Azactam alternatives?

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*sigh*

Yeah, I know. I mean for empirical broad spectrum coverage. The ID docs are doing stuff I find odd again and just want to know what others are doing with the upcoming shortage.
 
we use very little aztreonam. So I don't know what we would do in a shortage.
 
I'd say pip/tazo or cefepime, but again it would depend on the suspected bugs and the source/location (or likely source) of an infection. What are the ID guys at your institution using?
 
Ok...let's take a case I had today. Woman in hospital. Unknown site of infection. Unknown bug. Whites around 36. Physician orders Azactam for broad spectrum. It's on backorder as of this week. What should be the hospital's go to reco for people that want aztreo?

Lol...look, I know what WOULD work, I don't need an ID lesson. There are many combination that WOULD work...negatives and psuedomonas...yeah, ok. I'm just wondering what some other institutions are actually making temporary protocol for therapeutic substitutions in the real world.
 
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WVUPharm2007 said:
Ok...let's take a case I had today. Woman in hospital. Unknown site of infection. Unknown bug. Whites around 36. Physician orders Azactam for broad spectrum. It's on backorder as of this week. What should be the hospital's go to reco for people that want aztreo?

Lol...look, I know what WOULD work, I don't need an ID lesson. There are many combination that WOULD work...negatives and psuedomonas...yeah, ok. I'm just wondering what some other institutions are actually making temporary protocol for therapeutic substitutions in the real world.
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Why didn't you send out a bat call... just admit it, your DOP needs some help.. :meanie:

I know you don't want an ID lecture but here it is with some pharm-econ.

Azactam 1gram q8h = $25 X 3 = $75 per day
Azactam 2grams q8h = $50 X 3 = $150 per day

Aztreonam is good for one thing. Coverage of pseudomonas for positive PCN allergies. Not cephalosporin allergies...but PCN allergy. So for this instance, here are you alternatives.

Cefepime 1-2grams q12h ($12 to $20 per day) or Ceftazdime 1-2grams q8h. ($18 to $36 per day)
or
Aminoglycoside (tobra or gent) 7mg/kg EDR or Amikacin 15mg/kg EDR (cheap)

Some *****s do use it for broad spectrum intra-abdominal infection purely out of habit. Then sub with

Ceftraxone 1 gram + Flagyl 500mg IV q6h (< $15 per day) or Cipro 400mg IVPB q12h + Flagyl. (< $15 per day)

But remember, most often, Aztreonam has one of the worst susceptibility among Antipseudomal coverage...sometimes worse than quinolones.

Now, if docs are using it just for the heck of it without regards to PCN allergies, then you can recommend Zosyn ($60 for 3.375g q6h) or carbapenems ($90 for Merrem 1gram q8h or Primaxin 500mg q6h).. but I wouldn't.

The most important thing for you is to know why Azactam is ordered to treat what bug.. then you'll know how to therapeutically sub it. Make sure review your Antibiogram and look at the susceptibility of Azactam...

I would request to have it restricted only to PCN allergic patients who are not a candidate for AG.

:meanie:
 
I wouldn't really say she needs help, per se, I just think she defaults to the ID physicians too much...and the ideas she had were better than what the ID people had, IMO (and they were similar to what you are saying, Z - first thing out of her mouth was Fortaz and gent.) They were trying to peddle vanc and meropenem...which sounded stupid to me...and I was going to say something...but didn't...meh...
 
WVUPharm2007 said:
I wouldn't really say she needs help, per se, I just think she defaults to the ID physicians too much...and the ideas she had were better than what the ID people had, IMO (and they were similar to what you are saying, Z - first thing out of her mouth was Fortaz and gent.) They were trying to peddle vanc and meropenem...which sounded stupid to me...and I was going to say something...but didn't...meh...
Click to expand...


That's not like you to not speak up. Here is what you do. Study your antibiogram and find out what your pseudomonas susceptibility is like at your institution. Look at the urine vs non urine isolates and ICU vs non ICU isolates. Memorize it and quote it when you talk to your ID and your DOP. As a DOP, you should never ever ever never rely on ID docs because they thrive on using the most expensive and newest drugs out there...because they have to show other docs that they know the new and best thing..

Here is what you say...

Mike: Our Aztreonam's pseudomonas coverage here is __% for non urine ICU and __% non urine non-ICU isolates. So, if you're trying empiric coverage using Aztreonam for our known PCN allergic patients, we're better off using Cefepime which has __% (should be better than Azactam) and it's much more cost effective. And if you want to add some anaerobic coverage, metronidazole is the best option. Even the latest study shows its' superiority over Pip/Tazo and Carbapenems... which we couldn't use on our PCN allergic patients anyways..

Mike: Also, I'm not so sure about Vanc + Merrem option... if we suspect MRSA, ok let's add Vanco, but, do you really want to try the patient on Merrem when patient has PCN allergies? Going forward, we should consider keeping Azactam only for PCN allergic patients. Also, let's not forget about AG.
 
Is it me or are 95% of PCN "allergies" are complete bull****? The problem with that is finding the numbers..I assume they probably have them calculated. I've never seen them though. Hell, our vanc susceptibilities don't even have MICs and we use a Vd of 0.9...heh...

Speaking of which, did that vanc guideline ever come out?
 
WVUPharm2007 said:
Is it me or are 95% of PCN "allergies" are complete bull****? The problem with that is finding the numbers..I assume they probably have them calculated. I've never seen them though. Hell, our vanc susceptibilities don't even have MICs and we use a Vd of 0.9...heh...

Speaking of which, did that vanc guideline ever come out?
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probably higher than 95%. You've never seen your Antibiogram??????
Lord.. if you're ever so motivated, I can help you put together your hospital's Antibiogram.. It will probably promote you one step closer to becoming the next clinical manager and eventually a DOP..

Don't worry about the MIC...just make sure you get your trough high enough. Haven't seen the Vanc guideline yet.
 
WVUPharm2007 said:
Is it me or are 95% of PCN "allergies" are complete bull****? The problem with that is finding the numbers..I assume they probably have them calculated. I've never seen them though. Hell, our vanc susceptibilities don't even have MICs and we use a Vd of 0.9...heh...

Speaking of which, did that vanc guideline ever come out?
Click to expand...

No vanc. guideline yet, I visited the site today to peruse something else and noticed it was still pending. Projected "Late Fall 2008," aren't we there?
 
hey resident...how are y'all handling Clevidipine and Entereg? Could be a pharm-econ nightmare..
 
ItsOverZyvox said:
hey resident...how are y'all handling Clevidipine and Entereg? Could be a pharm-econ nightmare..
Click to expand...

Well, at this point, I can only say that I wish I worked in a hospital that had to handle such matters. The institution's drug budget is $260 million per year, and the Division of Pharmacy generates 30% of the place's revenue. I believe I was told at one point, "if it will save $1 million dollars annually, we can talk about it."
 
Priapism321 said:
Well, at this point, I can only say that I wish I worked in a hospital that had to handle such matters. The institution's drug budget is $260 million per year, and the Division of Pharmacy generates 30% of the place's revenue. I believe I was told at one point, "if it will save $1 million dollars annually, we can talk about it."
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aww dood... $1mil is only 0.38% of total.. there are ideas that can save 10% but you'll have to figure it out.

I hope you guys have a lot of outpatient onc... and the revenue is actual reimbursement not the ghost revenue that shows up on the P&L...

Well, Cleviprex and Entereg have been popping up...interesting stuff really.
 
Priapism321 said:
Well, at this point, I can only say that I wish I worked in a hospital that had to handle such matters. The institution's drug budget is $260 million per year, and the Division of Pharmacy generates 30% of the place's revenue. I believe I was told at one point, "if it will save $1 million dollars annually, we can talk about it."
Click to expand...

Jesus H Christ. That's a lot of damned Tylenol.
 
ItsOverZyvox said:
Well, Cleviprex and Entereg have been popping up...interesting stuff really.
Click to expand...

Yeah, why don't you call my director on that one. You should see the ghetto ass post-op bowel protocols I have to type in because we don't have prebuilt order sets for them yet. I got crap to do (*rimshot*) and I'm sitting there for 10 minutes typing up the 6-drug bowel protocol in which a different drug is added for each day the ****ers don't take a poo.
 
ItsOverZyvox said:
aww dood... $1mil is only 0.38% of total.. there are ideas that can save 10% but you'll have to figure it out.

I hope you guys have a lot of outpatient onc... and the revenue is actual reimbursement not the ghost revenue that shows up on the P&L...

Well, Cleviprex and Entereg have been popping up...interesting stuff really.
Click to expand...

I'm not really keen on this stuff, but everyone always mentions something called "DRG exemption," which my current institution also has (this applies to inpatient operations?). They also have a department dedicated to reimbursement.

I am up on all of these new drugs, and try and follow along at my PGY1 site where the formulary management is impressive.
 
WVUPharm2007 said:
Yeah, why don't you call my director on that one. You should see the ghetto ass post-op bowel protocols I have to type in because we don't have prebuilt order sets for them yet. I got crap to do (*rimshot*) and I'm sitting there for 10 minutes typing up the 6-drug bowel protocol in which a different drug is added for each day the ****ers don't take a poo.
Click to expand...

LMAO!!!

Are you having to add Entereg on it??
 
Priapism321 said:
I'm not really keen on this stuff, but everyone always mentions something called "DRG exemption," which my current institution also has (this applies to inpatient operations?). They also have a department dedicated to reimbursement.

I am up on all of these new drugs, and try and follow along at my PGY1 site where the formulary management is impressive.
Click to expand...

DRG applies to inpatient reimbursement as you already know. I can only assume DRG exemption means there is a different rate of reimbursement due to a high cost of treatment for certain disease. I bet a lot of the things you guys do lie outside of the conventional wisdom. I have not worked an a system with a budget as big as yours... the largest was $70 mil a year and that was plenty large enough for me. I think I know where you work.. :meanie:
 
WVUPharm2007 said:
No, dollars. We make saline IVs with crick water and boxes of Morton's salt. But we have brand Motrin, dammit.
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Dude, brand Motrin on contract is cheaper than air sometimes... check with your purchaser..
 
dude.

I'm at a state run psych facility at the moment.

The drug budget is $150K/month with lots of use of atypical antipsychotics. Those eat like 75% of that. I wrote a proposal to change all Depakote ER to Divalproex Sodium and save the place almost $90K per year on the current patients.

Just the patients currently receiving Depakote ER BID subbed to Divalproex Sodium would save $30K/yr. I got it through P&T uncontested. Booya!
 
njac said:
dude.

I'm at a state run psych facility at the moment.

The drug budget is $150K/month with lots of use of atypical antipsychotics. Those eat like 75% of that. I wrote a proposal to change all Depakote ER to Divalproex Sodium and save the place almost $90K per year on the current patients.

Just the patients currently receiving Depakote ER BID subbed to Divalproex Sodium would save $30K/yr. I got it through P&T uncontested. Booya!
Click to expand...

Dudette,

That's awesome yo..
Actually, I'm kinda proud..

Now...go wax on and and wax off..
 
ItsOverZyvox said:
Well, when your formulary consists of PCN, ASA, and Opium, I guess it's feasible..
Click to expand...

And meth. Lots of meth. Some people use neo or levophed to keep peeps sbp up in their ICUs...f that...give me some sudafed, some potassium permanganate, a 30cc syringe, and a microwave. I'll keep that BP up....
 
WVUPharm2007 said:
And meth. Lots of meth. Some people use neo or levophed to keep peeps sbp up in their ICUs...f that...give me some sudafed, some potassium permanganate, a 30cc syringe, and a microwave. I'll keep that BP up....
Click to expand...

:meanie::meanie:

What's the matter, don't y'all have 60CC syringes?
 
I remember the video of a gummy bear in potassium permanganate in HS chemistry. Pretty sweet reaction!
 
WVUPharm2007 said:
And meth. Lots of meth. Some people use neo or levophed to keep peeps sbp up in their ICUs...f that...give me some sudafed, some potassium permanganate, a 30cc syringe, and a microwave. I'll keep that BP up....
Click to expand...

couldn't you just use the sudafed alone... One of our residents did that for maintaining MAP last year.
 
njac said:
dude.

I'm at a state run psych facility at the moment.

The drug budget is $150K/month with lots of use of atypical antipsychotics. Those eat like 75% of that. I wrote a proposal to change all Depakote ER to Divalproex Sodium and save the place almost $90K per year on the current patients.

Just the patients currently receiving Depakote ER BID subbed to Divalproex Sodium would save $30K/yr. I got it through P&T uncontested. Booya!
Click to expand...


Make sure you keep an accurate record of all of your pharmacoeconomics interventions and incorporate it into your CV. Include $ figures. And keep coming up with these ideas and get it implementend throughout your residency. This will set you a part from the other residents.. Make your CV that spells "Hire me and I'll show you the money." I'm tired of CV that spell "Look at me I did all these cool worthlesss clinical things that saved no money but I felt good about doing them."

Before you finish your residency (if you're going to do it), send me your CV and we'll go from there.
 
njac said:
couldn't you just use the sudafed alone... One of our residents did that for maintaining MAP last year.
Click to expand...

Yeah, if you're a pansy. That's like going rabbit huntin' with a .22. I prefer a .50 cal myself. Barrett M82. That's take care of that pesky rabbit.
 
njac said:
couldn't you just use the sudafed alone... One of our residents did that for maintaining MAP last year.
Click to expand...

Why wouldn't sudafed work in an ICU patient on Neo or Levo Drip?? Sorry let me rephrase...

Why is Neo or Lev drip preferred over sudafed in an ICU patient?
 
WVUPharm2007 said:
Yeah, why don't you call my director on that one. You should see the ghetto ass post-op bowel protocols I have to type in because we don't have prebuilt order sets for them yet. I got crap to do (*rimshot*) and I'm sitting there for 10 minutes typing up the 6-drug bowel protocol in which a different drug is added for each day the ****ers don't take a poo.
Click to expand...


sounds like you need some pharmacy staff with IT skills, too.



no prebuilt order sets?
wow, you really ARE making NS with crick water and morton's salt!
 
ItsOverZyvox said:
Why wouldn't sudafed work in an ICU patient on Neo or Levo Drip?? Sorry let me rephrase...

Why is Neo or Lev drip preferred over sudafed in an ICU patient?
Click to expand...

Way to hit on a weak spot in pharmacology... Someone else feel free to chime in!

(I was enjoying my youth rather than pharmacy school at that point)

Titratability. When the #$$% hits the fan (as it can do in critical patients) you need to be able to crank it up or turn it off.

Phenylephrine has alpha-1 selectivity.

What else?

Oh, and to tie it in to the topic at hand, we use them in septic patients with profound hypotension.
 
njac said:
Way to hit on a weak spot in pharmacology... Someone else feel free to chime in!

(I was enjoying my youth rather than pharmacy school at that point)

Titratability. When the #$$% hits the fan (as it can do in critical patients) you need to be able to crank it up or turn it off.

Phenylephrine has alpha-1 selectivity.

What else?

Oh, and to tie it in to the topic at hand, we use them in septic patients with profound hypotension.
Click to expand...

Ehh..I wasn't even thinking that far.

Most of hypotensive ICU patients are usually intubated and NPO..and are under crisis.. didn't think sudafed was available IV.. :meanie:
 
ItsOverZyvox said:
Ehh..I wasn't even thinking that far.

Most of hypotensive ICU patients are usually intubated and NPO..and are under crisis.. didn't think sudafed was available IV.. :meanie:
Click to expand...

ha! I figured you can get it down a NG/OG/G tube.

The problem with the study they did was that the IRB required direct patient consent. Not many people get extubated/woken up enough to consent to a study while still on pressors (hypothesis was that PSE could wean them faster and get them out of the ICU quicker).
 
njac said:
ha! I figured you can get it down a NG/OG/G tube.

The problem with the study they did was that the IRB required direct patient consent. Not many people get extubated/woken up enough to consent to a study while still on pressors (hypothesis was that PSE could wean them faster and get them out of the ICU quicker).
Click to expand...

Eh...the way I look at it....it's IV...the effects are seen earlier...and because the infusion dose isn't a bolus, overcorrections can be more easily fixed. They are obviously precarious enough to warrant needing said "extra heart oomph". Using Sudafed PO just seems ghetto. Plus, I enjoy making the ICU nurses beg me every 5 hours for a new bag because most of them are blazing hot and flirt with me in obnoxiously overt ways when they come pick it up. Some of the ED nurses are good lookin', too. Now everywhere else...they are just old and obese. Makes sense...lazy work for lazy bodies. Exciting, more happening work for the younger set.

What the hell was I talking about again?
 
You guys get drug reps, we get salt reps. Just last week we got a huge package of Morton's gel pens. A hot chick dressed up as the little umbrella girl on the package came by and bought us Panera. Soup in a bread bowl for the whole department, baby.
 
that is kind of hot. I had a friend with the Morton Salt Girl tattooed - I don't remember where. But way cute.
 
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