John is a 74years old male and he was diagnosed 2 years ago with mild Chronic Obstructive Pulmonary Disease (COPD) confirmed by spirometry of FE1>50% (Ho et al., 2019).
John was referred by his General Practitioner (GP) following acute exacerbation of COPD. He is an ex-smoker with co-morbidities of Type 2 Diabetes and Essential hypertension, he had 2 exacerbations of his condition within 12 months and one of the episodes required hospitalization. He is being treated for his COPD with a Ventolin inhaler and Symbicort Turbohaler 400/12, his medication history recorded he had hypersensitivity reactions to amoxicillin antibiotics see appendix 1 for medication history.
I visited John to carry out a holistic assessment, and a detailed history was taken. Rull (2008) acknowledged that a good history is key in treating the patient. The set of presenting problems was 3 days before the visit. John presented with cough, breathlessness which is impending on day-to-day activities, purulent increased sputum volume, sputum normally white, now thick green, and difficulty clearing secretion. On examination, there was air entry with a wheeze heard in the left mid-lung field, the cardiac sound was heard, abdominal physical examination was unremarkable, the feeling of cold and hot was reported and has been taking paracetamol. Assessment and vital signs are included in Appendix 1.
From the patient’s condition and outcome of the assessment, the single measurable aim of this case study is to treat the infection (microbiologic cure) of John’s exacerbation which will be measured by the resolution of his symptoms. The patient is at risk of antimicrobial resistance with repeated courses of antibiotics with doxycycline according to a previous laboratory report.
John is considered at high risk of complications and has most likely developed a chest infection, hence sputum sample and blood were taken and sent for culture and sensitivity as urgent; laboratory values are in Appendix 1.
John’s white blood cell count was elevated which was indicative of an infection «The primary causes of (COPD) exacerbations are bacterial or viral infections» (Lewis, Bucher, Heitkemper,&Harding,2017).
The sputum sample result revealed bacterial infection of streptococcus pneumonia. John was diagnosed with Low severity of community-acquired pneumonia according to susceptibility results as advised by the microbiologist, I have the choice of clarithromycin and ciprofloxacin that are safe and feasible to clinically cure the infection.
I will be considering and analyzing two treatment options of ciprofloxacin (quinolones)and clarithromycin (macrolide) as they are unrelated to penicillin and are safe to use in the penicillin allergic patient and my non-pharmacological intervention for John is a referral to the pulmonary rehabilitation, a specialized program of exercise and education designed to help people with lung problems.
National Institute for Health and Care Excellence (NICE NG115) Chronic Obstructive pulmonary disease in over 16’s diagnosis and management recommend amoxicillin antibiotics as the first line of treatment, second-line treatment doxycycline, and 3rd line of treatment clarithromycin for a patient with community-acquired pneumonia not requiring hospital admission.
I have ruled out amoxicillin because the patient has a history of hypersensitivity reaction to penicillin with a rash.
Considering the health conditions of the patient, it becomes evident that both the first and the second line of treatment for community-acquired pneumonia (CAP) as an exacerbation of COPD are ineligible. Amoxicillin antibiotics that contain penicillin are likely to trigger an allergic reaction with undesirable treatment complications, whereas the administration of doxycycline does not align with the patient’s history of frequent antibiotic intake. For this reason, it is necessary to conduct detailed research on the treatment with fluoroquinolones like ciprofloxacin and macrolides such as clarithromycin.
The Use of Macrolides and Fluoroquinolones in COPD Exacerbation
Both antibiotics are classified to treat pulmonary bacterial infections, yet their administration differs according to the scope of exacerbation severity, risk of hospitalization, and co-morbidity aspects. Thus, in a retrospective cohort study by Scussel et al. (2019), the authors reveal that there is relatively no difference in the outcomes for treatment with both antibiotics. Indeed, the study justified a hypothesis outlined earlier, claiming that in patients with pulmonary complications such as Legionellosis, “no difference was found for mortality, length of stay, and duration of fever” (Scussel et al., 2019, p. 875). Thus, one can assume that John’s prescription of macrolides or fluoroquinolones will have an equal effect on his CAP.
Other studies, on the other hand, find the administration of macrolides more efficient when it comes to treating such COPD exacerbations as S. pneumoniae. Namely, in a randomized controlled trial by Yormaz et al. (2021), the researchers outline that “S. pneumoniae was determined to be most resistant to erythromycin, gentamicin, clindamycin, tetracycline, and trimethoprim,” whereas fluoroquinolones had a positive impact on the treatment of P. aeruginosa (p. 1522). However, these findings applied only to short-term treatment of CAP in patients with no regard for co-morbidity issues. Comparing both antibiotics, it may be concluded that both options are beneficial for patients with CAP, whereas the choice for every patient should be based on exhaustive medical data.
Macrolides and Fluoroquinolones in Complicated Patients
Given the medical history of the patient, it is necessary to take into account the drug’s compatibility with other medications, the age of the patient, and the frequency of exacerbation. It has been stated in a randomized controlled trial conducted by König et al. (2019) that macrolides “have been associated with cardiovascular toxicity and drug interactions” (p. 1). With a history of essential hypertension and low leukocyte count, the patient is at risk of developing health complications as a result of treatment. For this reason, it is reasonable to assume that ciprofloxacin can be a more beneficial option for John.
When tackling COPD acute exacerbations, the researchers pay specific attention to the scope of pulmonary complications. A retrospective cohort study conducted by Ernst et al. (2019) focused on the effect of fluoroquinolones in uncomplicated patients. The results of such a study revelated that when uncomplicated ambulatory patients have an acute exacerbation of COPD, the administration of fluoroquinolones does not benefit patients more than any other antibacterial drug. However, the conclusion of the study relevels that such a result “supports current recommendations that fluoroquinolones be reserved for AECOPD in patients with recurrent exacerbations, significant co-morbidity or requiring hospitalization” (Ernst et al., 2019, p. 2939). Hence, regarding the increased frequency of COPD exacerbation over the past 12 months and co-morbidities such as Type 2 diabetes, the choice in favor of ciprofloxacin can be reasonable. As far as the latter is concerned, one of the most recent studies on macrolides by Fennelly et al. (2022) demonstrates that COPD patients with long-term co-morbidities such as diabetes mellitus do not experience significant improvements after the prophylactic intake of macrolides. Hence, there is a high chance of unintended consequences in prescribing clarithromycin to complicated patients.
Fluoroquinolones in Treating Pneumonia
Since the patient in question is currently struggling with CAP, it is necessary to identify the overall implications of using fluoroquinolones during treatment. In a substantial meta-analysis by Kato et al. (2020), the emphasis was placed on the comparison of fluoroquinolones and macrolides in pneumonia treatment based on such variables as mortality rates and length of hospital stay. The findings have demonstrated that the administration of fluoroquinolones has significantly more benefits for pneumonia patients, indicating that “FQs exhibited superior effects in terms of mortality and length of hospital stay” (Kato et al., 2020, p. 1). Hence, it can be concluded that the prescription of ciprofloxacin is a better option for the patient with CAP, as it secures both efficient treatment and better compatibility with his co-morbidities, age, and exacerbation recurrence.
Pulmonary Rehabilitation Non-Pharmaceutical Intervention
To secure lower readmission rates and holistic treatment, any pharmaceutical intervention should be followed by a lifestyle improvement initiative. In the context of COPD exacerbation, the most acknowledged intervention is pulmonary rehabilitation (PR). According to Ryrsø et al. (2018), PR is “a supervised multidisciplinary program including exercise training” used to maintain the physical shape of COPD patients (p. 1). This systematic review also indicates that early PR intervention in patients with COPD exacerbations leads to a lower risk of mortality, shorter hospital stays, and a lower readmission rate. A retrospective cohort study by Lindenauer et al. (2020) concluded that starting a PR program within 90 days of discharge significantly reduces mortality rates among older patients. Another study by Hansen et al. (2019) defines PR as a standard for COPD treatment and outlines telemedicine approaches to PR in the modern context. Hence, it can be concluded that PR is a mandatory non-pharmaceutical intervention for the patient.
Based on the findings above, the primary medication for John’s CAP is ciprofloxacin. The initial treatment plan for the patient includes 400mg of ciprofloxacin IV every 12 hours. While there is little to no difference between oral and IV medication intake, the latter was chosen to avoid potential swallowing complications for a 74-year-old patient. The treatment will last for 14 days, and the patient will be recommended to stay at the hospital during treatment to monitor his health condition and response to the medication.
Since the patient struggles with diabetes and hypertension, both blood pressure and blood sugar will be measured daily to see the patient’s dynamics and avoid treatment complications. Along with ciprofloxacin, John will take his usual hypertension medication, Diuril, a thiazide diuretic, at a dosage of 500mg orally every 12 hours. Additionally, once a week, John will be administered 30mg of Tanzeum. However, in case there are any glucose level changes due to CAP treatment, John may be prescribed insulin shots to stabilize his condition. If, after 14 days, John’s condition is stable, he will be discharged. Otherwise, the treatment may be continued for another three days by reducing the dosage of ciprofloxacin to 200mg IV every 12 hours. When John is discharged, he will be provided with additional information on early PR intervention provided by the hospital’s local physical and respiratory therapists.
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