- You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts.
- All replies must be constructive and use literature where possible. They must be at least 100 words and supported by at least one source.
Reply 1:
Based on the patient’s history of available information, the diagnosis, in this case, is Clostridioides difficle (C.diff) associated diarrhea or infectious diarrhea. He recently started an antibiotic course of Ciprofloxacin BID for prostatitis; patients who are prescribed antibiotics risk getting C-diff as antibiotics can disrupt the normal intestinal flora, causing an overabundance of C. diff bacteria in the colon, causing diarrhea and colitis, which is an inflammation of the colon (Silva, 2020). Ciprofloxacin belongs to the fluoroquinolone class and is approved to treat prostatitis; it is the most potent against gram-negative bacilli bacteria (STATPearls, 2023). Diarrhea is a common side effect of different antibiotics such as Macrolides, Cephalosporins, Penicillin, and Fluoroquinolones (STATPearls, 2023).
The patient is susceptible to contracting C. diff due to his advanced age and autoimmune disorder. I would discuss with the patient the possibility of admitting him to the hospital. It will be safe to admit the patient since he can be better observed and treated. Also, this will eliminate the bacteria from spreading to the community and his wife. Concerning who will take care of his wife, since he is the primary caretaker, it will be best to involve a case worker or a social worker who can further assist in finding a helper to care for his wife while at the hospital.
I would immediately stop the Ciprofloxacin and order a toxigenic culture stool test, a gold standard for detecting C-diff (Qutub et al., 2019) to rule out C-diff-related diarrhea. I would also order a regular stool test to rule out parasites or ova to narrow the diagnosis.
This patient would also be assessed for any electrolyte imbalances. I would check for signs of dehydration, such as sunken eyes, parched lips, hypotension, and skin turgor. However, skin turgor is unreliable in elderly patients due to the loss of subcutaneous fat. Dehydration is common among older adults. Since this patient is hypotensive and mildly tachycardic, which are signs of dehydration, the writer would admit the patient as he elicits signs of dehydration. Elderly patients need a more cautious approach when ordering IV fluids.
After admitting the patient, I would order a Normal Saline Intravenous infusion (IV) of 100 ML /hour to rehydrate the patient. I would frequently reassess the patient and call additional boluses as needed. The patient’s blood pressure, heart rate, hematocrit, and urine output will be monitored to assess response to IV fluid and volume deficit before ordering an additional dose (Taylor and Jones, 2022).
I would discontinue Ciprofloxacin.
I would order a STAT comprehensive metabolic panel (CMP) test to explain his current fluid and electrolyte balance. The test will assist in knowing about his current potassium, sodium, and magnesium levels. This test will also help in knowing about his Bun and creatinine level since he has a history of hypertension and has been taking Lisinopril, Metoprolol, and Ibuprofen, which can negatively impact his renal system.
I will also order a complete blood count (CBC) since his WBC cells may be concurrently elevated due to the C-diff infection. I would hold on to his blood pressure medication for now as his blood pressure is trending on the lower side, and frequently recheck and reevaluate his status. I would also hold on to Ciprofloxacin until C. diff clears off.
If the stool test results return positive for C-diff, I would order Vancomycin, a tricyclic glycopeptide antibiotic for gram-positive bacteria approved for treating C-diff (STATPearls, 2023).
If the stool test is negative for C-diff, I will refer the patient to a gastrointestinal specialist to rule out if the patient has any GI problems. I would hold on to prescribing anti-diarrheal medication until the stool test results return. If the stool test results are negative for C. diff, I would start him on a different antibiotic and order anti-diarrheal medication such as Lomotil.
If the patient’s blood pressure stabilizes and he isn’t showing any signs of deterioration and having loose motions. Also, depending on how the patient responds to the treatment and the test results, he will be evaluated to see if he is medically stable to be discharged. The patient will be educated to remain compliant with the antibiotics and finish the course even if his symptoms improve. The patient will be educated on good hand-washing; using bleach products to wipe the areas and surfaces can help prevent the reoccurrence of C. diff.
References
Silva, B. (2020, April 1). Detection and prevention of C. disinfections. Medical Laboratory Observer, 52(4).
Rahmoun, L. A., Azrad, M., & Peretz, A. (2021). Antibiotic Resistance and Biofilm Production Capacity in Clostridioides difficile. Frontiers in Cellular & Infection Microbiology, 11, 1–10. https://doi.org/10.3389/fcimb.2021.683464Links to an external site.
STATPearls. (2023, March 7). Ciprofloxacin. STATPearls. Ciprofloxacin Article (statpearls.com)Links to an external site.
STATPearls. (2023, March, 24). Vancomycin. STATPearls. Vancomycin Article (statpearls.com)Links to an external site.
Qutub, M., Govindan, P., & Vattappillil, A. (2019). Effectiveness of a Two-Step Testing Algorithm for Reliable and Cost-Effective Detection of Clostridium difficile Infection in a Tertiary Care Hospital in Saudi Arabia. Medical Sciences, 7(1), 6–1. https://doi.org/10.3390/medsci7010006Links to an external site.
Taylor, K., & Jones, E. B. (2021). Adult dehydration. In StatPearls. StatPearls Publishing.
I would also like to add blackberry root to be discontinued for this patient. After admitting him, I will put the patient on contact precaution. Centers for Disease Prevention and Precaution guidelines state to use contact precaution to prevent C-diff from spreading. The staff will follow the contact precaution guidelines while caring for this patient: gloves, gown, and washing with soap and water, as alcohol-based hand sanitizers do not completely kill the bacteria (CDC. 2021).
Reference:
Centers for Disease Control and Prevention. (2021, July 20). Prevent the Spread of C. diff. https://www.cdc.gov/cdiff/prevent.htmlLinks to an external site.
Reply 2:
Diagnosis: Clostridium difficile infection CDI.
The patient is 72 years old with a history of hypertension, hyperlipidemia, and rheumatoid arthritis. This patient has been taking Ciprofloxacin for the treatment of prostatitis. For the past two days, the patient has complained of frequent loose stools (4-5 stools). One regular well-formed stool daily bowel movement is the norm for this patient. This patient presents with multiple risk factors that would increase the risk of CDI. One major risk factor is the patient age of 72years and having diarrhea which can easily cause dehydration because the patient takes medication for hypertension (Metoprolol XR 25mg PO Daily and Lisinopril / HCTZ 10/12.5mg PO Daily) and is losing fluids due to diarrhea. According to Mayo Clinic (2022), there is a 10 times greater risk of patients who are 65 years and older developing CDI. Secondly, the patient also exercises daily with senior peers out in the community increasing susceptibility and exposure risk to highly contagious infections like CDI. Another major risk factor is that this patient has recently been on antibiotics (Ciprofloxacin) which can increase the risk of CDI. Ciprofloxacin belongs to the drug class Fluoroquinolones and is commonly associated with the development of CDI because they disrupt gut bacteria and make one susceptible to a higher risk of CDI (Mayo Clinic, 2022).
Lab work and testing: The patient would need to be placed on isolation precautions at the Emergency Department while testing is done. The provider will order lab tests and stool samples for testing (Mayo Clinic, 2022). An antigen detection for C. diff detection and a PCR will be ordered, this is a rapid test that takes less than 1 hour to detect the presence of C. diff antigen glutamate dehydrogenase. Blood work will be tested for the patient for WBC, CBC, CMP, and serum creatinine to assess kidney failure associated with CDI.
Admission criteria: CDI can be categorized into three groups which could be non-severe, severe, or fulminant CDI. Non-severe CDiff is treated with vancomycin and the patient can be discharged home in the care of a caregiver, severe cases with a WBC higher than 15,000 and a creatinine level higher than 1.5 indicating kidney impairment will need hospitalization for treatment and fluid intervention to prevent dehydration. Fulminant CDI can cause toxic megacolons, hypotension, shock and have a high fatality rate, and will require ICU intervention. Depending on the results of the labwork, and WBC, the provider will likely decide to admit the patient.
Treatment plan:
Discontinue the Ciprofloxacin based on findings from research indicating that exposure to fluoroquinolones including third and fourth-generation cephalosporins are known to increase the risk of CDI (CDC.gov, 2022). Studies done by the University of Illinois Chicago in 2021 indicate that treatment with fidaxomicin is preferred in place of Vancomycin due to the benefits and safety effects of fidaxomicin in the older population. Provider to prescribe 200mg of fidaxomicin by mouth to be taken by mouth twice daily for 10 days. Discontinue the Blackberry root and provide education on safe medication usage and the importance of completing the full 10-day course of prescribed antibiotics. Educate the patient on the risks of reinfection and the importance of adhering to the full dose of the prescribed antibiotic regimen, 1 in 6 persons with CDI is likely to get reinfected in 2 to 8 weeks (CDC.gov, 2022). Major risks for patients at this age with CDI are the risk of dehydration, kidney failure, toxic megacolon, and death (Mayo Clinic, 2021). This patient is reported to exercise daily with peers in the community center, there is a need for education for peers at the site where they exercise, and education on personal hygiene and especially hand hygiene will be emphasized for the patient, patient’s family, caregivers, and anyone in contact with the patient because CDI is highly contagious (CDC.gov. 2022).
Question to peers: How does the provider assess the effectiveness of education on completing the full course of the antibiotic regimen for Patient John D?
References:
C. difficile infection – Symptoms and causes. (2021, August 27). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/c-difficile/symptoms-causes/syc-20351691Links to an external site.
Guidelines and prevention resources for clinicians. (2022, September 7). Centers for Disease Control and Prevention. https://www.cdc.gov/cdiff/clinicians/resources.htmlLinks to an external site.