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Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)

CASE PRESENTATION
Of A Patient With

Pulmonary Tuberculosis (TB),


Community-Acquired Pneumonia (CAP)

I. Discussion of the Patient:

A. Patient Information

Name: J.L.D
Age/Sex: 51/M
Religion: Roman Catholic
Occupation: Fisherman
Date of Admission: 02/18/16
Date of Discharge: 03/03/16
Attending Physician: Sheila Marie C. Rabang, M.D.

B. Chief Complaint

Body Weakness

C. History of Present Illness

About two months prior to admission, patient apparently stopped drinking alcoholic
beverages; from then on, patient suffered from loose bowel movements for 3-4 episodes/day.
No consult self-medicated with diatabs. Two weeks prior to admission, cough and cold, given
carboceistein capsule. Persistence with body weakness prompted consult.

D. Past Medical History

None

E. Family History

None

F. PSHx

(+) alcoholic-beverage drinker


(+) Smoker

G. Drug History

Date Medications Indications Dosing Monitoring Duration


Ordered Parameters
2/18/16 Ciprofloxacin 400 mg Anti-infective q 12 Monitor CBC, Discontin
initially then 200 mg IVP renal and ued
hepatic 02/19/16
function
2/18/16 Erceflora 1 nebule TID Anti-diarrheal TID Monitor Consume

Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
adverse d
reactions 02/24/16
2/18/16 Omeprazole 40 mg IVP Proton pump OD Monitor CBC, Shifted to
OD inhibitor AST, ALT, Ranitidine
bilirubin, and 02/21/16
alkaline
phosphatase
2/18/16 Paracetamol 500 mg tab Analgesic, q4 Monitor Revised
q4 antipyretic, hepatic to prn
anti- function, 02/21/16
inflammatory AST, ALT

2/18/16 NaCl tab 2 tabs TID Electrolyte TID Monitor Na, Revised
supplement and Cl levels to 1 tab
TID
02/20/16
2/19/16 Ceftriaxone 1 g IVP Anti-infective q8 Monitor CBC, Revised
renal and to 2g q24
hepatic 02/20/16
function
2/19/16 Metronidazole 500 mg Anti-infective q8 Monitor CBC, Revised
IVP renal and to tab
hepatic 02/20/16
function
2/20/16 NaCl 1 tab TID Electrolyte TID Monitor Na, Consume
supplement and Cl levels d
02/26/16
2/20/16 Ceftriaxone 2g Anti-infective q 24 Monitor CBC, Discontin
renal and ued
hepatic 02/25/16
function
2/20/16 Metronidazole 500 mg 1 Anti-infective q8 Monitor CBC, Consume
tab renal and d
hepatic 03/01/16
function
02/21/16 Salbutamol+Ipratropium Bronchodilator q8 Monitor K Revised
1 neb levels, blood to q12
pressure, 02/26/16
heart rate
02/21/16 Ranitidine 150 mg 1 tab H2 - blocker BID Monitor renal Consume
function, ALT, d
AST, and 03/03/16
creatinine.
02/21/16 Azithromycin 500 mg 1 Anti-infective OD Monitor CBC, Consume
tab renal and d
hepatic 02/25/16
function
02/21/16 NAC 600 mg/tab Bronchitis/ OD Ensure that Consume
Prevent anti- blood for d
TB drugs baseline 03/02/16
induced acetaminoph
toxicity en plasma
level, liver
Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
enzymes,
bilirubin, PT,
electrolytes,
blood sugar,
BUN, and
creatinine
have been
drawn before
initiating
therapy, and
then daily for
duration of
therapy.
02/25/16 Piperacillin + Anti-infective q8 Monitor renal Shifted to
Tazobactam 4.5 g for 2 and hepatic Levofloxa
hours infuse function, cin
serum 03/01/16
potassium,
CBC, BUN,
creatinine,
ALT, AST,
bilirubin,
alkaline
phosphatase,
and LDH.
02/25/16 MV+Buclizine 1 cap Multivitamins/ OD Monitor renal Consume
Nutritional and hepatic d
support function 03/02/16
02/25/16 Isoniazid 75 mg/ Anti-TB OD Monitor On-going
Rifampicin 150 mg / renal, hepatic
Ethambutol 275 mg / and
Pyrazinamide 400 mg 3 hematopoieti
tabs 1 hour before c functions;
breakfast occurrence of
toxicities
2/26/16 Salbutamol+Ipratropium Bronchodilator q 12 Monitor K Consume
neb levels, blood d
pressure, 03/02/16
heart rate
2/27/16 Vitamin B complex 1 tab Vitamins/ to OD Monitor Consume
prevent renal, hepatic d
peripheral functions, 03/02/16
neuropathy and CBC;
history of
gout
2/27/16 Metronidazole 500 mg 1 Anti-infective q8 Monitor CBC, Consume
tab q 8 for 2 more days renal and d
hepatic 03/01/16
function
3/1/16 Levofloxacin 750 mg p.o Anti-infective q 24 Evaluation of Consume
q 24 for 7 days organ system d
functions 03/07/16
(renal,
Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
hepatic,
ophthalmolog
ic, and
hematopoieti
c) is
recommende
d periodically
during
therapy; the
possibility of
crystalluria
should be
assessed;
WBC and
signs of
infection
3/1/16 Calmoseptine ointment Antipruritic/An q 12 Monitor Consume
algesic/Antise hypersensitivi d
ptic ty reactions 03/02/16

Stat

Date Ordered Medications Indications

02/21/16 KCl 2 tabs now then 1 tab Hypokalemia

PRN
Date Ordered Medications Indications

02/21/16 Paracetamol 500 mg 1 tab q 4 prn for T 38C Analgesic/Antipyretic

02/21/16 Paracetamol 300 mg IV q 4 prn for T 38.5C Analgesic/Antipyretic

Take home medications:

1. Ranitidine 150 mg 1 tab 2x a day


2. Levofloxacin 750 mg 1 tab OD
3. Isoniazid+Rifampicin+Ethambutol+Pyrazinamide 3 tabs before breakfast
4. Ferroplex 1 cap 1x a day

H. Physical Examination

GEN: awake, weak looking, not in cardiorespiratory distress


VITAL SIGNS:
BP: 100mmHg/80mmHg
HR: 119/minute
RR: 24/minute
BT: 37.9oC
HEENTS: dry, poor skin turgor, dry lip and oral mucosa, sunken eyeball
CHEST: SLE, harsh breath sounds
Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
ABD: scaphoid, soft to non-tender
EXTREMETIES: Bipedal edema

I. Relevant Baseline Laboratory Results and Diagnostic Tests

a. Complete Blood Count (Hematology)

Test Name 02/18/16 02/24/16 03/02/16 Reference value


WBC 26.42 20.70 16.90 5.00-10.00
Neutrophils 90.9 88.8 84.4 50.0-70.0
Lymphocytes 4.0 5.3 9.2 20.0-40.0
Monocytes 3.9 2.7 2.9 3.0-12.0
Eosinophils 1.1 2.9 2.4 0.5-5.0
Basophils 0.1 0.3 1.1 0.0-1.0
RBC 2.84 4.04 3.59 4.00-5.50
Hgb 93 127 112 120-160
Hct 26.0 35.4 32.6 40.0-50.0
MCV 91.5 87.7 90.8 82.0-95.0
MCH 32.7 31.4 31.2 27.0-31.0
MCHC 358 358 344 320-360
RDW-CV 11.6 12.5 13.8 11.5-14.5
RDW-SD 43.6 44.8 51.1 35.0-56.0
PLT 466 452 794 150-400
MPV 7.2 6.8 6.5 7.0-11.0
PDW 15.2 15.5 15.1 9.0-17.0
PCT 0.33 0.30 0.51 0.108-0.282

b. Clinical Microscopy & Parasitology- Urinalysis


Specimen: Urine

Macroscopic
Color: Straw(S)
Appearance: Clear (C)

Microscopic
WBC/Pus Cells: 0-2
RBC: 0-1
Epithelial cells: Few (F)
Amorphous Materials: Few (F)
Bacteria: Few (F)

Chemical Test
Protein: Negative (N)
Glucose: Negative (N)
Leukocytes: Negative (N)
Blood: Negative (N)
Nitrite: Negative (N)
Urobilinogen: Normal
Bilirubin: Negative (N)
Ketone: Negative (N)
Specific Gravity: 1.010
Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
pH: 5.5

c. Clinical Microscopy & Parasitology- Stool Exam


Specimen: Stool

Date: 02/20/16

Macroscopic
Color: Green (G)
Consistency: Soft (S)
Parasites: No ova or other intestinal parasites seen

Microscopic
WBC: 2-4
RBC: 0-2

Date: 02/21/16

Macroscopic
Color: Green (G)
Consistency: Mucoid (M)
Parasites: No ova or other intestinal parasites seen

Microscopic
WBC: 21-25
RBC: 2-4

Date: 02/22/16

Macroscopic
Color: Green (G)
Consistency: Soft (S)
Parasites: No ova or other intestinal parasites seen

Microscopic
WBC: 3-4

d. Clinical Chemistry

Date: 02/19/16

Myocardial Injury Profile- Electrolyte Panel


Test Result Reference Value
Sodium 128.0 135-148
Potassium 2.29 3.5-5.3
Chloride 92.1 98-107

Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)

Date: 02/21/16

Kidney Profile
Test Result Reference Value
Creatinine Male: 0.7-1.4
0.77
Female: 0.5-1.2

Liver Profile
Test Result Reference Value
SGOT/AST Male: 0-38
88
Female: 0-31
SGPT/ALT Male: 0-40
70
Female: 0-32

Myocardial Injury Profile- Electrolyte Panel


Test Result Reference Value
Sodium 127.5 135-148
Potassium 2.49 3.5-5.3

Date: 02/23/16

Myocardial Injury Profile- Electrolyte Panel


Test Result Reference Value
Sodium 133.8 135-148
Potassium 3.91 3.5-5.3
Chloride 104.4 98-107

Date: 02/25/16

Myocardial Injury Profile- Electrolyte Panel


Test Result Reference Value
Sodium 130.5 135-148

e. Radiology Report
Examination done: Abdomen

Date: 02/24/16

Findings: The liver is enlarged with rounded inferior edge.


It exhibits homogenous parenchyma with increased echogenicity.
No focal mass lesion seen.
The intrahepatic vessels, IVC, portal vein as well as the
intrahepatic ducts are undilated and unremarkable.
Minimal free peritoneal fluid is seen in the perihepatic region.
The gallbladder is well-distended with unthicken walls.
Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
No intraluminal echoes seen.
The common bile duct is not dilated.
The pancreas and spleen are unremarkable.

Impression: Fatty liver


Unremarkable sonogram of the gallbladder, spleen and pancreas
Minimal Ascites
There is incidental note of minimal pleural effusion in the right

Examination done: Chest

Date: 02/18/16

Findings: There are patches of fairly homogeneous opacities in the right


upper and left middle lung field with a suspicious lucency in the right.
Reticulonodular opacities are also seen in the paracardiac areas.
The pulmonary vascularity is within normal limits.
The heart is not enlarged.
The aorta is unremarkable.
The trachea is midline.
The hemidiaphragms and costophrenic angles are intact.
The visualized osseus structures and soft tissues are
unremarkable.

Impression: Findings suggestive of PTB with possible cavitation in the right.


Please correlate with clinical and laboratory parameters.

f. Electrocardiographic Report
Date: 02/18/16

Results: Premature Ventricular Contraction

g. Direct Sputum Smear Microscopy


Specimen: Sputum
Date: 02/25/16
Specimen 1 2
Visual Appearance Muco-purulent Muco-purulent
Reading +2 +2
Laboratory Result Positive

II. Brief Discussion of the Diseases

Pulmonary Tuberculosis

Tuberculosis (TB) is a communicable infectious disease that mainly affects the lungs. The bacteria that
cause tuberculosis (Mycobacterium tuberculosis) are spread from one person to another through tiny droplets
released into the air via coughs and sneezes. It can produce silent, latent as well as progressive, active
disease.

a. Etiology and Incidence

Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Leading to fever, chills, and fatigue

Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)


Mycobacterium tuberculosis, a slow-growing obligate aerobe and a facultative intracellular organism.
The organism is a slender bacillus with a waxy other layer that grows in parallel groups called cords. It retains
many stains after decoloration with acid-alcohol, which is the basis of the acid-fast stains used for pathologic
identification. Tuberculosis remains a leading infectious killer globally. Roughly, 2 billion people are infected
and 2-3 million people die from active tuberculosis each year despite the fact that it is curable. Tuberculosis is
the top 6 causes of mortality and morbidity in the Philippines.

b. Pathophysiology
Exposure to source.

Inhalation of Tubercle bacilli.

Tubercle bacilli reach the alveoli and enter


macrophages.

Tubercle bacilli multiply in the macrophages.

Granulomatous lesion begins to form


(caseous necrosis).

Caseous center undergo liquefaction.

Bacilli distributed throughout the respiratory


system and other parts of the body via blood.

Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)

c. Clinical Symptomatolgy

The onset of TB may be gradual. It is non-specific, indicative only of a slowly evolving infectious
process. The signs and symptoms of TB include weight loss, fatigue, fever, productive cough, fever, frank
hemoptysis and night sweats. Physical examination is nonspecific, but suggestive of progressive pulmonary
disease; physical examination results associated with TB are dullness to chest percussion, rales, and
increased vocal fremitus which are observed frequently on auscultation.

d. Laboratory Findings

Laboratory findings in patients of TB presents moderate elevations in the white blood cell count. Chest
radiograph results include patchy or nodular infiltrates in the apical area of the upper lobes or the superior
segment of the lower lobes, cavitation that may show air-fluid levels as the infection progresses.

e. Complications and Sequelae

Left untreated or improperly treated, Tuberculosis causes progressive tissue destruction and eventually
death. Untreated active disease typically affects the lungs, but it can spread to other parts of the body through
the bloodstream. The most common complications of TB include: spinal pain, joint damage, meningitis, liver
and/or kidney problems, and heart disorders.

Community-Acquired Pneumonia

Community- acquired Pneumonia is the most common type of pneumonia- an abnormal inflammatory
condition of the lung. CAP is one of the most common infectious diseases diagnosed by clinicians. It occurs
outside of hospitals or other health care facilities. CAP may be either bacterial on viral. Typical bacterial
pathogens that cause this condition include Streptococcus pneumoniae, Haemophilus influenzae, and
Moraxella catarrhalis. CAP is usually acquired via inhalation or aspiration of pulmonary pathogenic organisms
into a lung segment or lobe.

a. Etiology and Incidence

Streptococcus pneumoniae is a gram-positive, catalase-negative organism which is a penicillin-


sensitive and resistant strains. H. Influenzae which is an ampicillin-sensitive and resistant strains, and M.
Catarrhalis which has all strains penicillin resistant. Community acquired pneumonia estimated incidence
ranges from 4 million to 5 million cases per year with 25 % requiring hospitalization.

Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
b. Pathophysiology
Bacteria enter the lungs (from the throat or
nose, airborne droplets or blood).

Bacteria may invade the spaces between


cells and between alveoli.

The macrophages and neutrophils inactivate


the bacteria. The neutrophils also release
cytokines

This cause general activation of the immune


system

Leading to fever, chills, and fatigue

The neutrophils, bacteria and fluid fill the


alveoli

Resulting in the consolidation seen on chest


X-ray

c. Clinical Symptomatolgy

The clinical presentation of Pneumonia includes an abrupt onset of fever, chills, dyspnea, and
productive cough. Rust colored sputum or hemoptysis may also be included. Patients with this condition
usually may have a pleuritic chest pain and experiences tachypnea and tachycardia, dullness to percussion,
increased tactile fremitus, chest wall retractions and grunting respirations. A dry, non-productive cough is
initially present that over several days becomes productive of mucoid or purulent sputum. Fevers exceed 40 o C
and are typically unremitting and associated with a relative bradycardia. Pleuritic chest pain and progressive
dyspnea may be seen, and fine rales are found on lung examination, progressing to signs of frank
consolidation later in the course of illness.

d. Laboratory Findings
Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)

Laboratory findings include Blood pH (arterial) <7.35, Hypoxemia (arterial Pao2<60 mm Hg or O2


saturation <90%), Serum urea nitrogen (BUN) >30 mg/dL, Na <130 mEq/L, Blood sugar >250 mg/dL ,
Anemia (hematocrit <30%), and radiologic findings include pleural effusion.

e. Prognosis

With community acquired pneumonia, time for resolution of cough, sputum production, and presence
of constitutional symptoms progress should be noted in the first 2 days of treatment, with complete resolution
in 5 to 7 days.

f. Complications and Sequelae

Pleural effusion, sepsis and septic shock are the major potential complications of pneumonia. Pleural
effusion produces fluid accumulation on the space between the lungs and the wall of the chest. This fluid can
put pressure on the lungs, making it difficult to breathe. The most serious complication is sepsis and septic
shock. Patients with sepsis or septic shock requires hospitalization with intravenous antibiotics and other
medication that will maintain their blood pressure at normal level.

III. Problem List and Patient-Specific Drug-Related Problem(s)

1. Pulmonary Tuberculosis (TB)


2. Community-Acquired Pneumonia (CAP)

Pharmacists Workup of Drug Therapy for Pulmonary Tuberculosis (TB)

PWDT Components FARM Notes


Findings (F)

Subjective:
Dyspnea
Loss in appetite
Body weakness
Cough

Objective:
Chest X-ray: 02/18/16
Patches of fairly homogeneous opacities in the
Findings right upper and left middle lung field with a suspicious
lucency in the right.
High Blood Count on the following test:
Date: 02/18/16 Normal range:
WBC (26.42) 5.00-10.00
Date: 02/24/16
WBC (20.70)
Date: 03/02/16
WBC (16.90)
Direct Sputum Smear Microscopy
- Positive result

Desired outcomes Assessments (A)


Desired end points Rapid identification of new cases of TB

Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
Initiation of specific anti TB treatment
Prompt resolution of signs and symptoms of
disease
Achievement of a non-infectious state, thus
ending isolation
Adherence to the treatment regimen by the
patient
Cure of the patient as quickly as possible
Paracetamol may increase the risk of liver
failure.
Isoniazid, Rifampicin, and Pyrazinamide are
Drug-related problems contraindicated with the patient.
Omeprazole as well as Ranitidine marked
elevations in serum aminotransferase
levels(ALT&AST)
Resolutions/Recommendations (R)
Drug treatment is the cornerstone of TB
management. A minimum of 2 drugs and
generally 3 or 4 drugs must be used
simultaneously.
Drug treatment is continued for at least 6
months and up to 2-3 years for some cases of
MDR-TB
Measures to assure adherence, such as
directly observed disease.
Patients with active disease should be like
isolated to prevent of the disease.
Debiliated patients may require therapy for
Therapeutic Selection
other medical conditions.
Surgery may be needed to remove destroyed
lung tissue, space-occupying lesions and
some extrapulmonary lesions.
First line drugs include: Isoniazid, Rifampin,
Rifabutin, Rifapentine, Pyrazinamide,
Ethambutol
Second line drugs include:
Cycloserine, Ethionamide, Streptomycin,
Amikacin, Capreomycin, p-Aminosalicylic acid,
Moxifloxacin, Levofloxacin
Vitamin B complex is also used to prevent
painful neuropathy during treatment of TB
Monitoring (M)
Monitor BUN, Serum creatinine, aspartate
transaminase or alanine transaminase and
CBC.
Monitoring Parameters
Chest X-ray at baseline and then every three
to six months.
Monitor hepatotoxicity, neurotoxicity,
nephrotoxicity.
Follow-up Repeat chest radiography, and other relevant
laboratory tests.
Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
HIV testing may also be done.

CORE Pharmacotherapy Plan

Condition: Pulmonary Tuberculosis (TB)

Outcome:
Rapid identification of new cases of TB
Initiation of specific anti TB treatment
Prompt resolution of signs and symptoms of disease
Achievement of a non-infectious state, thus ending isolation
Adherence to the treatment regimen by the patient
Cure of the patient as quickly as possible

Regimen:
Take Home Medications:
Isoniazid+Rifampicin+Ethambutol+Pyrazinamide 3 tabs before breakfast
Ferroplex 1 cap 1x a day for 2 months

Evaluation:
Monitor adherence to the prescribed regimen such as directly observed therapy.
Symptomatic patients should be isolated and have sputum samples sent for acid-fast bacilli stains
every 1-2 weeks until 2 consecutive smears are negative
Evaluate BUN. Creatinine, AST, ALT, CBC
Evaluate hepatoxicity since the patient is at risk due to alcoholism.
Follow-up radiography

PRIME Pharmacotherapy Problems

P = Pharmaceutical-based problems:
Financial difficulties
Patient behavior
Inappropriate selection of medications based on the patients condition.
Giving of medications that can cause liver problems.

R = Risks to patient:
Rifampicincan cause hepatotoxicity
Isoniazid is contraindicated in acute liver disease, increased risk of drug induced hepatitis, chronic
alcoholism where there is also an increased risk of peripheral neuropathy.
Pyrazinamide can also cause hepatotoxicity and/or gout
When all combined, increased risk of hepatotoxicity.

I = Drug interactions:
Pyrazinamide + Rifampicin can cause severe hepatotoxicity

M = Mismatch between medications and condition or patient needs:


The anti-tuberculosis regimen containing Rifampicin,Isoniazid and Pyrazinamide is contraindicated to
the patient having an alcoholic liver disease because this may exacerbate further liver injury.
Giving of medications that can cause liver problems.
Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)

E = Efficacy issues
Too much of the agents can cause serious side effects

Pharmacists Workup of Drug Therapy for Community- Acquired Pneumonia

PWDT Components FARM Notes


Findings (F)

Subjective:
cough
cold
Objective:
Chest X-ray: 02/18/16
Patches of fairly homogeneous opacities in
the right upper and left middle lung field with a
suspicious lucency in the right. Reticulonodule
opacities are also seen in the paracardiac areas.
Findings ECG Findings
Premature ventricular contraction
High Blood Count on the following test:
Date: 02/18/16 Normal range:
WBC (26.42) 5.00-10.00
Date: 02/24/16
WBC (20.70)
Date: 03/02/16
WBC (16.90)
Less than 30% of the HCT test:
Date: 02/18/16
HCT: 26.0
Desired outcomes Assessments (A)
eradication of the offending organism and
complete clinical cure
associated morbiditybshould be minimized
(e.g Renal Pulmonary/Hepatic dysfunction)
Prevention of hospitalization/ reduction in
Desired end points length of work stay.
Prevention of acute respiratory failure and
death.
Improve quality of life.
Prompt resolution of signs and symptoms of
disease after initiation of treatment.
Drug-related problems Omeprazole will decrease the level or effect of
ciprofloxacin.
Multivitamins/minerals with folate/ion will
reduce the effectiveness of ciprofloxacin.
Ciprofloxacin as well as Levofloxacin can
cause difficulty of breathing.
Ceftriaxone can cause hemolytic anemia and
Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
leukocytosis (increase in total no.of WBCs)
Resolutions/Recommendations (R)
Evaluate the adequacy of respiratory function
and to determine the presence of signs of
systemic illness, specifically dehydration or
sepsis which may result to circulatory collapse
Assest the respiratory condition of the patient
administer oxygen or in severe cases,
mechanical ventilation and fluid resuscitation
should be provided as necessary
The supportive care of the patient with
pneumonia includes the use of humidified
oxygen for hypoxemia, administer
bronchodilators for bronchospasm, and chest
physiotherapy with postural drainage if there is
evidence of retained secretions seen
Therapeutic Selection Additional therapeutic adjuncts include
adequate hydration, optimal nutritional result,
and control of fever.
Selection of an appropriate antimicrobial must
be made; it must be initially involve the
empirical use of a relatively broad-spectrum
antibiotic that is effective against the probable
pathogen that causes the disease after
appropriate cultures and specimens for
laboratory evaluation have been obtained
Therapy should be narrowed to cover specific
pathogens after the results of cultures are
known
Avoid Smoking and secondhand smoke
Receive the influenza vaccine yearly
Monitoring (M)
Monitor patient's WBC, respiratory rate and
ECG after initial treatment of flouroquinolone
antibiotics
monitor serum antibacterial concentration to
ensure effective and successful treatment of
the disease
Monitoring Parameters
monitor patient's sputum sample to determine
the severity of bacteria
monitor patient's electrolytes as a result of
fever, vomiting or dehydration due to the
disease
observe anaphylactic reactions and any
untoward reactions of the patients
Follow up chest radiograph after a month to
ensure complete clinical cure
Follow up patient's adherence to the treatment
Follow-up
regimen
Follow up evaluation for patient's condition
after initiation of the treatment regimen
Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)

CORE Pharmacotherapy Plan

Condition: Community acquired pneumonia

Outcome:
time for resolution of cough, sputum production and presence of constitutional symptoms should be
assessed
achieve complete clinical cure
eradication and resolution to signs and symptoms
eradication of infection
prevention of relapse and complications
avoidance of antibacterial resistance

Regimen:
Ciprofloxacin 200mg IVP q12h
Ceftriaxone 1 gm q8h
Salbutamol + Ipratoprium 1 nebule q8h
Azithromycin 500mg 1 tab OD x 5 days
N acetylcysteine 600mg tab in 1/2 glass OD HS
Piperacillin + Tazobactam 4.5 g for 2 hours infuse
Levofloxacin 750 mg p.o q 24 for 7 days

Evaluation:
Evaluate the time of complete clinical cure of the disease and the condition of the patient should be
assessed
The condition of the patient must have improvement in the first 2 days, with complete resolution in 5 to
7 days
Evaluate the different laboratory results and interpret it; give treatment to abnormal values

PRIME Pharmacotherapy Problems

P = Pharmaceutical-based problems:
Patient behavior
Shifting to parenteral dosage from oral dosage form
Shifting of antibiotics
Financial difficulties
Giving of medications that are contraindicated with the patients condition.

R = Risks to patient:
Shifting to different antibacterial medicines can lead to antibiotic resistance

I = Drug interactions:
Azithromycin and levofloxacin can cause abnormal heart rhythm

M = Mismatch between medications and condition or patient needs:

Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
Giving of medications that are contraindicated with the patients condition.

E = Efficacy issues
Patient's non-compliance to the prescribed regimen
Antibiotic resistance

IV. Discussion of the Medications

a) Ciprofloxacin
Pharmacologic Class: Fluoroquinolone
MOA: The bactericidal action of ciprofloxacin results from inhibition of the enzymes
topoisomerase II (DNA gyrase) and topoisomerase IV (both Type II topoisomerases),
which are required for bacterial DNA replication, transcription, repair, and recombination.
Special Considerations: You should not use this medication if you are also taking
tizanidine. You may not be able to use ciprofloxacin if you have a muscle disorder.
Patient Information: Take this medicine with a full glass of water (8 ounces). Drink several
extra glasses of fluid each day while you are taking this medicine. Ciprofloxacin may be
taken with or without food, but take it at the same time each day.
ADR: Signs of an allergic reaction like hives, or the first sign of a skin rash; fast heartbeat,
difficult breathing; swelling of your face, lips, tongue, or throat if experienced seek for
medical assistance.Ciprofloxacin may cause swelling or tearing of (rupture) a tendon. It
can also have serious effects on your nerves, and may cause permanent nerve damage.

b) Erceflora
Pharmacologic Class: Antidiarrheal
MOA: The administration of Bacillus clausii contributes to the recovery of the intestinal
microbial flora altered during the course of microbial disorders of diverse origin. Bacillus
clausii is capable of producing various vitamins, in particular group B vitamins, hence it
contributes to correcting the consequent vitamin disorders caused by antibiotics and
chemotherapeutic agents in general. Bacillus clausii makes it possible to obtain a
nonspecific antigenic and antitoxic action, closely connected with the metabolic action of
clausii.
Special Considerations: During antibiotic therapy, Erceflora should be administered in the
interval between 1 dose of antibiotic and the next.
Patient Information: During antibiotic therapy, Erceflora should be administered in the
interval between 1 dose of antibiotic and the next.

c) Omeprazole
Pharmacologic Class: Proton Pump Inhibitor
MOA: Omeprazole suppresses gastric acid secretion by specific inhibition of the
hydrogenpotassium adenosinetriphosphatase (H +, K +-ATPase) enzyme system found
at the secretory surface of parietal cells. It inhibits the final transport of hydrogen ions (via
exchange with potassium ions) into the gastric lumen.
Patient Information: Tell patient to take drug exactly as prescribed and at least 1 hour
before meals.

d) Paracetamol
Pharmacologic Class: Analgesics
MOA: Acts on hypothalamus to produce antipyresis.
Patient Information: Before using paracetamol , tell your doctor if you have liver disease
or a history of alcoholism.

Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
ADR: Allergic reaction to like: hives; difficulty breathing; swelling of your face, lips, tongue,
or throat. low fever with nausea, stomach pain, and loss of appetite; dark urine, clay-
colored stools; or jaundice.

e) NaCl
Pharmacologic Class: Electrolyte
MOA: Sodium is involved in many cell processes such as muscle contraction,
transmission of nerve impulses, and kidney function. Chloride ions are responsible for
maintaining the acid-base balance.
Patient Information: You should not take sodium chloride if you have ever had an allergic
reaction to it, or if you have high sodium levels in your blood.

f) Ceftriaxone
Pharmacologic Class: Cephalosporin
MOA: It works by interfering with the formation of the bacteria's cell wall so that the wall
ruptures, resulting in the death of the bacteria
ADR: The most common side effects were eosinophilia, leukopenia, thrombocytopenia,
diarrhea, rash, and increased hepatic enzymes.

g) Metronidazole
Pharmacologic Class: Nitroimidazole
MOA: Inhibits nucleic acid synthesis by disrupting DNA and causing strand breakage;
amoebicidal, bactericidal, trichomonacidal.
Contraindication: Pregnancy 1st trimester (for trichomoniasis)
ADR: Seizures, peripheral neuropathy, GI upset, anorexia, constipation, headache,
metallic taste, ECT changes, dysuria.

h) Salbutamol + Ipratropium
Pharmacologic Class: Respiratory Inhalant Combos
MOA: Albuterol: Beta2-adrenergic bronchodilator
Ipratropium: Anticholinergic (parasympatholytic) agent; inhibits vagally mediated reflexes
by antagonizing acetylcholine action; prevents increase in intracellular calcium
concentration caused by interaction of acetylcholine with muscarinic receptors on
bronchial smooth muscle
Contraindication: Hypersensitivity to albuterol, ipratropium, atropine and derivatives, soy,
or peanut
Patient Information: Learn how to use this inhaler properly.
ADR: The combination of ipratropium and albuterol has been generally well tolerated

i) Ranitidine
Pharmacologic Class: H2 receptor antagonist
MOA: competitively inhibits H2 receptor in gastric parietal cells
Patient Information: If to be take OD, instruct patient to take it at bedtime; Patient should
swallow oral forms with water and not to chew tablets.
ADR:Thrombocytopenia

j) Azithromycin
Pharmacologic Class: Macrolides

Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
MOA: Binds to 50S ribosomal subunit of susceptible microorganisms and blocks
dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis
to arrest; does not affect nucleic acid synthesis
Special Considerations: Before taking azithromycin, tell your doctor or pharmacist if you
are allergic to it; or to other antibiotics (such as erythromycin, clarithromycin,
telithromycin); or if you have any other allergies.
ADR: Stomach upset, diarrhea/loose stools, nausea, vomiting, or abdominal pain may
occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.

k) N-Acetylcysteine
Pharmacologic Class: Mucolytic
MOA: Exerts mucolytic activity through sulfhydryl group, which opens up disulfide bonds
in mucoproteins and lowers mucous viscosity of pulmonary secretions
Contraindications: Acute asthma

l) Piperacillin + Tazobactam
Pharmacologic Class: Anti-infective
MOA: Piperacillin binds to bacterial cell wall membrane causing cell death. Spectrum is
extended compared with other penicillins. Tazobactam inhibits beta lactamase enzyme
that can destroy penicillins.
Caution: Renal impairment
ADR: Seizures, confusion, dizziness, HA, insomnia, lethargy, pseudomembranous colitis,
diarrhea, constipation, Nausea and vomiting.

m) Isoniazid 75mg/ Rifampicin 150mg/ Ethambutol 275mg/ Pyrazinamide 400mg


Pharmacologic Class: Antimycobacterial
Rifampicin MOA: Blocks transcription by interacting with the B-subunit of bacterial DNA-
dependent RNA polymerase, thus inhibiting RNA synthesis by depressing the initiation
step
Pyrazinamide MOA: It possesses its mycobacterial potency to actively dividing
microorganisms
Isoniazid MOA: Targets enzyme responsible for assembly of mycolic acids in the outer
layer of the mycobacteria, a structure unique to this microorganism
Ethambutol MOA: Ethambutol inhibits arabinosyl transferases which is involved in cell
wall biosynthesis. By inhibiting this enzyme, the bacterial cell wall complex production is
inhibited. This leads to an increase in cell wall permeability.

n) Levofloxacin
Pharmacologic Class: Fluoroquinolones
MOA: L-stereoisomer of parent compound ofloxacin; D-isomer form is inactive. Inhibits
DNA gyrase activity, which in turn promotes breakage of DNA strands.

o) Potassium Chloride
Pharmacologic Class: Electrolyte Supplement
MOA: Essential in physiologic processes
Contraindications: Hypersensitivity, Untreated Addison disease, Hyperkalemia, Renal
failure
Cautions: CV disease, Impaired renal function

Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)

V. General Evaluation of Therapy

Pulmonary Tuberculosis:
The anti-tuberculosis regimen containing Rifampicin 150 mg, Isoniazid 75 mg, Ethambutol
275 mg, and Pyrazinamide 400 mg is contraindicated to the patient having an alcoholic liver
disease because this may exacerbate further liver injury.
A liver-sparing regimen may be used for the patient at least temporarily.
Further test like liver biopsy and histopathologic examination should be performed to
evaluate the degree of liver cell injury and confirming the disease in order to be able to
withdraw drugs that mat exacerbate liver injury.
The advice of a clinical pharmacist should be seek as soon as possible to rule out the
proper medication regimen regarding the condition of the patient wherein he has a fatty liver
and tuberculosis. The advice of the clinical pharmacist is essential to detect possible anti
tubercular drug that is worsening the liver disease of the patient thus modification of therapy
is the remedy.
Lifestyle modification is recommended to improve patient condition. Such lifestyles that
should be modified are the following: good hygiene and good environment sanitation
avoidance of cigarette smoking and second-hand smoke will improve the patient's condition.
Debilitated patients may require therapy for other medical conditions, including substance
abuse and HIV infections, and some may need nutritional support.

Community Accquired Pneumonia:

The patient should be advised to comply with the medication even after they experience
clinical improvement.
Sepsis secondary to CAP is primarily due to prolonged use or repeated antibiotic therapy.
Consider strict monitoring to antibacterial therapy.
Lifestyle modification should be implemented such as abstinence to cigarette smoking and
any form of second hand smoke will improve the condition of the patient with CAP.
Important therapeutic adjuncts include adequate hydration, optimal nutritional support and
fever control

VI. General Recommendations

Routine monitoring of CBC and liver function tests is highly recommended.


Monitoring of patient's sputum sample to determine the severity of bacteria
Monitoring of patient's electrolytes as a result of fever, vomiting or dehydration due to the
disease
Lifestyle changes and management of alcohol withdrawal

Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.
Pulmonary tuberculosis (PTB), Community-Acquired Pneumonia (CAP)
Consider screening for tuberculosis to family members and every household near the
patients residence for possible transmission.
Monitor signs of adverse reactions or toxicities.
Repeat chest radiography, and other relevant laboratory tests.
Monitoring of serum antibacterial concentration to ensure effective and successful treatment
of the disease
HIV testing may also be done.
Therapy should be extended for patients with weakened immune systems
Measure to assure adherence, such as directly observed therapy are important.

VII. Discussion of Treatment

Treatment for Pulmonary Tuberculosis

Treating Active disease

The standard treatment for pulmonary tuberculosis category I includes isoniazid, rifampicin,
pyrazinamide, and ethambutol for 6 months. It is very important to finish the medicine and take the drugs
exactly as prescribed. If you stop taking the drugs too soon, you can become sick again. If you have not
completed the medicines prescribed, the bacteria that are still alive may become resistant to those drugs. TB
that is resistant to drugs is harder and more expensive to treat.

Latent Infection

The preferred treatment for latent TB is the chemical agent INH (300 mg daily). Individuals likely to be
non-compliant may be treated with a regimen of 15 mg/kg (to a maximum of 900 mg) twice weekly with
observations. Rifampin 600 mg daily for 4 months can be used wen INH resistance is suspected. Treatment
with latent TB infection is essential in controlling and reducing the risk of progressive to active disease.

Treatment for Community Acquired Pneumonia

Community Acquired Pneumonia may be treated with monotherapy or combination therapy. Effective
monotherapy antibiotics include macrolides, respiratory quinolones and doxycycline. Combination therapy
usually consists of (1) ceftriaxone plus doxycycline or azithromycin or (2) monotherapy with a respiratory
quinolone for inpatient treatment of patients admitted to medical floor beds. Immunocompromised hosts who
present with CAP are treated in the same manner as otherwise healthy hosts but may require a longer duration
of therapy. Most patients with CAP who are admitted to the hospitals are treated with intravenous medications
initially and then complete a 12-day oral course of therapy for a total of 14 days of combined intravenous and
oral therapy.

Acio, Theresa B./ Pascua, Christian D./ Pescador, Trelly Ann C./ Vidad, Keziah I.