Question

Ms. Espinoza is a 90-year-old Hispanic woman admitted to the hospital from her assisted living facility. She has a history of hypertension and dementia and had a stroke and a myocardial infarction 3 years ago. She has also had insomnia for the past month. Ms. Espinoza is admitted due to an alteration in her mental status. She has had a cold and a cough for a week, for which she took Coricidin (acetaminophen and chlorpheniramine) and Tylenol PM (acetaminophen and diphenhydramine). Her home medications include monthly Nascobal (vitamin B12) injections; Toprol-XL (metoprolol succinate), 100 mg daily; Plendil (felodipine), 10 mg daily; Allegra (fexofenadine), 180 mg daily; Ecotrin (aspirin EC), 325 mg daily; and Colace (docusate sodium), 100 mg daily. She also has a very unsteady gait. Ms. Espinoza's admitting diagnosis is pneumonia. The physicians order the following medications: Lasix (furosemide), 20 mg IV push, x 1; Pepcid (famotidine), 20 mg bid; Ecotrin (aspirin EC), 325 mg daily; Toprol-XL (metoprolol succinate), 100 mg daily; Colace (docusate sodium), 100 mg daily; Allegra (fexofenadine), 180 mg daily; Levoquin (levofloxacin), 250 mg daily IVPB; Plendil (felodipine), 10 mg po daily; and Ambien (zolpidem), 5 mg at bedtime as needed.

2. Would you alter Ms. Espinoza's drug regimen in any way? If so, how?

Answer 1

The normal treatment regimen for a pneumonia includes

1. common - Empiric antimicrobial regimens should cover S.pneumonia with Beta- lactam medications or new respiratory fluoroquinolones and atypical pathogens should be treated with macrolides or respiratory fluoroquinolones.
2. in ward- oral therapy and early discharge shoul be considered in this patient population.
3. severe cases - combined antimicrobial therapy (beta- lactam plus either a macrolide or a respiratory fluroquinolone). Patients should be admitted to the ICU should be stratified as to whether or not the patients are at risk for Pseudomonas species infection and be treated accordingly.

Duration of therapy

• patients requiring hospitalization is 7-10 days. but those with atypical pathogens such as Legionella species, shouldreceive tretment for 10-14 days.

Ms. Espinoza is a 90 year old women by considereing her age it is very important to control her condition as early as possible.

Key points to be considered for treatment include

• clinical presentation of pneumonia in the elderly may be subtle, may be afebrile.
• Altered mental status, a sudden decline in functional capacity, and worsening of underlying disease may be the only findings
• Physicians should be alert to the diagnosis of pneumonia in elderly patients, even in the absence of the classic symptoms.

In her treatment regimen Floxacilin is already there, it will be more good to add a macrolide such as azithromycin or clarithromycin for better prognosis

Tab. Azithromycin can be added with 500 mg orally as a single dose for the first day and 250 mg for the next 4 consecutive days is found beneficial.