Clinical Question of the Day Pilot Thread 4/18-4/19

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While he answers, what are your goals (for correction)? How to monitor? That's where you can play a big role, trust me, not only in tx choice but the entire course as the residents you are working with will likely have little clue on what should be done.

Or the attendings who are not sticklers to details.

Well you have to find the underlying cause of the imbalance-

For the euvolemic hyponatremia do you actually calculate the Uosm? It could be renal failure. But, CrCl would tell me what's going on with the kidneys. I would want to know thyroid fx. Is the patient on thiazides? I want to r/o SIADH

For hyper, I want to know glucose. Could be CHF or cirrhosis.

Monitor fluid I/O, VS, lytes, ABGs. Need to know: drugs patient is on, alcohol use, WBC

I had to go back to my notes for some of this :oops:
 
It's not that I don't like ID, because I do. I call on doses that are wrong and watch what people are getting in retail. I've made suggestions on doses in the charts, too, and checked a million kidney functions. I just despise the attitude that people have on this forum that ID is some kind of superior knowledge or whatever, because it's really not.

ID has nothing to do with superior knowledge or however you put it. It is however typically the highest cost classification medication for a non-oncology service. Also, because core measure compliance (which you have no experience with since LTACs and retail don't participate) with SCIP and Pneumonia are tied to CMS reimbursement, it's a very important component of healthcare and pharmacy practice. Your opinion of foo fooing on ID is really laughable. If you have nothing to contribute to this topic, then simply do not reply.

Tremors associated with a diphenhydramine overdose in a 100 year old, and tremors with possible serotonin syndrome in a patient with major depression.

Is that some sort of a superior knowledge??

Pharmacy is not that complicated...

Pharmacy practice is complicated. It involves clinical, operational, regulatory, quality, & financial challenges. It's complicated. Everyday I realize how much more I need to learn.
 
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Forget ID. With the current shortage of IV benzos + crazy ICU admits who are still bucking the vent on propofol drip + midazolam boluses, why don't we talk about nontraditional/2nd line sedation strategies? What can you use outside of propofol and benzos? A pros/cons list for each agent would be even better.

Let's not forget ID since your vented/sedated patients are at a risk for HAP/VAP.

But yeah.. Dexmedetomidine is an option.
 
What you really need to ask is why are they crazy and bucking the vent. What's the patient's background? Why are they on the vent? What were they on prior to admit (both pharmacy drugs and street pharmacy drugs)? Wow, are they in pain - you should read data and recommendations about the use of opioids/pain mgt in this situation? At what point is the "still bucking the vent?" - i.e. a few hours or a few days later.

alcoholic...
 
Ah - this one I know :) Core measure score indicates basically the quality of your care. I believe it measures readmittance for the same condition within 30 days of discharge. If the number of readmits is too high, then you can receive lower reimbursements - like 50% normal costs. It is supposed to disincentivize admittance and incentivize providing good care that doesn't result in readmissions. The value based purchasing is the practical method of this - how much they pay depends on the CMS.

In real life, this makes sense but has some problems - big hospitals that focus on very ill patients as opposed to community hospitals that primarily treat relatively simple conditions will have higher readmittance rates, and although they supposedly take this into account it doesn't always help enough to even out the difference.

Readmission is a very important component of the Core Measures. Very good.
 
Still no correct answer to 3 different criteria of pneumonia and drug selections.

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getting the patient set up for dialysis would take way too long if they are not already on dialysis

How many HD patients do you think take pradaxa?

What do you need to do in order to get a patient set up for dialysis?
 
ID has nothing to do with superior knowledge or however you put it. It is however typically the highest cost classification medication for a non-oncology service. Also, because core measure compliance (which you have no experience with since LTACs and retail don't participate) with SCIP and Pneumonia are tied to CMS reimbursement, it's a very important component of healthcare and pharmacy practice. Your opinion of foo fooing on ID is really laughable. If you have nothing to contribute to this topic, then simply do not reply.
This is exactly what I'm talking about. You act like how you practice is the only right way. What's the point in trying to intimidate people on SDN? It's not a game show. Worthless.

Is that some sort of a superior knowledge??
I suppose it could be. I mean... it's what I came across while working and had to figure out - very straight-forward practice. *note sarcasm*

It wasn't some kind of Scrabble game. :rolleyes:

Pharmacy practice is complicated. It involves clinical, operational, regulatory, quality, & financial challenges. It's complicated. Everyday I realize how much more I need to learn.
Seriously? Every day I realize how much I don't know about how things are made, too. And whenever I want to learn about it, I get to watch it on Youtube. :laugh:

[YOUTUBE]http://www.youtube.com/watch?v=WB3st6SQnsk&feature=related[/YOUTUBE]

[YOUTUBE]http://www.youtube.com/watch?v=WQPT_FMQKV8[/YOUTUBE]

[YOUTUBE]http://www.youtube.com/watch?v=C4EmLvzmTHA&feature=related[/YOUTUBE]



**My whole point in trying to knock this type of intimidating style of learning on SDN is to show that you don't need to be an expert to make a difference, contrary to what SDN seems to portray in regards to ID. I think you need to be an expert to manage full-blown AIDS, since genotype and phenotype testing are not available in most settings, but not to question Bactrim DS BID x 3 days for UTI, Macrobid 500mg BID x 7 days, or Levaquin 500mg TID x 7 days, etc. which will show up in actual practice. Just reference your Drug Information Handbook :idea:**

But until the superiority complex associated with ID is no more, it will be just another barrier to learning and patient care.
 
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Still no correct answer to 3 different criteria of pneumonia and drug selections.

HAP - occurs 48 hr or greater after admission
VAP - arises 48-72 hr after intubation
HCAP - acute care for 2 or more days w/in 90 days or LTC or abx within 30 days

if HAP, VAP, HCAP suspected --> late onset or MDR risk --> broad spectrum coverage --> zosyn (4.5g q6) , vanco (20mg/kg q12), levo (750mg qdaily) is reasonable

I hope that's what you're asking :oops:
 
HAP - occurs 48 hr or greater after admission
VAP - arises 48-72 hr after intubation
HCAP - acute care for 2 or more days w/in 90 days or LTC or abx within 30 days

if HAP, VAP, HCAP suspected --> late onset or MDR risk --> broad spectrum coverage --> zosyn (4.5g q6) , vanco (20mg/kg q12), levo (750mg qdaily) is reasonable

I hope that's what you're asking :oops:

Have you read the core measure document?
 
There is nothing intimidating about the way Im asking the question. And this isn't about the way I practice. Clinical quality measure is a standardized way the cms, tjc, and the rest of the accrediting bodies measure the quality of care provided to patients.



Perhaps your intimidation comes from the fact you have no clue how to answer it.

You can try to learn it if it interests you. If not there's no reason for you to dismiss this topic for others.


This is exactly what I'm talking about. You act like how you practice is the only right way. What's the point in trying to intimidate people on SDN? It's not a game show. Worthless.


I suppose it could be. I mean... it's what I came across while working and had to figure out - very straight-forward practice. *note sarcasm*

It wasn't some kind of Scrabble game. :rolleyes:

Seriously? Every day I realize how much I don't know about how things are made, too. And whenever I want to learn about it, I get to watch it on Youtube. :laugh:

[YOUTUBE]http://www.youtube.com/watch?v=WB3st6SQnsk&feature=related[/YOUTUBE]

[YOUTUBE]http://www.youtube.com/watch?v=WQPT_FMQKV8[/YOUTUBE]

[YOUTUBE]http://www.youtube.com/watch?v=C4EmLvzmTHA&feature=related[/YOUTUBE]



**My whole point in trying to knock this type of intimidating style of learning on SDN is to show that you don't need to be an expert to make a difference, contrary to what SDN seems to portray in regards to ID. I think you need to be an expert to manage full-blown AIDS, since genotype and phenotype testing are not available in most settings, but not to question Bactrim DS BID x 3 days for UTI, Macrobid 500mg BID x 7 days, or Levaquin 500mg TID x 7 days, etc. which will show up in actual practice. Just reference your Drug Information Handbook :idea:**

But until the superiority complex associated with ID is no more, it will be just another barrier to learning and patient care.
 
Have you read the core measure document?

I read the guidelines the other night to curb my insomnia but, as a friend pointed out, it was a page turner. So, maybe not? I will go back and look for the "core measurement" document specifically.

EDIT: found it. answer to follow

(PN-6) Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients
-Non – ICU Patient: ceftriaxone 1g IV q24 + azithromycin 500mg PO qdaily x3days

-ICU Patient: ceftriaxone 1g IV q24 + azithromycin 500mg IV q24 or zosyn 4.5g q6

Zosyn 4.5g q6 + levofloxacin 750mg IV q24 (if pseudomonal risk)
 
no reversal agents...FFPs to the pradaxa question
 
Ask and you shall receive.

Give a treatment option for hyper and euvolemic hyponatremia and why not salt tabs or concentrated saline. Provide the moa. How much does the treatment cost per day. Drug cost.

fluid restriction, vaptans
 
QUESTION FOR 4/19

In which patients is stress ulcer prophylaxis actually indicated? Our medical interns can never get this right.
 
In which patients is stress ulcer prophylaxis actually indicated? Our medical interns can never get this right.

Coagulopathies, mechanical ventilation
 
Ask and you shall receive.

Give a treatment option for hyper and euvolemic hyponatremia and why not salt tabs or concentrated saline. Provide the moa. How much does the treatment cost per day. Drug cost.

Demeclocycline: induces nephrogenic diabetes insipidus -> secrete diluted urine. Couldnt find cost on lexi. Unlabeled use for euvolemic hyponatremia caused by SIADH.

Tolvaptan: vasopressin (ADH) antagonist -> urinate more. Couldnt find cost on lexi. For euvolemic/hypervolemic hyponatremia.

IV would be furosemide.
Why not salt tabs/NS: central pontine myelinolysis with rapid correction.
 
QUESTION FOR 4/19

In which patients is stress ulcer prophylaxis actually indicated? Our medical interns can never get this right.

to add to the other poster:

history of GI ulcer/bleed in past year + 2 or more of following: in ICU for more than a week, GI bleed for a week, sepsis, glucocorticoids
 
Demeclocycline: induces nephrogenic diabetes insipidus -> secrete diluted urine. Couldnt find cost on lexi. Unlabeled use for euvolemic hyponatremia caused by SIADH.

Tolvaptan: vasopressin (ADH) antagonist -> urinate more. Couldnt find cost on lexi. For euvolemic/hypervolemic hyponatremia.

IV would be furosemide.
Why not salt tabs/NS: central pontine myelinolysis with rapid correction.

Hired!
 
I read the guidelines the other night to curb my insomnia but, as a friend pointed out, it was a page turner. So, maybe not? I will go back and look for the "core measurement" document specifically.

EDIT: found it. answer to follow

(PN-6) Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients
-Non – ICU Patient: ceftriaxone 1g IV q24 + azithromycin 500mg PO qdaily x3days

-ICU Patient: ceftriaxone 1g IV q24 + azithromycin 500mg IV q24 or zosyn 4.5g q6

Zosyn 4.5g q6 + levofloxacin 750mg IV q24 (if pseudomonal risk)

Nice...but about 70%. But you're getting hot.
 
Core Measure Pneumonia PN6 refers to antibiotic selection.

Tell me the 3 different Criteria in pneumonia categories and what antibiotics are acceptable for each. Bonus.. dosing of antibiotics..

1) Non-ICU:
[Beta-lactam (ceftriaxone, cefotaxime, amp/sulbactam, ertapenem) + (Macrolide OR doxycycline)] OR Respiratory FQ

2) ICU:
Beta-lactam (same as above) + (Macrolide IV or Respiratory FQ IV) OR (Respiratory FQ + Aztreonam) if pen allergic OR tigecycline

3) Pseud risk documented:
Antipseud beta-lactam (Cefepime, imipenem, meropenem, doripenem, pip/tazo) + Antipseud quinolone (IV if ICU)
OR
Antipseud beta-lactam + AG + (Respiratory FQ OR Macrolide [IV if ICU])
OR
Aztreonam + Respiratory FQ + AG (may omit if renal insufficiency documented AND using levofloxacin)

At my shop this equals:
Non-ICU: Ceftriaxone + doxy OR Moxifloxacin
ICU: Ceftriaxone + Moxifloxacin
Pseud: Zosyn + Cipro

All within 24 hours of first healthcare contact. We've used tigecycline a few times (I hate CMS sometimes)...and getting actual CMS-friendly Pseud risk documented is tougher than it seems.



So I guess core measures (clinical quality measures) aren't very well taught in school?

To expand upon this, why is core measure score important what does value based purchasing mean to hospitals and health systems? It can make or break a hospital. This is huge.

$$$$$$$$$$$ - and cutthroat money at that. Can win big, can lose big, but it's zero-sum. Some hospitals stand to lose a lot more than they can gain. Gotta meet those metrics!
 
And some say residency is useless. Thank you for the answer.. good work but ertapenem and tigecycline really? Your institution really has those drugs on CAP orders?


1) Non-ICU:
[Beta-lactam (ceftriaxone, cefotaxime, amp/sulbactam, ertapenem) + (Macrolide OR doxycycline)] OR Respiratory FQ

2) ICU:
Beta-lactam (same as above) + (Macrolide IV or Respiratory FQ IV) OR (Respiratory FQ + Aztreonam) if pen allergic OR tigecycline

3) Pseud risk documented:
Antipseud beta-lactam (Cefepime, imipenem, meropenem, doripenem, pip/tazo) + Antipseud quinolone (IV if ICU)
OR
Antipseud beta-lactam + AG + (Respiratory FQ OR Macrolide [IV if ICU])
OR
Aztreonam + Respiratory FQ + AG (may omit if renal insufficiency documented AND using levofloxacin)

At my shop this equals:
Non-ICU: Ceftriaxone + doxy OR Moxifloxacin
ICU: Ceftriaxone + Moxifloxacin
Pseud: Zosyn + Cipro

All within 24 hours of first healthcare contact. We've used tigecycline a few times (I hate CMS sometimes)...and getting actual CMS-friendly Pseud risk documented is tougher than it seems.





$$$$$$$$$$$ - and cutthroat money at that. Can win big, can lose big, but it's zero-sum. Some hospitals stand to lose a lot more than they can gain. Gotta meet those metrics!
 
Non-ICU (CURB-65 score of 2): either a respiratory fluoroquinolone (levofloxacin 500 mg daily IV) or an anti-pneumococcal beta lactam + a macrolide (ex: ceftriaxone 1g daily IV + azithromycin 500 mg daily IV). Covers Strep pneumiae and the atypical pathogens (mycoplasma, legionella, chlamydophila pneumoniae).

ICU (CURB-65 score of 3 or more, septic shock, requiring ventilation): ceftriaxone 1g daily IV + azithromycin 500 mg daily IV as above is acceptable. Or can add ceftriaxone to the respiratory fluoroquinolone like levofloxacin.

Healthcare-associated (recent hospitalization in 90 days, been in nursing home or hemodialysis, recent IV antibiotic therapy, etc) + MDR risk factors (ex: immunsuppressive disease or therapy): anti-pseudomonal beta lactam (cefepime 1-2g q 8-12h, or imipenem 500 mg q6h, or zosyn 4.5g q6h) + MRSA coverage (vancomycin 15mg/kg q12h IV or linezolid 600 mg bid IV). Can also add combination therapy for pseudomonas with an anti-pseudomonal FQ (cipro 400 q8h IV) or an aminioglycoside. FQ if the resistance is low at the institution and aminoglycoside dosing and interval will depend on patient's renal function, etc.

I guess healthcare-associated isn't really CAP but my preceptor said that the pseudomonas and MRSA risk factor section on CAP are weird and that those 2 are kind of like HCAP. Never seen tigecycline used for pneumonia though lol. But technically it should work.. ceftaroline wasn't studied for pneumonia but it should work too. Don't typically see ertapenem for pneumonia either. I see it for like mild community acquired intra-abdominal infections.
 
Not bad....but I like levofloxacin. 750mg and vancomycin 25mg/kg loading dose.
 
3 criteria

Non ICU
Non ICU pseudomonas risk
ICU
 
I didn't know you wanted me to copy and paste the whole thing :rolleyes:

And here I picked my own little regimen.

I don't want copy and paste but you left out pseudomonas risk category
 
Prazi had the best answer for the PN6 question
 
Why tigecycline for pseudomonas risk? It's not as effective against pseudomonas.

edit: nvm you just said ICU
 
And some say residency is useless. Thank you for the answer.. good work but ertapenem and tigecycline really? Your institution really has those drugs on CAP orders?

Those were just the CMS metrics, not part of our order sets. We don't use azithromycin for anything in adults because of crappy pricing/S. pneumo coverage. Tigecycline we have used a few times for CAP, but only when we identify a patient that won't meet metrics due to multiple allergies, etc. We run through all potential included patients twice a day every day to make sure they've met metrics for their risk category. Proper ICU antibiotic selection and documentation of Pseud risk are our two biggest barriers.

Not having vanc on the ICU metric is a pain in the neck, because it meets the spirit (double S. pneumo coverage) but not the letter of the law. Oh well.

Not bad....but I like levofloxacin. 750mg and vancomycin 25mg/kg loading dose.

We don't load vanco! All dosing is based on a hospital nomogram targeting a 10-15 trough for all indications. I wasn't a believer at first, but I think the literature that has come out in the last year, year and a half really fails to support higher troughs at this point.
 
Why tigecycline for pseudomonas risk? It's not as effective against pseudomonas.

No one is making that recommendation. Its for atypicals and strep. Now for mrsa tygacil may cover it but since it resides in EFL where tygacil doesn't attain enough concentration its a horrible drug for it.
 
We don't load vanco! All dosing is based on a hospital nomogram targeting a 10-15 trough for all indications. I wasn't a believer at first, but I think the literature that has come out in the last year, year and a half really fails to support higher troughs at this point.


For pneumonia, evidence is weak I agree. But this has a lot to do with Zyvox funded studies.

However, for bacteremia, there's a nice study done at Wayne State recently published in CID where early high trough resulted in a better outcome. R Kullar is one of the primary investigator. It published this year.
 
I had Zosyn and levo 750 for pseudomonas

...

But now I have that document as a pdf Hehe

But you categorized it under HAP/VAP. Not CAP nor a part of the core measure.
 
For pneumonia, evidence is weak I agree. But this has a lot to do with Zyvox funded studies.

However, for bacteremia, there's a nice study done at Wayne State recently published in CID where early high trough resulted in a better outcome. R Kullar is one of the primary investigator. It published this year.

I saw that one, but I'm still not convinced. See Brown J, AAC 2012;56(2):634-8. I think MRSA-vanc troughs are one of those grey areas that are never going to go away. Some people are firmly on the less vanc side, others are on the more vanc side. At this point, you can make a very reasonable argument in either direction.

What it really comes down to is the same reason we don't use linezolid up front for suspected MRSA pneumonia - it benefits the people who actually have the infection they're treating, but there is no good way to empirically figure out who actually has MRSA pneumonia, bacteremia, etc. I believe the benefits of more aggressive dosing in the few patients who actually have true infections are outweighed by the risks to those who never had it. Perhaps as RT-PCR identification picks up, the picture will get clearer, but I'm not hopeful.

ETA: This doesn't account for the people who need vanc for one reason or another (Enterococcus, PCN-reistant S. pneumo, CoNS) yet still get dosed at 15-20. That's one of the biggest problems - as we push for MRSA trough targets, people forget that there is absolutely no data for, yet real harm associated with, aggressive dosing in non-MRSA infections.
 
too many inpatient based ?s

let me bring a different perspective from the payor side

Zytiga is used in castration resistant prostrate cancer for patients who have tried docetaxel

However, we get a lot of requests for patients who have not tried docetaxel

In which type of patient would you use (and should I pay for) zytiga before docetaxel
 
But the answer isn't completely right.

I guess you have settled for "good enough" in your old age?

No one has 100% completely perfect answer... I certainly don't.
 
I saw that one, but I'm still not convinced. See Brown J, AAC 2012;56(2):634-8. I think MRSA-vanc troughs are one of those grey areas that are never going to go away. Some people are firmly on the less vanc side, others are on the more vanc side. At this point, you can make a very reasonable argument in either direction.

What it really comes down to is the same reason we don't use linezolid up front for suspected MRSA pneumonia - it benefits the people who actually have the infection they're treating, but there is no good way to empirically figure out who actually has MRSA pneumonia, bacteremia, etc. I believe the benefits of more aggressive dosing in the few patients who actually have true infections are outweighed by the risks to those who never had it. Perhaps as RT-PCR identification picks up, the picture will get clearer, but I'm not hopeful.

ETA: This doesn't account for the people who need vanc for one reason or another (Enterococcus, PCN-reistant S. pneumo, CoNS) yet still get dosed at 15-20. That's one of the biggest problems - as we push for MRSA trough targets, people forget that there is absolutely no data for, yet real harm associated with, aggressive dosing in non-MRSA infections.

Let me think about it.
 
I got an interesting clinical question for you wizards! (too busy to answer yours :p i know im lazy).. I made a hypothetical clinical case based on the question in mind, but if you like, you can skip to bottom to get to the actual clinical question.

Patient is recovering hospital from acute renal failure due to a pre-renal insult, but has CKD stage to the point where their day to day crcl is 18. For whatever reason (lets say acute hospital related infection and bacteremia develops), they will be in the hospital long term (1-2 weeks) and needing VTE prophy ( hx of vte, current sepsis/bacteremia, ie they absolutely NEED VTE prophy). Initial choice is heparin SC. They develop HIT (confirmed) and you treat successfully short term with argatroban to the appropriate APTT indicator until their platelets go back up. After the platelets normalize, what do yo udo next, since heparin , lmwh, and fondaparinux are all contraindicated.



TL;DR version

Patient has ABSOLUTE need of VTE prophy, but is in ARF , CrCl=18 , HIT develops within days of hospital admission and is confirmed and treated with argatroban. Now that platelet count is normal, what do you use for VTE prophylaxis, given that heparin, LMWH, and fondaparinux all seem like inappropriate choices?

Would you continue DTI (and break the bank?) ? Start oral anticoagulation or antiplatelet therapy short term? Go with some oddball option? Do you risk renal dosing of fonda?

Im intersted in knowing what you guys think would be the most effective real world option based on the costs and overall likelyhood of efficacy. Personally I would probably pick warfarin on gut instinct alone, but am unsure if this is effective for VTE prophy. (edit.. looked up some articles, warfarin is good VTE prophylaxis .. and is still my top choice pick, but is it the best for this patient?)
 
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