Scenario 1: Jessica, a 9-year-old Caucasian girl with moderate intermittent asthma, is seen in your primary care clinic. She is using a daily inhaled corticosteroid (Flovent 44mcg, 2 puffs BID) as well as albuterol two puffs up to every four hours PRN to relieve her cough and wheeze. According to her mother, she uses about 6 doses of albuterol daily.

1. Do you believe this is demonstrates good control of Jessica’s asthma? Why or why not?

2. What medication modifications do you recommend in this case?

3. Discuss specific patient education on the prescribed therapy.

4. What are the parameters for monitoring success of the therapy?

Scenario 2: A 66-year-old male presents to the urgent care clinic with a 4-day history of dry cough, progressing to rusty colored sputum, sudden onset of chills the previous evening, subjective fever, and malaise. Originally, the man thought he had a cold, but the symptoms had worsened and he “barely slept last night with all this coughing.”

He denies experiencing shortness of breath but suggests he may be breathing “a little faster than normal.” He relates that, on the way to the clinic, he felt some sharp right-sided chest pain after a particularly long bout of coughing. He denies any leg swelling, orthopnea, or left-sided/substernal chest pain. He also denies any gastrointestinal symptoms (no nausea, vomiting, or diarrhea). His past medical history included hypertension and hypercholesterolemia. He reported no antibiotic use in the previous three months. You complete a chest x-ray confirming a diagnosis of right lower lobe pneumonia.

1. What is your antibiotic treatment of choice and duration? Why?

2. If this scenario were the same, except for recent antibiotic use within the last three months, how would that change your prescribed therapy and why?

3. What if this were a 6-year-old with CAP? What antibiotic, dose and duration would you choose?

Please include references

ANSWER

Scenario 1

Jessica’s Asthma Control Assessment:
Jessica’s asthma control can be considered suboptimal. Despite using a daily inhaled corticosteroid (Flovent), she still relies heavily on her albuterol inhaler, averaging about 6 doses daily. This frequent use of albuterol indicates that Jessica is experiencing persistent symptoms, which is indicative of inadequate asthma control. Her cough and wheeze, despite using both medications, suggest a need for further intervention.

 Medication Modifications:
Given Jessica’s suboptimal asthma control, medication adjustments are warranted. One approach could be to step up her controller therapy. This may involve increasing the dose of inhaled corticosteroid or considering the addition of a long-acting beta-agonist (LABA) to her current regimen. Consulting with a pediatric pulmonologist may be beneficial for further guidance on adjusting her asthma management plan.

Patient Education on Prescribed Therapy:
Jessica and her mother should receive comprehensive education on the proper use of both the inhaled corticosteroid (Flovent) and albuterol inhaler. This includes correct inhaler technique, understanding of when and how to use each medication, and recognizing signs of worsening symptoms. Additionally, they should be educated on the importance of adhering to the prescribed regimen and the significance of regular follow-up visits for asthma management.

Parameters for Monitoring Therapy Success:
Monitoring Jessica’s response to therapy involves assessing her symptom control, frequency of albuterol use, and any adverse effects of the medications. Regular follow-up appointments will be crucial to evaluate her progress. Objective measures such as peak expiratory flow rate (PEFR) can also provide valuable data on lung function and help guide treatment adjustments.

Scenario 2

Antibiotic Treatment Choice and Duration:
For the 66-year-old male with confirmed right lower lobe pneumonia, an appropriate choice would be to prescribe a respiratory fluoroquinolone like levofloxacin or a combination of a beta-lactam (such as ceftriaxone) and a macrolide (like azithromycin). The duration of treatment typically spans 5 to 7 days, but this may vary based on clinical response.

Impact of Recent Antibiotic Use:
If the patient had recent antibiotic exposure within the last three months, consideration should be given to potential antibiotic resistance. In such cases, it might be prudent to choose an antibiotic regimen that targets a broader spectrum of pathogens. This could involve selecting a different class of antibiotics or a combination therapy to ensure efficacy against potentially resistant strains.

CAP Treatment in a 6-Year-Old:
For a 6-year-old with community-acquired pneumonia (CAP), the antibiotic of choice would be amoxicillin or amoxicillin-clavulanate. These agents provide coverage against the most common pathogens associated with pediatric CAP, including Streptococcus pneumoniae. The duration of treatment typically spans 10 days in this age group.