hepatitis, ACS, Gastroenteritis, AAA, Cannabis hyperemesis

Labs: Elevated tbili on labs. Normal leukocyte count with neutrophil predominance

POCUS Gallbladder US: Gallstone present without pericholecystic fluid. No anterior gallbladder wall thickening. +Sonographic murphy sign.

CT – Significantly enlarged gallbladder wall

Disposition to Baptist for surgery