Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer.
So, if you're ready, let's jump right in.
Margaret Fitzgerald: A 72-year-old man presents to primary care for a sick visit, with the chief complaint of a 1-day history of fever, productive cough with yellow sputum, and increasing shortness of breath. He denies GI distress but states his appetite is not what it usually is. He has a history of hypertension, type 2 diabetes, and dyslipidemia, all at guideline-based goals.
He's a former smoker, quitting about 10 years ago and has approximately a 35-pack-year cigarette smoking history and was diagnosed with COPD 5 years ago. Clinical assessment confirms the diagnosis of community-acquired pneumonia suitable for outpatient treatment. Which of the following represents the most appropriate antimicrobial option?
A: Oral levofloxacin.
B: Injectable ceftriaxone.
C: Oral azithromycin.
D: Oral amoxicillin.
The correct answer is A: Oral levofloxacin. Where should we start? First, determine what kind of question this is. Of course, we're being given the diagnosis and asked to choose what to treat this disease with.
This is clearly a planned/intervention question. Let's take a few minutes and look at some background information on pneumonia. In other podcasts, I included Q and A's on determining the location of care for a person with community-acquired pneumonia. I would really encourage you to listen to that one as well. But let's get back to treating it.
Most often caused by bacteria or virus, pneumonia is an acute lower respiratory tract infection involving the lung parenchyma, interstitial tissues, and alveolar spaces. Usually, the bronchi are involved as well. Although numerous organisms are capable of causing pneumonia, particularly when pneumonia is community-acquired, relatively few are seen with any great frequency. Streptococcus pneumoniae, also known as the pneumococcal organism, is a gram-positive diplococci and is one of the most common community-acquired pneumonia pathogens in adults, and is also the organism that is most closely associated with fatal community-acquired pneumonia.
Haemophilus influenzae can also be noted. Gram-negative organism, and particularly in people with a history of COPD, H. flu is often, causative organism, or at least in the mix. M. pneumoniae and C. pneumoniae are common organisms that can cause CAP, and these two are what is known as the atypical pathogens and are highly communicable. You'll often see these in people who spend a good deal of time in close proximity to one another.
Such as households, colleges, college dorms, military barracks, residential settings including long-term care. Legionella, of course, can also be a cause of community-acquired pneumonia. Yet, interestingly enough, there has never been a person-to-person case of Legionella transmission. So, how is it we hear about Legionella in outbreaks? There usually is a common source of the Legionella organism.
And this bug likes to grow in warm, standing water. And then if that water gets vaporized, somebody inhales it, and voila, you have a group of people who come down with Legionella. Hot tubs, shower heads, air conditioning systems. These are examples of where Legionella can breed and then people will pick it up. In this scenario, getting back to this patient, the patient presented with community-acquired pneumonia.
And we're being told that he is suitable for outpatient treatment. But he has comorbidities, particularly COPD and diabetes. It's interesting when you look at the comorbidity of the hypertension and dyslipidemia, and treating lower respiratory tract infections, those tend not to really come into the mix all that much. As far as influencing choice of antimicrobial and how you would treat CAP. On the other hand, COPD and diabetes, we do need to consider those.
In treating COPD with these comorbidities, the risk of resistant pathogens is increased and therefore that influences the choice of the drug we're going to give the person. And what we're really trying to do is avoid the risk of treatment failure. Because these we've got a guy in his 70s who's got COPD.
We do not want him to fail therapy. With that information in mind, let's take a look at the question and the choices provided. A 72-year-old man presents to primary care for a sick visit with the chief complaint of a 1-day history of fever, productive cough and yellow sputum, with increasing shortness of breath.
He denies GI distress, but states his appetite is not what it usually is. He has a history of hypertension, type 2 diabetes, and dyslipidemia, all at guideline-based goals. He's a former smoker, quitting about 10 years ago with approximately a 35-pack-year history, and was diagnosed 5 years ago with COPD. Clinical assessment confirms the diagnosis of community-acquired pneumonia suitable for outpatient treatment.
Which of the following represents the most appropriate antimicrobial option? A: Oral levofloxacin. And you'll recall this is the correct answer. Why is it the correct answer? According to the recommendations found in the Sanford Guide and from the IDSA, or the Infectious Disease Society of America, this is one of the preferred options in CAP with comorbidity. The rationale is that the antimicrobial will provide activity against the most common CAP organisms, particularly in older adults with the aforementioned health challenges. In particular, this drug has great activity against strep pneumo, including some drug-resistant strains, Haemophilus influenzae, as well as the atypical pathogens including Legionella.
B: Injectable ceftriaxone. Well, we already know this isn't the correct answer because A was the correct answer. Now, ceftriaxone is a cephalosporin. I can tell that because of the CEF- prefix, and it would be effective against strep pneumo and H. flu. The cephalosporin class do not provide activity against the atypical cold pathogens and therefore they're not considered to be solo products to use for the treatment of CAP.
In addition, this patient does not need an injectable antimicrobial because what is he telling you he can eat and drink. His appetite's not as great as it usually is, but that's nothing of great concern in a person with pneumonia. And remember the nursing 101 adage: do not inject what you can give PO. With a working gut, oral antimicrobials are as effective as injectables.
And you might recall this from your acute care hospital work, there are certain antimicrobials that are only available parenterally.
But we've got a guy here who's well enough to be treated at home. And there's nothing magic about giving a shot of ceftriaxone as you start oral antimicrobial therapy in the treatment of community-acquired pneumonia. C: Oral azithromycin. This drug is not considered to be a first-line as solo therapy in a patient with comorbidity and community-acquired pneumonia due to high rates of bacterial resistance and the risk of treatment failure.
In fact, it really is sad to see how azithromycin, over the past 25 years since it's been on the market, has been rendered an antimicrobial of very, very limited effectiveness, in part because it's strep pneumo coverage is really quite poor. And if you go to the community-acquired pneumonia guidelines for people with pneumonia without comorbidity, it is mentioned as a possible medication to be used in the absence of a comorbidity.
But there are all sorts of caveats about knowing what the local patterns of strep pneumo resistance to macrolides are and a number of other factors. But clearly, in this situation, not an appropriate choice. And D: Oral amoxicillin. Amoxicillin would take care of the strep pneumo if you gave enough of it. But then again, what are we doing in community-acquired pneumonia?
Are we doing a sputum culture? No, we're doing empiric antimicrobial therapy. Or that, if you will, best guess therapy on what organisms you believe are causing the infection. And oral amox, if the dose was sufficient, would cover strep pneumo. It could cover the H. flu, if the H. flu is not beta-lactamase-producing, but it will be ineffective against the atypical pathogens, and it is mentioned as a possible drug to use in people who have pneumonia without comorbidity.
But it is an inappropriate drug with too great a risk of treatment failure in a person with comorbidity. Key takeaway: as with all choices of antimicrobials, to choose the right drug you must know the causative bug. Evidence-based practice is predicated on these principles, as is NP board success.
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