Case 6 “Yellowish sputum”

Amira, a 44-year-old female patient, presented to the outpatient clinic with symptoms of
productive cough with yellowish sputum and fever. The symptoms started 5 days ago. Her
medical history revealed that she is type I diabetic patient and she is also on fluoxetine for
treatment of depression. On examination, her blood pressure was 153/94 mmHg, pulse rate was
100 beats/minute, respiratory rate was 30/min, and temperature was 38.5°C. Physical
examination revealed dullness to percussion of the chest and crackles on auscultation. Chest
radiography revealed a lobar consolidation.

Use the following Step by step guide to fully write a prescription

1. Does the patient have an infection?

√ Yes No
 Clues from history:

1. Productive cough with yellowish

sputum

2. Fever

 Clues from examination:

1. Pulse rate was 100 beats/minute

2. Respiratory rate= 30/min

3. Temperature= 38.5°C

4. Dullness to percussion of the chest

5. Crackles on auscultation

 Clues from investigations:

1. Chest radiography revealed a lobar

2. If the patient has an infection, what is
the likely site?
3. What are the likely causative
microorganisms?
consolidation
Lung (lower respiratory tract)
Streptococcus pneumoniae (50 %)
Haemophilus influenzae
 Atypical microorganisms (Chlamydia
pneumoniae, Mycoplasma pneumoniae,
Legionella species)
Your provisional diagnosis is chest infection/ lower respiratory tract infection/ community
acquired pneumonia

4. Does the patient need an antimicrobial,

(or the infection is self-limited)?
5. Is the antimicrobial required used for
treatment or prophylaxis?
Your therapeutic goal (s) is/are to eradicate the causative organism, bring about clinical
cure and prevent the development of complications
6. Which antimicrobial drug(s) are active
against the suspected
microorganism(s)?
√ Yes No
√ Treatment prophylaxis
Benzylpenicillin, Amoxicillin, Ampicillin, Co-
Amoxiclav, Flucloxacillin, Piptazobactam,
Cefradine, Cefalexin, Cefuroxime, Ceftriaxone,
Cefotaxime, Ceftaroline, Etrapenem,
Meropenem, Erythromycin, Clarithromycin,
Azithromycin, Clindamycin, Levofloxacin,
Vancomycin, Teicoplanin, Daptomycin,
Doxycycline, Tigecycline, Linezolid, Co-
trimoxazole, Chloramphenicol
N.B.: Fosfomycin in the table of spectrum is
active against streptococcus, but it is used as
urinary antiseptic only due to its localized action
in urinary tract.
Rifampin is used mainly for treatment of T.B

7. Which of the probably acting Add in the inventory table

antimicrobial drug(s) is/are narrower in
its spectrum of activity?
8. Which of the probably acting Compare and score
antimicrobial drug(s) is/are suitable for
your particular patient?
9. Which of the probably suitable Compare and score
antimicrobial drugs(s) is/are safer?
10. Which of the mostly recommended Compare and score
antimicrobial is least expensive?
 Compare cost and score
Your comparative inventory of effective drugs
Drug Efficacy Suitability Safety Cost Total
Benzylpenicillin ++ ++ ++ …………… 6
Amoxicillin ±++ +++ +++ …………… 8/9
Ampicillin
Co-amoxiclav +++ +++ +++ …………… 9
Erythromycin ++ +++ +++ …………… 8
Azithromycin ±+++ +++ +++ …………… 9/10
Clarithromycin ±+++ ++ +++ …………… 8/9
Doxycycline ++++ +++ ++ …………… 9
Cefuroxime +++ +++ +++ …………… 9
Levofloxacin ++++ ++ + …………… 7

Efficacy:
++++ = cover all organisms
+++ = cover streptococcus and H.influenza
++ = cover streptococcus pneumoniae
±= increased reports of resistance of streptococcus pneumoniae
Suitability and safety
Benzylpenicillin : associated with resistant strains, allergic reactions and multiple injections.
Clarithromycin: risk of drug interactions
Doxycycline: due to its side effects
Levofloxacin: patient is diabetic, risk of dysglycemia and its side effects
Consider Erythromycin in pregnancy (Not our case)

Your choice is Azithromycin, Amoxicillin, Co-amoxiclav……………………..

11. What is the dose of the selected For azithromycin

antimicrobial drug? (BNF and 500 mg once daily, alternatively initially 500 mg
NICE/IDSA guideline) once daily, then 250 mg once daily
For Clarithromycin
500 mg twice daily
For Benzyl penicillin
 Not included in NICE or IDSA but might be
chosen by students
0.6–1.2 g every 6 hour IM/ slow IV/ IV
infusion
For Cefuroxime
500 mg twice daily oral or 750 mg every 8 hours
IV/IM
In BNF it is written 250 mg and to be doubled if suspected
pneumonia, basically the same but not as clear as IDSA

For Levofloxacin
500 mg once or twice daily oral or IV
750 mg once daily
Acc to NICE, it is only used in sever pneumonia
750 mg acc to IDSA

For amoxicillin
500 mg every 8 hours

For ampicillin
0.5–1 g every 6 hours

For Co-amoxiclav
250-500/125 mg every 8 hours

For Doxycycline
200mg on day 1, then 100mg OD

12. What is the duration of treatment?
(BNF and NICE/IDSA guideline)
………………………………………….
For azithromycin
3 days or 4 days depending on the chosen
regimen
For clarithromycin, benzyl penicillin,
amoxicillin, ampicillin, Co-amoxiclav,
ampicillin/sulbactam, doxycycline
5 days
For Cefuroxime
2 days parenteral followed by 5 days oral

13. What are the precautions or the patient
important counselling information?
For Levofloxacin
7 to 14 days
Common for all antibiotics
1. This drug works by killing the
microorganism and eliminating the
infection.
2. Improvement is expected within 48-72
hours after starting the antibiotic.
3. Take the drug the same time each day and
complete the course even if there is
improvement.
4. Swallow the tablets and capsules whole
with a full glass of water; do not chew or
crush them.
5. Discontinue it immediately and contact
your doctor if any signs of an allergic
reaction occur.
For azithromycin/ clarithromycin
1. Clarithromycin can be taken with or
without food
2. Don’t take it with aluminum and
magnesium-containing antacids at the
same time.
3. Common adverse effects: (gastrointestinal
discomfort and diarrhea), if sever contact
your doctor.
4. Avoid the use of over the counter (OTC)
drugs without consultation of your doctor
as it predisposes to prolongation of QT
interval that may presented as palpitation,
syncope and chest pain
For benzyl penicillin
1. Pain/redness/swelling at injection site may
occur.
For amoxicillin
1. Can take it with or without food
 2. Diarrhea is a common side effect, if it
becomes severe watery and associated
with mucus and blood, you should contact
your treating doctor.

3. Itching, redness and discomfort in or

around your mouth, armpits, vagina, penis
or groin area – these are symptoms of
thrush (a yeast infection)

For ampicillin

1. As amoxicillin except it should be given

30 minutes before food and diarrhea more
common with it than amoxicillin.

For Co-amoxiclav
1. As general and amoxicillin
2. It is associated with risk of cholestatic
jaundice, if you developed yellowish
discoloration of the skin, pale urine and
dark stool, contact your doctor.
For Cefuroxime:
1. Diarrhea, nausea or vomiting have been
reported.

For doxycycline
1. Avoid food or drugs containing calcium,
iron, magnesium, zinc, and aluminum, as
they decrease its absorption. therefore,
they should not be administered
concurrently with them.
2. Heart burn, nausea, and vomiting are
common side effects. Don’t drink milk or
take antacid to relieve this heart burn.
3. Photosensitivity to sunlight or ultraviolet
rays: Photosensitivity reactions ranged
from itching and burning sensation to mild
 erythema of sun-exposed face and
extremities. So, avoid direct sunlight
exposure and use sunscreen.

For levofloxacin:

1. Tablets can be taken with or without food

while oral solution should be administered
on an empty stomach (at least 1 hour
before or 2 hours after a meal)
2. Avoid the use of over the counter (OTC)
drugs without consultation of your doctor
as it predisposes to prolongation of QT
interval that may presented as palpitation,
syncope and chest pain
3. It can cause glucose dysregulation, so in
case of DM, strict f/u of blood glucose
level
4. Serious mood or behavior changes--
nervousness, confusion, agitation,
paranoia, hallucinations, memory
problems, trouble concentrating, thoughts
of suicide may occur during treatment.
5. Tendinitis and tendon rupture could occur
as a side effect from levofloxacin in the
form of sudden pain, swelling, bruising,
tenderness, stiffness, movement problems,
or a snapping or popping sound in any of
your joints. If that occurred, rest the joint
until you receive medical care.
6. In rare cases, levofloxacin may cause
damage to your aorta, the main blood
artery of the body. This could lead to
dangerous bleeding or death. Get
emergency medical help if you have
severe and constant pain in your chest,
stomach, or back.
Your final prescription
Patient’s name: Amira Doctor’s name:
Patient’s age: 44 Doctor’s address:
Patient’s address: Date:
Diagnosis: Community acquired pneumonia
Rx: Azithromycin tab, 500 mg/tab
Send 3 tabs
One tablet to be taken once daily at the same time every day for 3 days.
Or
Rx: Azithromycin Cap, 250 mg/cap
Send 6 caps
Initially 500 mg(2 capsules) once daily for 1 day, then 250 mg once daily for 4 days

Or
Rx: Amoxicillin Cap, 500 mg/cap
Send 15 caps
One capsule to be taken every 8 hours for 5 days

Or
Rx: Ampicillin Cap, 500 mg/cap
Send 20 caps
one capsule to be taken every 6 hours for 5 days

Or
Rx: Co-amoxiclav tab, 500/125 mg/tab
Send 15 tabs
One tablet to be taken every 8 hours for 5 days

Or
Rx: Doxycycline cap, 100 mg/cap
Send 6 caps
Two capsules to be taken on the first day then one capsule one daily for4 days

Or
Rx: Levofloxacin tab, 500 mg/tab
Send 14 tabs
One tablet to be taken every 12 hours for 7 days

Or
Rx: Benzyl penicillin vial, 0.6 g (600 mg)/vial
Send 20 vials
One vial to be given with slow IV injection every 6 hour for 5 days
Or
Rx: Clarithromycin tab, 500 mg/tab
Send 10 tabs
One tablet to be taken every 12 hours for 5 days.
Or
Rx: Cefuroxime vial, 750 mg/vial and Cefuroxime tab, 250 mg/tab
Send 6 vials and 20 tablets
A vial to be taken IM every 8 hours for 2 days, then 2 tabs to be taken every 12
hours for 5 days

14. When the patient should be reviewed? The patient should be reviewed for response to
treatment, 2-3 days after initiation of antibiotic
therapy

15. Are there any required monitoring

Yes √ No
investigations?
According to IDSA 2019, routine use of
follow-up chest imaging is not recommended

16. Is there any additional non-

Yes √ No
pharmacological intervention that
should be concomitantly done with
………………………………………
pharmacotherapy?

17. Was culture-sensitivity required? How

Yes √ No
its results could change the prescribed
drug? According to IDSA guidelines 2019, Culture is
recommended for patients with CAP managed in
the hospital who:

1. are classified as severe CAP, especially if

they are intubated

2. are being empirically treated for MRSA or

P. aeruginosa

3. were previously infected with MRSA or

P. aeruginosa, especially those with prior
respiratory tract infection
 4. were hospitalized and received parenteral
antibiotics, whether during the
hospitalization event or not, in the last 90
days.

Plan for reviewing the patient and follow up

Check your choice with the most recently available guidelines