Allergic Drug Reaction Amanda, Becca, Greg, Robby, Sam Patient - - PowerPoint PPT Presentation

Allergic Drug Reaction

Amanda, Becca, Greg, Robby, Sam

Patient Presentation

Chief Complaint: "My cough is back and I feel like I did when I was admitted two weeks ago."

Problem List

• 1. Hospital acquired pneumonia
• 2. Problem: COPD
• 3. Problem: CVD: S/P MI and HTN

Subjective Data

• Chief Complaint: "My cough is back and I feel like I did when I was admitted two

weeks ago."

• AA is a 55-year-old man
• Two weeks ago, he presented to the ER with a 3-day history of tiredness, cough and

productive greenish sputum. ○ Sputum cultures at that time revealed Pseudomonas aeruginosa ○ Sensitive to aztreonam and cefepime ○ Intermediate sensitivity to piperacillin–tazobactam and tobramycin. ○ Desensitized to cefepime ○ He was treated for 7 days with IV cefepime without incident. He was discharged from the hospital to his home 2 weeks ago.

• He has had four admissions this year for COPD and pneumonia.

Subjective Data

PMH:

• COPD x 17 years
• Chronic empyema secondary to bronchopleural fistulae with chest tube placement

7 months ago

• Right upper lobe abscess secondary to Candida and Aspergillus; S/P upper lobe

lobectomy 11 years ago

• HTN x 10 years
• S/P MI 15 years ago

SH:

• Lives with his mother; he is unemployed. He has a 40 pack-year smoking history.

Admits to occasional alcohol use; denies use of recreational drugs. ROS

• (+) Fatigue, fever, sore throat, shortness of breath, and cough with thick sputum;

(–) nausea,vomiting, diarrhea, chills, or chest pain

ALLERGIES!

• Ampicillin–sulbactam: facial edema, tongue swelling, periorbital edema
• Ceftazidime: urticarial rash on chest and face with shortness of breath
• Codeine: nausea, pruritus

Objective Data

Meds

• Albuterol MDI two puffs Q 6 h PRN
• Ipratropium MDI two puffs Q 6 h
• Aspirin 325 mg po once daily
• Amlodipine 10 mg po once daily
• Prednisone 20 mg po daily (initiated as 60 mg po daily during previous hospital

admission; plan was to taper the dose and discontinue therapy within 2 weeks of hospital discharge)

Objective

Physical Examination:

• Gen: A 55-year-old Caucasian man appearing older than his stated age in moderate

respiratory distress. He is lethargic and hard of hearing.

• VS:100/60|85|16|39°C|52 kg|5'5″
• Skin: Dry scaly skin; no tenting
• HEENT: PERRLA, EOM intact, dry mucous membranes
• Neck/Lymph Nodes: (–) Bruits, (–) lymphadenopathy
• Lungs/Thorax: (+) Diffuse crackles at the left base; wheezes throughout with poor

breath sounds

• CV: Normal S1 and S2, RRR, (–) MRG
• Abd: Distended with (+) bowel sounds; (–) hepatosplenomegaly
• Genit/Rect: Deferred
• Ext: (+) Clubbing; (–) cyanosis or edema; poor muscle tone

Objective

ABG: pH 7.44, pO2 55 mm Hg, pCO2 38 mm Hg, O2 sat 90% Chest X-Ray: Haziness in the left lower lobe S/P right upper lobe resection Sputum Gram Stain: Pending Sputum Cultures: Pending Blood Cultures: Pending

Labs

Assessment: Pneumonia

• Patient presenting with Hospital Acquired Pneumonia, due to a relapse of

recent infection or new infection

• signs and symptoms: PMH, productive sputum, WBC, Neutrophils
• Goals:

○ Initiate antibiotic therapy within 4 hours of arrival at hospital ○ Reduce fever and other symptoms of infection ○ Limit the side effects and avoid allergic reactions ○ Prevent future infection ○ Counsel on side effects

Assessment: Pneumonia

• Treatment options, dosing ranges:

○ Recurrent infection: Gram negative P. aeruginosa ■ Aztreonam (2 g IV every 6-8 hours, Max 8g/day) ■ Cefepime (1 to 2 g IV every 8-12 hours) ○ New infection: MRSA ■ Vancomycin (patient based to Desired peak 20-40 mg/L, Desired trough 10-20 mg/L) ■ Linezolid (600 mg IV every 12 hours) ○ New infection Double coverage : aminoglycoside ■ Gentamicin (3mg/kg/d IV in divided doses every 8 hours)

• Studies:

○

Variability in Antibiotic Prescribing Patterns and Outcomes in Patients With Clinically Suspected Ventilator-Associated Pneumonia ○ Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines

• n the Management of Community-Acquired Pneumonia in Adults

Assessment: Pneumonia

• Patient education/Monitoring

○ consider allergies, ○ skin test ○ possible desensitization

• Non-pharmacological recommendations

Assessment: COPD

AA presents with COPD and likely an exacerbation brought on by a pulmonary infection. His staging (according to GOLD Guidelines) needs more information (FEV1/FVC)

Assessment COPD

Goals

• relieve symptoms, prevent disease

progression, improve health status, treat complications and exacerbations, reduce mortality and quit smoking!

Assessment COPD

COPD is evident by PMH (COPD x17 years), clubbing of fingers, multiple recurrent bacterial infections, smoking history and risk factors (smoking, infections/inflammation in airway, socioeconomic status, gender?)

Important to treat fully as part of treatment for patient’s overall pneumonia treatment and CVD

Assessment: COPD

Pharmacologic and nonpharmacologic therapy recommendations…

• btain FEV1 to stage properly
• give LABA as needed
• ipratropium while inpatient

○ initiate tiotropium as outpatient better adherence

• give SABA as needed
• give PO corticosteroids for 10x day and taper starting at 40 mg prednisone

for 2 days ○ after 10 days D/C SABA initate a combined LABA/corticosteroid

• evaluate vaccine history, once healthy give vaccines (especially influenza

and pneumococcal vaccine

Assessment: COPD

EDUCATE ON SMOKING CESSATION

• Assess patient’s motivation to quit and

provide with education on why and how to quit

Assessment: CVD

Diagnosis: S/P MI 15 years ago, HTN x 10 years, HTN currently controlled using Amlodipine, reassess blood pressure after HCAP is resolved, (+) Clubbing, Infection may have role in current BP Risk factors: S/P MI 15 years ago, 40 pack year smoking history, HTN x 10 years Goals: Prevent recurrent MI, stroke, atherosclerosis, and control blood pressure below 140/80, Goal HR between 55-60 Secondary Prevention: According to 2013 ACCF/AHA STEMI Guidelines: D/C Amlodipine, Start a cardioselective beta- blocker such as metoprolol for secondary prevention of MI, switch to Aspirin 81 mg per day. Consider starting an ACE-I, such as lisinopril and a HMG CoA Reductase Inhibitor, such as atorvastatin. Blood pressure, fasting Lipid panel and baseline LFTs should be measured upon resolution of current infection. Education: Educate patient on the changes in the medication regimen, and decreasing sodium intake, and increasing exercise. Assess patient’s motivation for quitting smoking, and educate about the benefits of smoking cessation.

Plan: Nosocomial Pneumonia

Perform allergic skin test for aztreonam

• If no reaction is triggered within an hour after the

test:

• Initiate aztreonam 2 grams intravenously
• ver 20 minutes every 6 hours for 7 days
• If a reaction is triggered, initiate desensitization

protocol and titrate up to 2 grams intravenously

• ver 20 minutes every 6 hours for 7 days.
• Desensitization: (To the right)
• Monitor vitals, O2 saturation, breathing sounds,

hypotension, dysrhythmias, hives, facial edema, vomiting, sneezing, cough or flushing. Desensitization Protocol:

• Start with 0. 0002 mg in 51ml over 20 minutes

○ Watch/wait 10 minute between EVERY infusion

• Start with 0. 002 mg in 51ml over 20 minutes
• Start with 0. 02 mg in 51ml over 20 minutes
• Start with 0. 2 mg in 51ml over 20 minutes
• Start with 2 mg in 51ml over 20 minutes
• Start with 20 mg in 51ml over 20 minutes
• Start with 200 mg in 51ml over 20 minutes
• Start with 2000 mg in 51ml over 20 minutes
• Administer aztreonam 2g IV every 6 hours per

pneumonia protocol

Plan: Nosocomial Pneumonia

• Initiate Gentamicin IV 50 mg every 8 hours

○ Monitor and adjust dose accordingly ■

• btain Peak 3o minutes after admin (4-12 mcg/L)

■ Obtain Trough 30 minutes before next dose (0.5 to 2 mcg/mL) ○ Monitor ■ proteinuria ■ serum calcium, magnesium, potassium and sodium ■ CBC, Fever, symptoms ○ Side effects ■ Ototoxicity

Vancomycin Population Dosing

Desired peak 20-40 mg/L Desired trough 10-20 mg/L (15-20 if severe) Ototoxicity occurs peak > 80 mg/L Nephrotoxicity occurs trough > 20 mg/L Red man syndrome occurs with infusion > 15 mg/min

Plan: Nosocomial Pneumonia

Initiate vancomycin 500 mg intravenously over an hour every 12 hours for 7 days

• Monitor peak and trough levels after the 4th dose.
• Trough before infusion
• Peak should be 2 hours after infusion
• Monitor Chem 7, CBC, and auditory and renal function.

All antibiotic measures are dependent upon pending cultures.

Plan

COPD:

• Obtain lung function tests and assess if severe; if

so:

• Give albuterol MDI 2 puffs PO Q4 hours PRN

indefinitely

• Give ipratropium MDI 2 puffs PO Q6 hours while in

hospital

• Salmeterol (Serevent Diskus) Inhale 1 powder PO

Q12 x10 days

• Prednisone Taper

○ Prednisone 40mg PO QAM x2 days ○ Prednisone 20 mg PO QAM x2 days ○ Prednisone 10mg PO QAM x2 days ○ Prednisone 5 mg PO QAM x2 days ○ Prednisone 1 mg PO QAM x 2 days and then stop

• Give influenza vaccine (yearly) in one month if

healthy ○

• btain vaccine history and give missing

vaccines if not up to date

• Give pneumococcal vaccine in one month if healthy
• Once discharged start of tiotropium; inhale

contents of one capsule by mouth daily

• Salmeterol/fluticasone 100/50mcg inhale one

actuation twice daily starting at day 11

• Assess patient’s motivation to quit

○ Educate on different options and importance

• f quitting
• Educate on side effects and importance of disease

state

Plan: CVD

• D/C amlodipine; monitor patient for hypertension in hospital (BP greater than 140/90)
• Change to aspirin 81 mg by mouth once daily
• Begin metoprolol tartrate 100 mg by mouth twice daily, and should be continued indefinitely

(cardioselective beta-blocker) should be initiated upon discharge ○ Monitoring: ■ Blood pressure, heart rate every 4 weeks ○ Education: ■ Drug may cause diarrhea, depression, or fatigue ■ Avoid activities requiring coordination until drug effects realized ■ Report signs of hypotension; dizziness

Plan: CVD continued

Begin atorvastatin 10 mg by mouth at bedtime once daily, perform fasting lipid panel upon infection recovery and titrate dose if needed to achieve LDL <100, TC <200, HDL > 40. May titrate up to Atorvastatin 80 mg daily if tolerated or needed. ○ Monitoring: ■ Baseline LFTs, Lipid panel in 4 weeks, and 2-4 weeks after dosage changes ○ Education: ■ May cause muscle pain; report muscle pain, weakness, tenderness to PCP immediately. Avoid grapefruit juice with this medication. Avoid excessive alcohol intake. Counsel on signs/ symptoms of jaundice: dark urine, yellowing of skin, upper abdominal discomfort, weakness, anorexia, fatigue). Begin lisinopril 2.5 mg by mouth every day, and titrate to 10 mg/ day as tolerated ○ Monitoring: Chem-7, blood pressure in 3-4 weeks ○ Education: Drug may cause a dry cough, consult PCP if this persists. Counsel on signs of angioedema; swelling lips, tongue- seek immediate medical attention. Counsel on signs of hypotension. This drug may cause N/V/D and headache.

• Educate on lifestyle modifications: lower sodium intake, and increase exercise to at least 30 minutes three to four times per

week

• Assess motivation for smoking cessation, and educate on mortality benefits and decreased cancer risk with quitting

References

Sylvia LM. Drug allergy, pseudoallergy and cutaneous diseases. In: Tisdale JE, Miller DA, eds. Drug-Induced Diseases: Prevention, Detection and Management, 2nd ed. Bethesda, MD, ASHP Publications, 2010:51–97. Solensky R. Drug hypersensitivity. Med Clin North Am 2006;90:233–260. Romano A, Di Fonso M, Viola M, et al. Selective hypersensitivity to piperacillin. Allergy 2000;55:787. Pichichero ME. Cephalosporins can be prescribed safely for penicillin-allergic patients. J Fam Pract 2006;55:106–112. Kelkar PS, Li JT. Cephalosporin allergy. N Engl J Med 2001;345:804–809. Win PH, Brown H, Zankar A, et al. Rapid intravenous cephalosporin desensitization. J Allergy Clin Immunol 2005;116:225–228. Solensky R. Drug desensitization. Immunol Allergy Clin North Am 2004;24:425–443.

References (Cont)

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Atanaskovic-Markovic M, Gaeta F, Medjo B, et al. Tolerability of meropenem in children with IgE-mediated hypersensitivity to penicillins. Allergy 2008;63: 237–240. Wilson DL, Owens RC, Zuckerman JB. Successful meropenem desensitization in a patient with cystic fibrosis. Ann Pharmacother 2003;37:1424–1428. http://www.nebraskamed.com/app_files/pdf/careers/education-programs/asp/aztreonam.pdf http://bmjopen.bmj.com/content/3/10/e003912.long O’Gara P, Kushner F, Ascheim D, et al. 2013 ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction. Journal of the American College of Cardiology 2013; 61 (4).