Sử dụng thuốc điều trị nhiễm khuẩn đường tiết niệu

D B N Phan N H Ái hoaai.phan@gmail.com Copyrights apply N UTI) N Sinh lý -N (UTI): • Viêm bàng quang bàng • Viêm trên) UTI gây xâm vi phân vào : vào bàng quang (viêm bàng quang) sau thông qua (viêm ) Y nguy : • N • Quan tình • S tinh trùng trùng • Các kèm: tháo UpToDate, Acute simple cystitis in tránh thai , UTI) B nguyên - E coli nguyên nhân (75-95%) - Ngồi cịn có: Klebsiella pneumoniae Proteus mirabilis Staphylococcus saprophyticus Pseudomonas tinh trúc UpToDate, Acute simple cystitis in N Nguy sau M vi gram âm ba tháng : phân B S UTI nhân kháng (MDR) có có vi gram âm MDR (vi ba nhóm kháng sinh; vi trú sóc (ví Du Ban Nha, Mexico) có sinh U T D P n khơng ESBL) UTI : lão ) MDR cao (ví beta-lactam : Đ Israel, Tây Guidelines on urological infections EAU 2018 A UTI P n UTI N Urinary tract infection (UTI) • UTI • UTI • • • • Uncomplicated UTI Complicated UTI Cystitis Pyelonephritis Recurrent UTI Catheter-associated UTI • N • V • Guidelines on urological infections EAU 2018 n fluoroquinolone, trimethoprim-sulfamethoxazole : cephalosporin ba, ) (ví P Viêm bàng quang V UTI tái phát UTI UTI Urosepsis Asymptomatic bacteriuria UTI Đ • UTI khơng UTI B • Các khơng (viêm bàng quang tính bàng quang lan bàng quang, bao : S (> 37,7 ° C) Các tồn thân: , rùng mình, ) Đ Đ góc tính): tình lâm sàng : lâm sàng viêm bàng quang tính : khó mu, có t máu Xét ni khơng v Ni xét nên nhân có nguy vi MDR, có tình suy cho khó q • Các • P N Đ A viêm bàng quang có khó quan sát nghi viêm bàng quang khơng có rõ ràng Xét nên / • N U T D khơng có mùi có mùi không dõi cách thay mùi màu UTI liên quan trùng viêm bàng quang thông trùng khác Do ban lý cho U T D không Màu theo nhân phàn nàn A không B lâm sàng : • Xét : o K tra dịng L o Xét dipstick test: Phát nitrite (vi nitrite) Leukocyte esterase dipstick test phát U T D A kính có vi có > 10 nitrate thành uptodate L Đ UTI • ý UTI ngồi bàng quang Có nguy vi gram âm MDR khơng? (có sau vịng tháng khơng?) • Phát vk gram âm MDR ni • B nhân trú • Đ fluoroquinolone, trimethoprim-sulfamethoxazole, hay beta lactam lên) • Đ vùng có MDR cao 37,7oC, q Đ góc Có khơng? • S hình kèm theo T H • khơng hình VBQ khó vùng mu Có • L ý • T • • • • • • • gian : UTI khơng UTI nghiên nhân có tình suy tháo sốt kém, nhân gian dài (7 ngày) L kê dành cho nhân có bình có u tình suy Lý tránh kháng sinh bao : không dung tác phân kháng vòng ba tháng qua Nên tránh dùng Nitrofurantoin creatinin 20% Các nghiên trì hỗn kháng sinh cho có xét ni an tồn cho viêm bàng quang mà khơng có trùng lan bàng quang L nitrofurantoin tiên fosfomycin TMP-SMX Khi có fluoroquinolones nên dành riêng cho trùng nghiêm viêm bàng quang khơng tính N nhân nên thơng báo tác kinh khơng có nghiêm liên quan fluoroquinolones U T D UTI • Ni quang kháng sinh B nhân có theo kinh hành • Đ • Khơng nhân phenazopyridine (hai ngày) có ích khó lâu dài có che :Đ xét thơng liên khó nghiêm không kê ba ngày Phenazopyridine không nên lâm sàng thay U T D không thông A UTI theo dõi khơng tính mà nhân viêm bàng sau dai 48 72 sau có tái phát vài theo kinh kháng sinh khác Đ theo kháng sinh N CT giá có kháng sinh U T D khác A Theo dõi • Các can khơng A : kháng sinh ni sau nên Đ • UTI tính (viêm bàng quang ngồi bàng quang, bao : S (> 37,7 ° C) Các toàn thân: ) Đ Đ góc tính): tình , rùng mình, UpToDate, Acute complicated urinary tract infection in khó UTI UTI B lâm sàng • Các lâm sàng UTI : Các viêm bàng quang: khó mu, t máu, kèm theo rung khó q Các viêm : , nôn / nôn H : Xét vi C CT (phát viêm, áp xe ) • Khơng khu trú quang suy kinh có có nhân Ví có UTI nhân tính khơng có B mà khơng có UpToDate, Acute complicated urinary tract infection in B • UTI tồn thân góc tính có • Viêm sang áp xe • Đ quan, suy tính có áp xe quanh ra nhân viêm khí sock trùng nhân tháo rõ ràng bàng nhân cao UpToDate, Acute complicated urinary tract infection in khác, uptodate L UTI uptodate 92 Adult Immunizations Kathryn R Matthias CASE LEARNING OBJECTIVES • Evaluate adult immunization records and identify missing recommended vaccinations based on patient’s age, comorbid conditions, risk factors, and time since previous vaccinations • Recognize appropriate contraindications and precautions for administration of immunizations in adult patients • Develop an appropriate plan for vaccine catch-up including an evaluation of which vaccines can be administered at the same time • Describe appropriate patient education for potential benefits and adverse reactions of vaccines PATIENT PRESENTATION Chief Complaint “I was told to see my physician after being discharged from XYZ Hospital I was admitted to the hospital for days because I broke my arm after a bad car accident.” History of Present Illness Eric Jones is a 22-year-old college student who was a restrained driver in a MVA days ago on December 2nd, 2009 He was not ejected from the car and had no loss of consciousness In the ED, he was found to have a left mid-shaft humerus fracture and spleen laceration He was taken emergently to the operating room and a splenectomy was performed due to uncontrollable bleeding The rest of his hospital stay was uneventful but he was told to see his primary care physician (PCP) after discharge for follow-up and to make an appointment with an orthopedic specialist for his humerus fracture During his initial visit to his PCP, his physician asks the clinic’s pharmacist to review his immunization history Past Medical History Migraines diagnosed years ago Left humerus fracture days ago Past Surgical History Splenectomy days ago Family History Mother and father are both alive Father is 52 and has a history of T2DM Mother is 48 and has no significant past medical history He has no siblings Social History Patient is currently a third year college student (psychology major) and lives off-campus in an apartment with his girlfriend and two other roommates He has two healthy indoor-only cats He denies smoking and IV drug use He drinks alcohol socially (3–4 beers per week) Allergies/Intolerances/Adverse Drug Events NKDA Medications (Current—No Medications Prior to Car Accident) Acetaminophen 650 mg PO q h PRN musculoskeletal pain Docusate 100 mg PO q 12 h Famotidine 20 mg PO q 12 h Oxycodone (oral solution) 5–10 mg PO q h PRN pain Immunizations Most recent photocopy from 06/20/2008 of immunization record in patient’s medical chart at clinic: As per the patient’s discharge paperwork from XYZ Hospital, he received a diphtheria, tetanus, pertussis (DTaP) vaccination on 12/2/2009 No other administered vaccinations were listed The patient states that he got his annual influenza vaccine that was administered into his “nose rather than a shot” last month at a Flu Clinic on his college campus He does not remember the exact date and did not bring an immunization record with him to clinic today but thinks it was mid-November Review of Systems Mild left arm pain; arm is in a sling Minor abrasions over flank, arms, and face Physical Examination General Twenty-two-year-old Caucasian man in no acute distress Vital Signs BP 126/74 mm Hg, P 88, RR 18, T 37.1°C Weight 162 lb (73.6 kg) Height 71 in (180 cm) Pain 2/10 (left arm) Skin Multiple healing abrasions over flank, arms, and face Three healing 2-inch (5 cm) surgical wounds on abdomen from splenectomy with no signs of infection Neck and Lymph Nodes (−) Lymphadenopathy Chest Clear to auscultation Cardiovascular RRR, normal S1, S2; (−) S3 or S4 Abdomen Slight tenderness around surgical wound site Neurology Grossly intact; DTRs normal Genitourinary Examination deferred Rectal Examination deferred Laboratory Tests Obtained days ago Assessment Twenty-two-year-old man in no acute distress with left humerus fracture and splenectomy days ago after a MVA Pharmacist to review immunization record TARGETED QUESTIONS Which comorbid conditions and lifestyle risk factors put the patient at higher risk of infection that can be prevented by vaccination? Hint: See p 1411 in PPP Hint: See guide to Vaccine-Preventable Adult Diseases (by the CDC), http://www.cdc.gov/vaccines/vpd-vac/adult-vpd.htm Why and when should adult asplenia patients receive additional vaccines beyond the recommended adult immunization schedule? Hint: See p 1411 in PPP Hint: See Adult Immunization Schedule (by the CDC), http://www.cdc.gov/vaccines/recs/ schedules/adult-schedule.htm Does the patient have any comorbid conditions that would contraindicate him from receiving live or inactivated vaccinations today? Hint: See pp 1414 and 1415 in PPP Hint: See Guide to Vaccine Contraindications and Precautions (by the CDC), http://www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm or http://www.cdc.gov/vaccines/recs/vac-admin/downloads/contraindications-guide-508.pdf Which recommended vaccinations are missing from the patient’s immunization record and when should they be administered? Hint: See p 1414 in PPP Hint: See Adult Immunization Schedule (by the CDC), http://www.cdc.gov/vaccines/recs/ schedules/adult-schedule.htm What are the common and serious potential adverse effects of recommended vaccines determined in question 4? Hint: See pp 1414 and 1415 and Table 86-2 in PPP FOLLOW-UP Eric receives all immunizations as per the pharmacist and physician recommendations He returns to his PCP months later for his annual checkup He had no further complications related to the motor vehicle accident and his left arm healed well His physician asks the clinic pharmacist to evaluate his immunization record for any missing vaccinations Which vaccine(s) should be recommended and why? Hint: See p 1414 in PPP Hint: See Adult Immunization Schedule (by the CDC), http://www.cdc.gov/vaccines/recs/ schedules/adult-schedule.htm GLOBAL PERSPECTIVE An annual review of immunizations reports from countries and territories from across the world is conducted by the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF).1 Although global rates of certain immunizations have increased dramatically over the past 30 years, many vaccines on the United States’ Immunization Schedule are not yet recommended in other countries’ national immunization schedules Although the United States and other industrialized countries have estimated vaccinated target populations (by antigen) above 90% based on childhood recommended immunization schedule, missed opportunities to vaccinate adult patients often occur In a case-cohort study of two large tertiary medical centers in Australia only 2.3% of patients had their vaccination status for influenza or pneumococcal determined during a hospital visit.2 In another study of adult patients who developed invasive pneumococcal disease, it was determined that 92% of these patients had at least one missed opportunity for vaccination such as a hospital, emergency department, or primary care visit in the years prior to infection.3 Due to high rates of missed opportunities to vaccinate, the Advisory Committee on Immunization Practices (ACIP) through the Centers for Disease Control (CDC) has recommended the use of institution protocols for standing order immunization programs for administration of vaccines by nurses or pharmacists to decrease rates of eligible, unvaccinated patients.4 REFERENCES World Health Organization: Immunization surveillance, assessment and monitoring http://www.who.int/immunization_monitoring/data/en/ Accessed February 10, 2010 Skull SA, Andrews RM, Byrnes GB, et al Missed opportunities to vaccinate a cohort of hospitalized elderly with pneumococcal and influenza vaccines Vaccine 2007 25:5146–5154 Kyaw MH, Greene CM, Schaffner W, et al Adults with invasive pneumococcal disease: Missed opportunities for vaccination Am J Prev Med 2006 31(4):286–292 Centers for Disease Control and Prevention Use of standing orders programs to increase adult vaccination rates MMWR 2000 49(No RR-1):15–26 CASE SUMMARY • Eric presents to his PCP days after a motor vehicle accident and splenectomy Despite receiving diphtheria/tetanus/pertussis vaccination while admitted to XYZ Hospital, additional immunizations were missed during the hospital admission • Eric is in no acute distress but certain medical conditions and lifestyle put him at higher risk of certain infections that could be prevented by vaccination • Eric should receive his missing immunizations as per the recommended adult immunization schedule by the ACIP within the CDC • Eric should be counseled on potential adverse effects of recommended vaccines For more information on the care plan and facilitator’s guide please visit http://www.mhpharmacotherapy.com 10 American Council for Pharmacy Education Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree, 2006 www.acpe-accredit.org/standards/default.asp Accessed June 1, 2010 11 Frye CB Module 5: Monitoring the pharmacist’s care plan In: ASHP Clinical Skills Program—Advancing Pharmaceutical Care Bethesda, MD, American Society of HealthSystem Pharmacists, 1993 12 Beardsley RS, Kimberlin CL, Tindall WN Communication Skills in Pharmacy Practice, 5th ed Philadelphia, PA, Lippincott Williams & Wilkins, 2007 13 Rantucci ML Pharmacists Talking with Patients, 2nd ed Philadelphia, PA, Lippincott Williams & Wilkins, 2007 PRACTICE CASE Case Learning Objectives • Recognize the signs, symptoms, and risk factors for hypovolemia, hypokalemia, and metabolic alkalosis • Develop an appropriate treatment and monitoring plan for hypovolemia, hypokalemia, and metabolic alkalosis • Recognize the impact of pregnancy on medication choice and disease management PATIENT PRESENTATION Chief Complaint “I feel so tired and dizzy, and I can’t stop throwing up.” History of Present Illness Susan Jones is a 23-year-old woman brought to the Urgent Care Center c/o severe weakness and dizziness She states it started days ago when she began to have frequent vomiting She thinks that “maybe I ate something bad.” She also says that her bowel movements have been “a little looser than normal.” She states that before she got sick days ago, she felt fine Past Medical History Bulimia with two psychiatric hospitalizations Depression, s/p suicide attempt × (slashed wrists) Pelvic inflammatory disease Family History Mother died from drug overdose at age 34; she does not know her father Social History Single community college student; no children; works part time in restaurant Tobacco/Alcohol/Substance abuse (+) cigarettes ½ ppd; admits to occasional marijuana use, denies current other illicit or unprescribed drug or alcohol use; used IV heroin until year ago Medications Prozac 20 mg bid PO Trazodone 50 mg q hs PO K-DUR 40 mEq q AM PO Methadone 120 mg q AM PO Prilosec 20 mg q day PO Lo-Estrin q AM PO Review of Systems (+) Weakness, dizziness, fatigue, nausea, and diarrhea; denies headache, chest pain, or abdominal pain; (+) dysuria; (−) vaginal pain or discharge Physical Examination General Very thin, chronically ill-appearing young woman who fainted when sitting up Vital signs BP 105/75 mm Hg lying, 70/0 mm Hg sitting; P 110 lying, 160 sitting; RR 12, T 37.1°C Weight 47 kg (103.4 lb), height 5′4″ (163 cm) Skin Dry, poor skin turgor; no rashes or lesions noted HEENT PERRLA; mouth very dry; poor dentition Neck and lymph nodes JVD (neck veins flat); thyroid gland normal; no lymphadenopathy Chest Clear to auscultation and percussion Breasts Examination deferred Cardiovascular Tachycardic; normal S1, S2; no murmurs, rubs, or gallops Abdomen No tenderness or organomegaly; bowel sounds slightly hyperactive Extremities Very thin; trace pedal edema; multiple “tracks” both arms Genitourinary Normal vaginal discharge; uterus appears to contain approximately 12-week pregnancy Rectal Mild hemorrhoids; Hemoccult (−) Laboratory Tests Fasting, obtained upon admission Urine pregnancy test (+) ABG: pH 7.56, pO2 98 mm Hg (13.03 kPa), O2 sat 99%, pCO2 44 mm Hg (5.85 kPa), HCO 31 mEq/L (31 mmol/L) Urine toxicology screen: (+) cocaine, THC, methamphetamine, nicotine, HCTZ Electrocardiogram: flat T waves; (+) U wave Assessment Twenty-three-year-old pregnant woman with ECF volume depletion, vomiting and? diarrhea, significant hypokalemia with ECG changes, hyponatremia, and metabolic alkalosis Urine tox screen indicates active illicit drug use TARGETED QUESTIONS What signs and symptoms of ECF volume depeletion, hypokalemia, and metabolic alkalosis does the patient have? Hint: See pp 255, 480, 487–488, 502–503 in PPP What are the causes of this patient’s alkalosis? Hint: See pp 502–503 in PPP What are the risks of administering potassium intravenously? Hint: See p 488 in PPP What are the signs and symptoms of opioid withdrawal, and what drug interactions may occur with methadone? Hint: See pp 615, 620 in PPP What medications have proven teratogenic effects in humans? Hint: See p 824 in PPP FOLLOW-UP Three months later, the patient calls you after being discharged from an inpatient substance abuse program She says she feels great, is staying clean, and her baby is doing well (“Look how fat I am!”) Her obstetrician recently told her that she has low thyroid and wants her to take levothyroxine She is aftraid that it will hurt her baby and she wants your advice You look up her laboratory tests in the computer and note that her TSH is 10.1 mU/L (10.1 μU/ L) What is your advice to her? Hint: See p 772 in PPP GLOBAL PERSPECTIVE Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration These problems can become chronic or recurrent and lead to substantial impairments in an individual’s ability to take care of his or her everyday responsibilities At its worst, depression can lead to suicide, with the loss of about 850,000 lives every year Depression in the year 2000 was the leading cause of disability worldwide as measured by years lived with disability (YLD) and the fourth-leading contributor to the global burden of disease based on disability-adjusted life-years (DALYs) By the year 2020, depression is projected to reach second place in the ranking of DALYs calculated for all ages, both sexes Today, depression already is the second cause of DALYs worldwide in the age category 15 to 44 years for both sexes combined According to the World Health Organization, fewer than 25% of depressed patients have access to care, and in some countries fewer than 10% have access to care Barriers to effective care include the lack of resources, lack of trained providers, and the social stigma associated with mental disorders, including depression REFERENCE World Health Organization www.who.int/mental_health/management/depression/definition/ en/ index1.html Accessed January 31, 2010 CASE SUMMARY • Young pregnant woman with history of depression, eating disorder, and substance abuse who presents with ECF volume depletion, hypokalemia, and metabolic alkalosis due to vomiting and diuretic use Volume and potassium replacement must be initiated, and the underlying causes addressed to prevent recurrence • She is actively abusing drugs, placing her and the fetus at risk for multiple complications Substance abuse treatment referral is warranted • The patient needs a referral to an obstetrician for assessment and prenatal care For more information on the care plan and facilitator’s guide please visit http://www.mhpharmacotherapy.com