RESPONSE 1

Good job on your initial post. I prescribed A. M. with amoxicillin-clavulanic acid but I also agreed with your approach to treat his acute bronchitis with azithromycin. In fact, it has been proved that azithromycin has significant lower clinical failure in treatment of acute bronchitis compared to amoxycillin or amoxicillin-clavulanic acid (Laopaiboon et al., 2015). However, a thorough cardiovascular examination should be done prior to initiating therapy with azithromycin due to risk of prolonged QT interval and torsades de pointes. A study found that azithromycin possesses 2-fold increased risk of cardiovascular death and noncardiovascular death compared with amoxicillin in outpatient settings within a 5-day window (Zaroff et al., 2020). Syncope may be indication of cardiac QT interval prolongation. Therefore, it is critical to educate patient that he should stop taking the medication and contact the prescriber immediately when he experiences fainting. Additionally, when A. M. is started with Azithromycin, he should be advised to take the medicine for the full prescribed length of time, even when he feels better or symptoms resolve. Azithromycin is associated with liver abnormalities since it is mainly excreted via the liver (Woo & Robinson, 2020, pg. 745). As a consequence, patient should be instructed to inform healthcare providers if patient experiences abdominal pain in the upper right quadrant, itchy skin, dark urine, clay-colored stools or yellowing of the skin or eyes. 

Reference

Laopaiboon, M., Panpanich, R., & Swa Mya, K. (2015). Azithromycin for acute lower respiratory tract infections. Cochrane Database of Systematic Reviews.https://doi.org/10.1002/14651858.cd001954.pub4

Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers(5thEdition). F.A.Davis 

Zaroff, J. G., Cheetham, T. C., Palmetto, N., Almers, L., Quesenberry, C., Schneider, J., Gatto, N., & Corley, D. A. (2020). Association of azithromycin use with cardiovascular mortality. JAMA Network Open3(6). https://doi.org/10.1001/jamanetworkopen.2020.8199

 

RESPONSE 2

I enjoyed reading your discussion post. You discuss the likely pathogen as streptococcus pneumonia and the appropriate antibiotic for treatment would require amoxicillin-clavulanate. Chronic bronchitis is caused by increased mucus production by goblet cells, leading to worsening airflow. The increased mucus provides an excellent medium for recurrent bronchial infections causing further damage to the airways (Woo & Robins, 2020, p. 961). The most common organism found in the sputum of chronic obstructive pulmonary disease is streptococcus pneumoniae (Rabe et al, 2007 as cited in Woo & Robinson, 2020, p. 963). A sputum culture and sensitivity should be obtained, along with starting A. M. on antibiotic therapy. Amoxicillin/clavulanic acid, macrolides, or tetracycline are considered first-line treatment (Gold, 2018 as cited in Woo & Robinson, 2020, p. 963). The culture and sensitivity will determine if A. M. is taking the appropriate antibiotic based on the organism and the sensitivity to specific antibiotics. Penicillins work by hindering bacterial growth that inhibiting the biosynthesis of a bacterial cell wall mucopeptide; when penicillins bind to penicillin-binding proteins it causes the cell wall to be weakened (Woo & Robinson, 2020, p. 715). You also brought up some important counseling points that included pulmonary rehabilitation and how it can reduce hospital admissions as well as mortality. According to a study by Kubincova et al. (2018) comprehensive pulmonary rehabilitation for 3 weeks, all patients demonstrated significant improvements in exercise capacity including quality of life scores. Pulmonary rehabilitation may help manage dyspnea, improve, activities of daily living, improve lung ventilation, strengthen muscles, and improve overall quality of life. Initiation of pulmonary rehabilitation within three months of discharge was significantly associated with lower risk of mortality at one year (Lindenauer et al., 2020). References Kubincova, A., Takac, P., Kendrova, L., Joppa, P., & Mikulakova, W. (2018). The effect of pulmonary rehabilitation in mountain environment on exercise capacity and quality of life in patients with chronic obstructive pulmonary disease (COPD) and chronic bronchitis. Medical Science Monitor, 12(24), 6375-6386. https://doi.org/10.12659/MSM.909777 Lindenauer, P. K., Stefan, M. S., Pekow, P. S., Mazor, K., M., Priya, A., Spitzer, K. A…ZuWallack, R. (2020). Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among Medicare beneficiaries. JAMA, 323(18), 1813-1823. https://doi.org/10.1001/jama.2020.4437 Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5th ed.). F. A. Davis Company.

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