What is the best course of action for an 85-year-old male (YOM) with underlying cellular nonspecific interstitial pneumonia (NSIP) on prednisone (50mg PO daily) and intravenous (IV) ceftriaxone and azithromycin, who is experiencing increasing hypoxia, shakiness, and elevated temperature?

From the Guidelines

The best course of action for this 85-year-old male with worsening respiratory status is immediate hospitalization for escalation of care, preferably in an intensive care unit, with broadened antibiotic coverage to include antipseudomonal agents and consideration of antifungal coverage, given his immunocompromised state from high-dose steroids 1. His current condition suggests progressive respiratory failure despite treatment with high-dose prednisone (50mg daily) and IV antibiotics (ceftriaxone and azithromycin). The patient requires urgent arterial blood gas analysis, comprehensive laboratory workup including procalcitonin, C-reactive protein, and cultures, and high-resolution chest CT to assess disease progression. Key considerations include:

• Oxygen therapy should be titrated based on oxygen saturation levels, potentially requiring high-flow nasal cannula or non-invasive ventilation.
• Antibiotic coverage should be broadened to include antipseudomonal agents like piperacillin-tazobactam (4.5g IV every 6 hours) and consideration of antifungal coverage with voriconazole (6mg/kg IV twice daily on day 1, then 4mg/kg twice daily) given his immunocompromised state from high-dose steroids.
• Prednisone should be continued but potentially adjusted based on clinical response, as suggested by guidelines for managing interstitial lung disease 1.
• Bronchoscopy with bronchoalveolar lavage should be considered to identify potential opportunistic infections. This aggressive approach is warranted because the combination of underlying NSIP, immunosuppression, increasing hypoxia, and fever suggests either disease progression or a superimposed infection, both of which carry high mortality risk in elderly patients with interstitial lung disease.

From the Research

Patient Assessment and Treatment

• The patient is an 85-year-old male with underlying cellular nonspecific interstitial pneumonia (NSIP) admitted to the hospital with increasing hypoxia, and is currently on prednisone 50mg PO daily and intravenous (IV) ceftriaxone and azithromycin for possible underlying pneumonia.
• The patient is experiencing shakiness and elevated temperature, which may be indicative of a worsening condition or a potential side effect of the current treatment regimen.

Potential Treatment Options

• The use of azithromycin in combination with other medications, such as oseltamivir, has been shown to be effective in treating influenza and reducing mortality rates 2, 3.
• The combination of clarithromycin, naproxen, and oseltamivir has been found to be effective in treating patients hospitalized for influenza A(H3N2) infection, with reduced 30-day and 90-day mortality rates and shorter hospital stays 3.
• The concurrent administration of azithromycin and ceftriaxone has been found to have no significant pharmacokinetic interactions, suggesting that this combination can be safely used in patients 4.

Clinical Reasoning and Communication

• Effective clinical reasoning and communication are essential in advanced practice nursing, particularly in complex cases like this one 5.
• A thorough assessment of the patient's condition, including their medical history, current symptoms, and treatment regimen, is necessary to determine the best course of action.
• Clear communication with the patient, their family, and other healthcare professionals is crucial in ensuring that the patient receives optimal care and that any changes to their treatment regimen are made in a timely and effective manner.