Week 13 reply to TWO discussion posts i am inserting the posts that you must reply to it is on infectious disease a page each is fine if you need more info message me
Discussion # 1
You are managing an 84-year-old male admitted to the hospital with acute lumbar vertebral osteomyelitis. Currently, you do not have culture results and will need to start treatment empirically while waiting on the remaining diagnostic tests to result. What is your clinical decision making and rationale on pharmaceutical management? What aspects are important to consider when making decisions on drug choice?
Vertebral osteomyelitis most often occurs as a result of hematogenous seeding of one or more vertebral bodies from a distant focus (Peel, 2021). It can also occur as a result of trauma, invasive spinal procedures, or from an adjacent soft tissue infection. Vertebral osteomyelitis can even occur as a result of spreading of a genitourinary tract infection, dental infection, or infective endocarditis (Peel, 2021). Whatever the cause, it is particularly important to obtain cultures prior to antibiotic therapy. Additionally, in cases of vertebral osteomyelitis, empiric therapy should be held while awaiting culture results unless the patient is hemodynamically unstable, septic, or experiencing neurological deficits (DiPiro et al., 2020).
The most common cause of vertebral osteomyelitis is Staphylococcus aureus (DiPiro et al., 2020). Importantly, cases of vertebral osteomyelitis caused by methicillin-resistant S. aureus in community and hospital settings have increased (Peel, 2021). If empiric antibiotic therapy is warranted, this patient should be provided with Vancomycin 15mg/kg every 12 hours (Peel, 2021). This should be used in combination with a fluoroquinolone or third/fourth generation cephalosporin such as ceftriaxone (DiPiro et al., 2020). Peel (2021) suggests use of ceftriaxone 2g IV daily. Importantly, anaerobes are an uncommon cause for vertebral osteomyelitis so coverage is typically not warranted for empiric therapy. However, if clinical presentation suggests that infection may be due to an anerobe, such as presence of an intraabdominal abcess, or if aerobic cultures are negative, metronidazole 500mg IV every 6 hours should be added to the regimen (Peel, 2021). Osteomyelitis requires a longer duration of antibiotics than typical infections. This patient will likely require 4 to 6 weeks of therapy (DiPiro et al., 2020). Longer therapy, such as 8 to 12 weeks may be warranted, especially if the patient presents with undrained vertebral abscesses or if they have a drug-resistant infection (Peel, 2021). However, oral antibiotics may be sufficient following at least two weeks of IV therapy depending on the patient presentation, current comorbidities, and medication compliance.
Due to this patients age (84 years) it would be important to pay attention to dosing and any adverse effects of these medications as older adults are typically more vulnerable to side effects of these drugs. For example, IV vancomycin and ceftriaxone both can cause C. Difficile infection so this patient should be monitored for signs and symptoms and tested for frequent loose BMs (Bui & Preuss, 2022; Lexicomp, n.d.). Older adults are also at higher risk for ototoxicity caused by vancomycin (Lexicomp, n.d.). Additionally, older adults frequently have decreased renal function or CKD which can leave them vulnerable to nephrotoxic effects of vancomycin (Lexicomp, n.d.). For these reasons it would be important to draw a vanco trough every 4th dose to ensure the patient is not sub or supratherapeutic. It would be critical to know this patient’s preexisting conditions, medical history, and concurrent medications. Allergies must also be assessed prior to ordering any medications. Additionally, daptomycin 6mg/kg IV once daily can be used as an alternative if this patient is unable to tolerate vancomycin due to allergy (Peel, 2021). Additionally, if this patient is allergic to penicillin, I would prescribe ciprofloxacin 400mg IV every 12 hours instead of ceftriaxone (Peel, 2021). Ceftriaxone should also be used in caution with patients with renal or hepatic impairment, as often seen in older adults (Bui & Preuss, 2022). The patient should have frequent CBCs, BMPs, and monitoring of renal and liver function during hospitalization. These laboratory findings could result in decrease in dosages or frequency of ceftriaxone and vancomycin due to development of an AKI or other abnormality.
References
Bui T. & Preuss C.V. (2022). Cephalosporins. StatPearls. StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK551517/
DiPiro, J. T., Yee, G. C., Posey, L. M., Haines, S. T., Nolin, T. D., & Ellingrod, V. L. (2020). Pharmacotherapy: A pathophysiologic approach (11th ed.). McGraw Hill Medical.
Lexicomp. (n.d.). Vancomycin: Drug information. UpToDate. Retrieved from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/vancomycin-drug-information?source=auto_suggest&selectedTitle=1~1—1~4—vanco&search=vancomycin#F54416571
Peel, T. (2021). Vertebral osteomyelitis and discitis in adults. UpToDate. Retrieved from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/vertebral-osteomyelitis-and-discitis-in-adults?search=vertebral%20osteomyelitis&source=search_result&selectedTitle=1~72&usage_type=default&display_rank=1#H23
Discussion #2
Question #1: You are managing a 35-year-old male admitted to the hospital with infective endocarditis felt secondary to intravenous drug abuse. Currently, you do not have culture results and will need to start treatment empirically while waiting on the remaining diagnostic tests to result. What is your clinical decision making and rationale on pharmaceutical management? What aspects are important to consider when making decisions on drug choice?
Endocarditis is inflammation that occurs in the endocardium of the heart. The endocardium is the membrane that lines the hearts chambers and covers the cusps of the heart valves. Typically, endocarditis refers to an infection within the heart’s valves caused by different microorganisms. Bacteria is the primary cause of endocarditis; however, fungus and multiple other types of microorganisms can cause endocarditis in an individual which is why “infective endocarditis” is a more appropriate term for this disease. Infective endocarditis occurs most frequently in the heats’ native valves, but it can arise in implanted devices as well such as pacemakers, prosthetic heart valves, cardiac defibrillators, and heart catheters). Infective endocarditis can either be acute or subacute, completely depending on the severity and pace of the patients’ clinical presentation. When a patient present with an acute form, they will likely have systemic toxicity and high fevers. A patient left untreated in this form can result in death within days to weeks. When a patient presents with a subacute form, they are likely to have develop this from an already existing heart disease that is valvular in nature, the infection is slow progressing in nature, and the bacteria causing this form tend to be less virulent. Both the acute and subacute form should be treated and taken seriously (DiPiro et al., 2020).
The diagnosis of infective endocarditis (IE) cannot rely solely on signs and presenting symptoms. Between laboratory data, and echocardiographic findings the diagnosis of infective endocarditis can be diagnosed. Diagnosis of infective endocarditis is done via the Modified Duke Criteria. According to Chu & Wang (2022), “The modified Duke criteria stratify patients into the following categories: definite IE, possible IE, and rejected IE based on pathologic and clinical criteria. The Duke criteria should be used as a diagnostic guide together with clinical judgment and must be interpreted in view of the pretest probability for IE. The criteria were developed for evaluation of patients with left-sided native valve IE; their sensitivity is diminished in patients with suspected prosthetic valve IE, right-sided IE, and cardiac device infection.” Definite IE criteria has to have both a pathologic criteria (pathologic lesion or a microorganism on culture) and clinical criteria consisting of at least 2 major criteria (+blood cultures & + echocardiogram for vegetations); Possible IE criteria has to have the presence of 1 major criteria (+echocardiogram for vegetations) and 1 minor clinical criteria (Fever >100.4F); and Rejected IE has to have either a firm alternate diagnosis that is made or resolution of clinical manifestations occurs after ≤4 days of antibiotic therapy (Chu & Wang, 2022).
Infective endocarditis typically arises in adult individuals who have certain risk factors placing them at risk of developing infective endocarditis. These risk factors are intravenous drug use, valvular disease, heart failure, and a healthcare exposure. As mentioned above, individuals who also have medically implanted devices specific to their hearts are also at an increased risk of developing infective endocarditis (DiPiro et al., 2020). There are 3 groups of organisms that typically cause infective endocarditis. These organisms are enterococci, streptococci, and staphylococci. Like most infections, it is highly important to isolate the pathogen that is causing the infection and determine its antimicrobial susceptibilities in order to effectively treat infective endocarditis. Once this is achieved, high dose-IV bactericidal antibiotics are utilized for an extended length of time (Wang & Holland, 2022). Interestingly, Wang & Holland (2022, P.2) stated, “For patients with suspected infective endocarditis who present without acute symptoms, empiric therapy is not always necessary, and can be deferred until blood culture results are available, particularly since accurate microbiologic diagnosis is a critical first step in planning the treatment strategy.” Wang & Holland (2022) go on to explain however, patients who present with acute signs and symptoms of infective endocarditis who are acutely ill (systemic toxicity, high fevers) should be started on empiric therapy ONLY AFTER at least two sets of blood cultures have been obtained. Wang & Holland (2022, P.2) stated, “The choice of empiric therapy should take into consideration the most likely pathogens. In general, empiric therapy should cover staphylococci (methicillin-susceptible and methicillin-resistant), streptococci, and enterococci.”
In the case of this patient, I will assume that he is presenting acutely ill with signs and symptoms of infective endocarditis so empiric treatment will need to be started. After obtaining 2 sets of blood cultures, empiric antibiotic therapy will be initiated. Vancomycin will be started as part of the empirical therapy regimen as it is able to cover the most common causes of infective endocarditis including enterococci, staphylococci, and streptococci. I would order a loading dose of Vancomycin 25-30 mg/kg followed by Vancomycin 15-20 mg/kg IV every 8-12 hours with a target trough concentration of 15-20 mcg/ml. I will also order Cefepime in order to cover any potential gram (-) bacilli that could potentially result on the culture in patient who present acutely ill. I would order Cefepime 2g IV Q8 hours (DiPiro et al., 2020). Once cultures came back for this patient and the infectious organism/etiology was determined, antimicrobial therapy should be tailored and targeted to its specific pathogen in order to better get rid of the patients’ infective endocarditis. It is important to note that current guidelines from both the European Society of Cardiology and the American Heart Association require patients with infective endocarditis to have a team on their case consisting of cardiovascular surgeons, cardiologists, and infectious disease doctors to better manage their infective endocarditis. This allows for a better “team approach” when assessing the need and time frame for any surgical needs that the patient may have. (DiPiro et al., 2020).
References
Chu, V. H., & Wang, A. (2022, June 27). Clinical manifestations and evaluation of adults with suspected left-sided native valve endocarditis. UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-and-evaluation-of-adults-with-suspected-left-sided-native-valve-endocarditis
DiPiro, J. T., Yee, G. C., Posey, L. M., Haines, S. T., Nolin, T. D., & Ellingrod, V. L. (2020). Infective Endocarditis. In Pharmacotherapy: A pathophysiologic approach (11th ed., pp. 1883–129). essay, McGraw Hill.
Wang, A., & Holland, T. L. (2022, April 8). Overview of management of infective endocarditis in adults. UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-management-of-infective-endocarditis-in-adults
