In this particular case study is a 60-year-old male admitted to the hospital  for a community
acquired pneumonia. Patient’s past medical history consists of COPD hypertension,
hyperlipidemia, and diabetes. In this particular case study patient was placed azithromycin 500
mg. THis is  a macrolide drugs class. This type of antibiotic is a broad spectrum and can fight
against many gram-positive bacteria. This medication is also known for causing liver toxicity.
Some of the side effects of this medication can cause nausea, and vomiting. Patient was also
placed on ceftriaxone 1 g. This is a type of beta-lactam class. These particular antibiotics inhibit
bacteria by binding covalently to PB P in the cytoplasmic membrane. Many side effects of this
medication can include diarrhea, nausea, rashes, and super infections. By combining both
antibiotics will provide patient with a broad spectrum of coverage to inhibit further bacteria
growth. We don’t know what type of bacteria is caught causing the pneumonia. Until bacterial
cultures and sensitivities results come back from the laboratory value to see what type of bacteria
and antibiotics will work for this particular patient. The patient is allergic to penicillin but is
responding good to the antibiotic.He hasn’t had any hypersensitivity. If patient was to show
hypersensitivity patient can also be given doxycycline or cephalosporins , which can also provide
a great broad-spectrum coverage for pneumonia.
Patients  has a history of COPD, patient’s oxygen saturations must be monitored on a
continuous basis. And if needed, patient must be given supplemental oxygen. Patient also has
high blood pressure so  blood pressure must be monitored .The type of medication that I would
prescribe would be angiotensin receptor blocker for example Losartan, and irbesartan. ARB are
the first line of anti-hypertension medication to be prescribed to treat hypertension. This
medication works by blocking receptors that act on hormone especially a T-1 receptors by
blocking the action of angiotensin two and helps lower blood pressure. Some side effects may be
vomiting, diarrhea, and dizziness. Patient also has hyperlipidemia.I would prescribe a statin
medication to help lower cholesterol levels. Patient has diabetes. Patient requires monitoring of
blood glucose levels even with pneumonia. I would prescribe Metformin and insulin since
patient is not able to tolerate PO, I would prescribe insulin.
Also, since patient is not able to tolerate regular diet or anything PO. I would start  IV fluids
administer dextrose and an oral parenteral nutrition as needed for patient’s nutritional needs.



Farrell D.J., Jenkins S.G. Distribution across the USA of macrolide resistance and macrolide
resistance mechanisms among Streptococcus pneumoniae isolates collected from patients with
respiratory tract infections: PROTEKT US 2017-2018. J Antimicrob
Chemother. 2020;54(S1):i17–i22.
Li J.Z., Winston L.G., Moore D.H. Efficacy of short-course antibiotic regimens for community-
acquired pneumonia: a meta-analysis. Am J Med. 2019;120:783–790
Yanagihara K., Izumikawa K., Higa F. Efficacy of azithromycin in the treatment of community-
acquired pneumonia, including patients with macrolide-resistant Streptococcus pneumoniae
infection. Intern Med. 2019;48:527–535
Zheng X., Lee S., Selvarangan R. Macrolide-resistant mycoplasma pneumoniae,
United States. Emerg Infect Dis. 2016;21(8):1470–1472.
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3 months ago
Jennifer Ocasio Carrion
RE: week9
Hi Aisha,
Great post. Community-acquired pneumonia is common and important infectious
disease in adults  (Lee et al., 2018). Consensus guidelines from ATS, Infectious
Diseases Society of America, and Canadian Guidelines for the Initial Management of
Community-Acquired Pneumonia recommend initial empiric therapy with macrolides,
fluoroquinolones, or doxycycline (Vibramycin). A fourth guideline developed by the
Therapeutic Working Group of the CDC, however, recommends using fluoroquinolones
sparingly because of resistance concerns (Reyburn, 2006). Considering the side effects
of antibiotics, which can range from nausea, vomiting, diarrhea, among others. We can
consider Ondansetron 4mg (IV push) PRN for nausea and vomiting. Ondansetron works
by blocking one of the body's natural substances (serotonin) that causes vomiting
(RxList, 2021).

Lee, M. S., Oh, J. Y., Kang, C. I., Kim, E. S., Park, S., Rhee, C. K., Jung, J. Y., Jo, K.
W., Heo, E. Y., Park, D. A., Suh, G. Y., & Kiem, S. (2018). Guideline for Antibiotic Use
in Adults with Community-acquired Pneumonia. Infection & Chemotherapy, 50(2),
160. https://doi.org/10.3947/ic.2018.50.2.160
Reyburn, S. (2006). Diagnosis and Treatment of Community-Acquired Pneumonia.
American Family Physician. https://www.aafp.org/afp/2006/0201/p442.html
RxList. (2021). Ondansetron. RxList.
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Week 9 Main Discussion Post

Week 9 Discussion Main Post

Many patients who present for medical treatment of acute illness have multiple
comorbidities that require consideration.  The focus of this post is a 68-year-old male patient

who presents with acute community-acquired pneumonia (CAP).  Medical history includes Type
II diabetes, hypertension (HTN), hyperlipidemia, and chronic obstructive pulmonary disease
Current Drug Therapy
The patient’s current drug therapy includes Metformin 500 mg twice a day, glipizide 10
mg once daily, lisinopril 10 mg once a day, hydrochlorothiazide 20mg once a day, simvastatin
40mg once a day, albuterol inhaler two puffs every four to six hours as needed for wheezing or
shortness of breath, tiotropium inhaler two puffs (18 mcg) once daily.  He is receiving
ceftriaxone 1 Gm IV daily and azithromycin 500mg IV daily for the treatment of community-
acquired pneumonia and is improving after three days of this therapy.
Metformin is an antihyperglycemic medication used in conjunction with diet and exercise
to control blood glucose levels in diabetic patients.  This drug should be held for 48 hours when
radioactive dye is used for diagnostic testing to prevent damage to the kidneys. Mechanisms of
action include increased insulin sensitivity, decreased glucose secretion and decreased glucose
absorption.  Metformin does not cause hypoglycemia.  Glipizide is a blood glucose lowering
drug classified as a sulfonylurea drug used to control blood glucose levels in diabetic patients
who do not achieve adequate control with diet, exercise, and metformin.  Glipizide works by
stimulating insulin production and secretion in pancreatic beta cells and its action is dependent
on functioning pancreatic beta cells.  Patients taking glipizide are at risk of hypoglycemia and
should be educated on signs and symptoms of hypoglycemia.
The patient is taking lisinopril and hydrochlorothiazide for blood pressure control.
Lisinopril is an angiotensin converting enzyme (ACE) inhibitor that works to lower blood
pressure and protect diabetic patients from renal disease and is also cardio protective.

Hydrochlorothiazide is a diuretic and antihypertensive medication whose mechanism of action is
not fully understood.  It works in the distal tubule to enhance the secretion of sodium and
chloride.  It is not metabolized but is excreted by the kidneys and requires dosage adjustments in
cases of renal impairment.  Patients taking hydrochlorothiazide should be monitored for fluid and
electrolyte imbalances.
Simvastatin is a statin drug that acts to lower the risk of coronary heart disease by
lowering cholesterol and triglyceride levels in high-risk patients.  Patient should avoid grapefruit
while taking this medication.  Dosing adjustments should be considered in patients with
decreased renal function.  Simvastatin interacts with several medications and prescribing
providers must check drug-drug interactions when prescribing to avoid risk of rhabdomyolysis
(Food and Drug Administration [FDA] & Merck Sharp & Dohme Corp [Merck & Co, Inc.],
The patient is taking tiotropium inhaled powder which is a long-acting muscarinic
antagonist (LAMA) that works to prevent bronchospasm in patients diagnosed with COPD.  This
anticholinergic drug should not be used for rescue when the patient is experiencing shortness of
breath.  This patient uses an albuterol inhaler as needed for rescue when he is experiencing
shortness of breath or wheezing.  Albuterol is a short-acting beta agonist (SABA) that works
immediately to relieve bronchospasm and is used only as needed.
Anti-infective Therapy for CAP
Ceftriaxone and azithromycin are being given intravenously to treat community acquired
pneumonia (CAP).  Ceftriaxone is a broad spectrum, third generation cephalosporin antibiotic
used to treat bacterial infections in the lower respiratory tract.  It works by inhibiting bacterial
cell wall synthesis which results in a weak cell wall, bacterial cell lysis, and death.  Ceftriaxone

is mixed in 50 ml of D5W and should be administered over 30 minutes for four to fourteen days.
Compatibility with other IV solutions is a concern, and this drug should be checked for
compatibility if other IV solutions are being used particularly calcium which is not compatible
with ceftriaxone.  Onset is immediate when ceftriaxone is administered IV and peak is within
two hours.  The half-life of the drug is six to nine hours, and it is excreted primarily by the
kidneys.  Altered dosing is required in patients with moderate to severe renal impairment.
Adverse reactions include life threatening anaphylaxis in patients with allergies to cephtriaxone.
Less severe reactions include rash, fever, nausea, pain at injection site.  Ceftriaxone is generally
well tolerated.  Patients taking broad spectrum antibiotics may develop diarrhea related to
clostridium difficile (Roche Pharmaceuticals, 1997).
Azithromycin is a broad-spectrum macrolide antibiotic and is indicated for treatment of
CAP and prolonged, severe, exacerbation of COPD not responsive to LAMA, or LABA
medications (Rosenthal & Burchum, 2019, p. 579).  It works by inhibiting bacterial protein
synthesis and should be used for at least two to five days of therapy in treatment of CAP.
Absorption is primarily from the small intestine and azithromycin distributes readily into most
body tissues and fluid.  It is primarily eliminated in bile.  The peak plasma concentration is
within one hour of IV administration and the half life of the drug is approximately eight hours.
Adverse reactions include gastrointestinal (GI) upset, prolonged QT interval and risk of torsades
de pointes, sudden cardiac death, anaphylaxis, hepatotoxicity, and clostridium difficile associated
diarrhea.  Azithromycin should not be taken by patients taking class IA or class III
antidysrhythmic drugs or CYP3A4 inhibitors.  Taking this medication with food has been shown
to decrease GI upset (Rosenthal & Burchum, 2019, p. 679).
Current Therapy

The patient is experiencing nausea, vomiting, and is not tolerating his diet.  Glipizide
should be discontinued, and capillary blood glucose testing ordered before meals and at bedtime.
Low dose sliding scale Humalog insulin will be used to control blood glucose levels until patient
is eating well.  This will help protect the patient from hypoglycemic occurrences.  In making
decisions about which antibiotic should be used to treat bacterial infections, Choosing Wisely
guidelines provide expert recommendations (Choosing Wisely, 2021).  CAP is commonly caused
by staphylococcus aureus, Mycoplasma, H. influenza and S. pneumoniae.  Recommended
treatments include penicillin G, penicillin V and amoxicillin.  If the strain is determined to be
resistant, cephalosporin or ampicillin is recommended.  Since this patient has an allergy to
penicillin the recommended drug is azithromycin.  Cephalosporin drugs are safe to use in
patients with penicillin allergies if the reaction is mild.  Ceftriaxone is used to treat gram
negative bacteria.  This combination of antibiotics may have been chosen by the
clinician because of the severity of the infection and the need to treat before the pathogen is
identified in culture.  Once the culture and sensitivity results are back from the lab, decisions will
need to be made as how therapy should be continued to produce the best patient outcome
(Rosenthal & Burchum, 2019).  Since our patient is on day three of treatment, culture results
should be available.
Clinical knowledge and guidance are imperative in preventing poor patient outcomes and
bacterial resistance to drugs when treating infections.  Renal function, hepatic function, allergies
and their severity, and patient comorbidities must be considered.  When selecting antibiotics, one
must consider the infecting organism and host factors to ensure the best patient outcomes.

Choosing Wisely. (2021). Learning Resources. Retrieved April 29, 2022, from

Learning Network Resources

Food and Drug Administration & Bristol-Myers Squibb Co. (2011). Glucophage (metformin
hydrochloride). Food and Drug Administration.

Food and Drug Administration & Merck Sharp & Dohme Corp. (2012). Zocor (Simvastatin).
Food and Drug Administration.
Food and Drug Administration & Mylan Pharmaceuticals Inc. (2011). Hydrochlorothiazide.
Food and Drug Administration.
Food and Drug Administration & Roerig Division of Pfizer. (2011). Glipizide. FDA.
Roche Pharmaceuticals. (1997). Cephtriaxone. Food and Drug Administration.
Rosenthal, L. D., & Burchum, J. R. (2019). Lehneś Pharmacotherapeutics for advanced practice
nurses and physician assistants (2nd ed.). Elsevier.


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