Question

Chriscelle, a 25-year-old nursing student with asthma and a documented penicillin allergy, developed a dry cough that tended to get worse at night. She felt fatigued and lost her appetite. She decided that she probably just had a cold. About three days after her initial symptoms had developed, Chriscelle experienced an increasing tightness in her chest that made breathing difficult. Her boyfriend reminded her that as an asthmatic she really shouldn’t put off being seen for her respiratory symptoms. Chriscelle reluctantly agreed and went to the nearby urgent care center, where the doctor prescribed her azithromycin—a “Z-Pack”—to treat what was probably walking pneumonia caused by Mycoplasma pneumoniae. Within a few days Chriscelle felt much better. Although she did have some asthma flare-ups, she never missed attending her nursing school rotations at the hospital. About a week after finishing the Z-Pack, Chriscelle woke up at about midnight with flu-like symptoms and terrible abdominal cramping. She ended up vomiting and she suffered diarrhea every hour throughout the night. By 9:00 a.m. she was exhausted and feeling worse; she was running a fever and was dehydrated. She knew from her training that it was time to be seen for her symptoms. Her boyfriend drove her to the emergency room. Based on Chriscelle’s patient history, the ER doctor suspected a Clostridium difficile infection. A stool sample was taken and then Chriscelle was started on vancomycin and admitted to the hospital. The next day she was informed that rapid screening methods on the stool sample had confirmed a Clostridium difficile infection. A couple of days later, Chriscelle was released from the hospital. She was careful to stick to her vancomycin dosing and finished her whole 10-day prescription. She took things a bit easier than usual, but was concerned about falling behind at school. Within a month Chriscelle was back at the ER with the same symptoms. Rapid screening tests confirmed a C. difficile relapse and she was once again prescribed vancomycin. She was discharged after a couple of days and again diligently took her vancomycin prescription at home. Fortunately, her nursing program faculty and the program director were able to work with Chriscelle to help her get back on track and graduate just one semester behind her original cohort.

Case-Based Questions

1. Based on the presumed causative agent of Chriscelle’s pneumonia, what drugs would have been immediately ruled out of the empiric therapy and why?

2. What are the pros and cons of a Z-Pack prescription?

3. What aspects of Chriscelle’s patient history made the ER doctor suspect C. difficile and why were they clues for her diagnosis?

4. What is the most likely explanation for Chriscelle’s C. difficile relapse?

5. What transmission precautions would have been instated for Chriscelle’s stay in the hospital?

Answer 1

1)The immediate drug to be ruled out is one free of pennicillin, here she can be given a macrolide antibiotic to get treated for her pneumonia.This is a best antibiotic to treat pneumonia who has penicillin allergy.Here due to her medical condition she has been prescribed azithromycin which is amacrolide antibiotic

2)Pros:

• Can treat multiple infection
• short course for medication
• to be taken just once a day

Cons:

• Adverse effects are unpleasant
• Gastrointestinal disturbance like nausea,vomiting and abdominal pain
• Cholestatic hepatitis can occur
• may even cause heart problems
• Clostridium difficile is seen 1ith usage of this drug

3)The patient history of abdominal pain, vomiting, severe diarrhoea ,Azithromycin intake has given clue to diagnose C.difficile

4)The relapse is because she has taken things bit easier than usual because the organism of C.difficile symptoms can be treated effectively but the spores remains active for quite a long time,during this phase if there is poor hygiene or poor quality contaminated foid,immunity determine the relapse if the infection.