Question

Write prescription for following conditions below. Also, alternative medications for patients who may have allergies to Penicillin.

1. 36 yr old pregnant female in second trimester with Urinary Tract Infection.

2. 52 year female with poorly controlled diabetes with Pyelonephritis.

3. 78 year old male with acute Diverticulitis that is managed on outpatient setting.

4. 45 year old female with Bacterial Vaginosis.

5. 28 yr old male with Gonorrhea.

Answer 1

Introduction :

Penicillin allergy

The antibiotics belonging to the

a]quinolone groups such as ciprofloxacin

b]macrolide groups such as clarithromycin

,c]aminoglycoside group such as Erythromycin and Azithromycin and gentamicin

can be used to safely in patients with penicillin allergy

The patients with penicillin allergy cannot take antibiotics belonging to the beta lactam group of the drugs including most of the cephalosporins. The patients with penicillin allergy should avoid ampicillin, amoxicillin, piperacillin- tazobactam as well as cephalosporin group of drugs like cephalexin.The common symptoms of drug allergy include itching, skin hives, difficulty in breathing,dizziness and so on.However severe anaphylaxis can occur with penicillin.

The patient's history of drug allergy must be noted and penicillin and cephalosporins should be avoided in the antibiotic prescription if the patient gives history of drug allergy to penicillin

1. 36 yr old pregnant female in second trimester with Urinary Tract Infection

Answer:

The urinary tract infection is caused by a number of bacteria most of which are gram-negative such as E coli, enterococcus,klebsiella and also,staphylococcus aureus.Antibiotic therapy for urinary tract infection using broad spectrum antibiotics specially those having Gram negative bacteria coverage is indicated.

The prescription of a pregnant woman in the second trimester of pregnancy having urinary tract infection would include

Plenty of oral fluids + tablet Paracetamol 500 milligrams 6 hourly if fever present + antibiotics

The antibiotics of the choice would be as under

1.Amoxicillin plus clavulanic acid [Augmentin375 mg= 250 amoxi+125mg clavulinic acid mg] 8 hourly for 7 days [category B drug}

or

2. Cephalexin tablets{ category B drug} 250 milligrams 4 times daily for 7 days

alternatives in case of penicillin allergy

1.T nitrofurantoin[macrodantin ]category B drug 100 milligrams twice daily for 7 days

or

2.T.Ciprofloxacin 500 milligrams twice daily for 3-5 days

[Category B ---no evidence of risk to the foetus in humans on consumption of the drug by the pregnant female]

2. 52 year female with poorly controlled diabetes with Pyelonephritis.

The pharmacotherapy and prescription for infection of Pyelonephritis with poorly controlled Diabetes mellitus will be directed at control of diabetes mellitus along with treatment of infection. The Gram Negative bacteria like E coli are generally involved in Pyelonephritis and hence broad spectrum antibiotic prescription should be given to the patient with Gram Negative coverage.

Prolonged antibiotic treatment may be warranted till the infection clears and symptomatic improvement is achieved.Hospitalization of the patient may be recommended if the severe symptoms are present and sugar levels are very high. intravenous antibiotics may be recommended during the course of hospitalization along with insulin drip in order to control the sugars . Along with this patient is also advised hydration and plenty of oral fluids and Paracetamol tablet for fever.

The prescription for this patient would include

Plenty of oral fluids

insulin/ oral hypoglycemic agents for diabetes control plus

antibiotics for Pyelonephritis Plus

tablet Paracetamol 500mg 6 hourly for fever

The patient may be switched to insulin injection if taking oral hypoglycemic drugs or insulin doses may be titrated in view of poor control of diabetes

The antibiotic drug of choice in outpatient setting is

T ciprofloxacin 500 milligrams BD for 7 days.

0r

T levofloxacin 750 milligram once a day for 7 days.

Prolonged therapy is indicated in Pyelonephritis in diabetes mellitus on account of the severity of infection and treatment can extend upto 10-14 days.

However in view of poor control of diabetes and pyelonephritis, it is advised that the patient is admitted and put on insulin drip for blood sugar control and monitoring.

The inpatient prescription of the patient would be

1. insulin drip/ oral hypoglycemic agents as required for blood sugar control plus Plenty of oral fluids

2.tablet Paracetamol 500mg 6hourly for fever

3. injection levofloxacin 500mg iv once a day  for injection for 7 days

       or

injection iv ciprofloxacin 500 milligrams 12 hourly for 7 days

Followed by switching to oral antibiotics for 7 days if patient is still symptomatic

if no allergy to penicillin

Injection ceftriaxone 1000 milligram iv once a day for 7 days can be given.

3. 78 year old male with acute Diverticulitis that is managed on outpatient setting

Answer:

Diverticulitis is the acute inflammation of the diverticula/outpouchings of mucosa that are present in the colon. The treatment of only acute complicated acute diverticulitis should be done on an outpatient basis. Broad spectrum antibiotics with Gram Negative cover and anaerobic cover are required in the prescription for acute diverticulitis

The prescription for acute diverticulitis in a 78 year old male patient is as under

Soft high fibre diet plus Plenty of oral fluids

T Amoxicillin clavulanate { Augmentin  625 milligram= [500 mg amoxi+125mg clavulinic acid ] } orally every 6 hours for 7-10days

Tablet metronidazole[Flagyl] 500 milligrams orally every 6 hours for 7 to 10 days

Tablet Paracetamol 500 milligram every 6 hours for fever and pain

In case of penicillin allergy, the prescription would be

Soft high fibre diet plus Plenty of oral fluids

tablet ciprofloxacin 750 milligrams every 12 hours for 7 to 10 days

Tablet metronidazole [Flagyl] 500 milligrams orally every 6 hours for 7 to 10 days

Tablet Paracetamol 500 milligram every 6 hours for fever and pain.

The above doses are for a 50 kg adult male patient. if the elderly male patient is grossly underweight then weight adjusted doses of the above drugs need to be prescribed

4. 45 year old female with Bacterial Vaginosis{cdc guidelines based prescription}

Answer:

The diagnosis of bacterial vaginosis is based on the presence of vaginal discharge and fishy odour. The presence ofvaginal pH greater than 4.5 with presence of clue cells on the saline smear confirm the diagnosis.

The treatment prescription for 48 year old female with bacterial vaginosis is

T.Metronidazole 500 milligram orally BD for 7 days [alcohol consumption to be restricted as it interferes with the action of metronidazole drug]

or

metronidazole gel 0.75% 1 full applicator [5 gram] intravaginally once a day for 5 days preferably at night time

Or

clindamycin cream 2% 1 full applicator [5 grams] intravaginally at bedtime for 7 days [ weakening of latex condoms related to clindamycin drug additional safe sex precautions to be taken]

Both metronidazole and clindamycin can be safely taken in a patient with penicillin allergy

Treatment of the male sexual partner not recommended; treatment of female sexual partner recommended.

5. 28 yr old male with Gonorrhea.

Answer:

Gonorrhea is a sexually transmitted bacterial infection characterized by painful urination and abnormal discharge from the genitalia.it is an infectious disease transmitted sexually.

The prescription for Gonorrhea { uncomplicated}for a 28 year old male patient is

injection intramuscular 250 milligrams ceftriaxone stat plus Tablet Azithromycin one gram as a single dose.

The simultaneous evaluation and treatment is recommended for the sexual partners of the patient.Sexual abstinence is advised for 7 days after the treatment.

in case of penicillin allergy

tablet gemifloxacin 320 milligram single oral dose stat plus Azithromycin tablet 2 grams single oral dose is recommended

Or

injection gentamicin 240 milligram single intramuscular dose stat with Azithromycin tablet 2 grams single oral dose is recommended