Cefepime dosage argument--This will make or break my grade!!

RxWildcat

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Ok here's the deal. I currently have a 89.34% in my lab class and if I'm able to argue these few points back I can get an A in the class. There was a case involving proper selection of an antimicrobial for empiric treatment of VAP in a relatively healthy (normal hepatic/renal function, hemodynamically stable) I don't have the case in front of me anymore so thats about all the detail I can remember. I selected cefepime 1g q12h but the teacher knocked it down a letter grade stating that this is less correct then a 2g q12h dose. If anyone wants to help me search and find some literature stating that the 1g q12h dose is adequate and the 2g q12h hasn't been shown to be superior for severe VAP I would greatly appreciate it! I already presented her with several sources showing the 1g q12h is an acceptable dosage, but I really need some literature showing the equivanlency in efficacy to the 2g dose.
 

bigpharmD

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Sorry, I always recommend/start patients on 2 q12 if they are on the vent and in the ICU and will de-escilate therapy as cultures come back. This is especially true depending on the patients age/weight and renal function. Just my opinion. Typically relatively healthy does not = ventilator.
 

RxWildcat

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In retrospect I wish I would have chosen the 2g q12 but I still don't think that the 1g dose should be incorrect until I see some evidence. The pt was getting tobra as well if that makes any difference, probably not though. I guess I meant relatively healthy for a critically ill person.
 
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girllein

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Tell us what you've found so far in the journal world, cause we ain't gonna do your homework, just like the rest of 'em! :D
 

girllein

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Oh, and make or break your grade is getting a C vs getting a D.
 

RxWildcat

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Here is the package insert, table 12 is the dosage recommendations

http://www.elan.com/Images/MAXIPIME_PI_tcm3-4348.pdf


Also, The American Thoracic Society "Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia" Indicate that cefepime 1g q12h may be used as emperic therapy for VAP.

http://www.thoracic.org/sections/publications/statements/pages/mtpi/guide1-29.html


Here is an article showing that the two dosages produce very similar T>MIC goals

.http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200510000-00011.htm;jsessionid=JKrNXbQ4WZ2D1tFLtvpQ3PLYdjGGJN5zqh7b99pD1fyC3DrN0JLm!-450575803!181195629!8091!-1.




That's all I have so far, I'll keep digging though.

 

girllein

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Can you get access to this trial? http://clinicaltrials.gov/ct2/show/NCT00177736?intr=%22Cefepime%22&rank=7 I can't tell if it's been published yet.

The fact that your professor asked you this question is pretty lame. Did they tell y'all this in class *specifically* or was this one of those BS interpretation types of questions? What does DiPiro say?

The Drug Info Handbook says 1-2 grams every 8-12 hours for HAP/VAP.

Oh, and monkeys eat bananas, not soap.
 

RxWildcat

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This wasn't a point at all in lecture, this was merely a small portion of a larger case and this dang dose threw me off a letter grade. I agree it's a BS question. That clinical trial would be a perfect if I could access the results but I can't figure out how or if they are even available yet.
Primary literature trumps DiPiro.
 

bigpharmD

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I think you have to worry about increasing MICs to cefepime. The article you ref. was 2005. Hopefully the slide deck I tried to attach works. Go to the cefepime section and look at the info about pseudomonas. Also check the article out, especially the discussion. Granted it is talking about bacteremia, but it brings up good points about cefepime. There are some people that argue you should always dose q8h until you know the organism.

http://aac.asm.org/cgi/reprint/AAC.01487-06v1.pdf

I just dont think there is any way you would ever see 1gram q12 in a patient on the vent these days. But treatment of VAP is controversial.
 

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RxWildcat

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I think you have to worry about increasing MICs to cefepime. The article you ref. was 2005. Hopefully the slide deck I tried to attach works. Go to the cefepime section and look at the info about pseudomonas. Also check the article out, especially the discussion. Granted it is talking about bacteremia, but it brings up good points about cefepime. There are some people that argue you should always dose q8h until you know the organism.

http://aac.asm.org/cgi/reprint/AAC.01487-06v1.pdf

I just dont think there is any way you would ever see 1gram q12 in a patient on the vent these days. But treatment of VAP is controversial.
Well, those definitely make the 1g q12h look very ineffective.


Crap.

Thanks for looking though guys.
 

ItsOverZyvox

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If it was ur family member would u be comfortable with 1g q12h?

I can argue either way, but..
 

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"Healthy" is pretty freakin' relative. CrCl could play a decent factor in a clinician's decision and to play it safe would mean to dose 1g q 12 hours, if the CrCl is unknown (<60 ml/min requires 1g q 12 hours).

I don't see how you're going to win the argument, but you will know way more about cefepime dosing in VAP next time around. Consider it a blessing in disguise. :smuggrin:


For example, I will always remember that Tussionex is dosed 1 tsp q 12 hours, because a pharmacist wouldn't let a 1-1.5 tsp q 12 hours dose slide for a patient, and that made the patient really mad, because we had to wait for the doctor to call back.
So... I got a random lab question correct several months later, because I knew that 30ml/day of Tussionex was 100% wrong.
The risk with too much Tussionex is resp. depression, cause it's extended release and the dosing can stack up after a few doses.

A grade is a grade. Don't put too much into it. Although, I have never made a B in a lab class, unless you really want to count Organic lab back in the day. :smuggrin:
 
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As long as it is within dosing range for "normal patients", it's pretty ticky-tack to take off points. If anything, it expresses more of a viewpoint of the professor that it's better to err on the higher end of the dose range. Perhaps a difficult, yet indelible way of learning how important it is to eradicate the bug first and foremost. Good luck, and either way, B+ is actually a good grade
 

RxWildcat

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Their Scr and BUN were normal 12 hours ago and there was no UOP info, so I had to assume their renal function was normal. After looking over everything in depth in real life I would do the 2g q12h, but I still think I shouldn't lose a letter grade on an acceptable dose. Either way, after about a dozen e-mails back and forth, she's not wavering on the matter. I'm not complaining about the B, I just hate being so close, I'd rather have an 80 even.
 

All4MyDaughter

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Just a lucky guess. :D

Gee, how could a lab exam ever have ambiguous answers? And how could you not INSTINCTIVELY know which answer was more correct, when choosing between two answers that Lexi Comp would say are correct? Come on, dude. You are a professional! Act like one! Professionals read minds! :smuggrin:

I am sorry about your grade though. It stinks to be so close but yet not quite there. :thumbdown:
 

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I wouldn't give up that easily. Raise a question regarding pseudomonal MIC for this ICU and see if this patient attains sufficient serum level. Write a pk analysis then compare to psedomonal break point.
 

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Let me give you a lesson in life. Your grades don't mean squat. It's what you know that counts. Here is the way it is. Your teacher has decided for some reason to be a jerk-off instead of a teacher. If your answer is wrong, he/she/it should explain exactly why it's wrong or lead you to the information so you can make an informed decision.

You have two choices:

1. Be a jerk like your teacher and fight it out. It's Over Zyvox (An excellent teacher by the way) gave you enough information for you to make a reasoned argument that would give you a chance to raise your grade.

2. Be a man (or woman) and realize your answer was not the "best" answer and learn from your experience. What counts is what will you do when you have to make a recommendation and your patient is in the ICU with VAP and they want to know what YOU recommend. The patient would prefer you get a B+ and know the right answer than get an A and not know the right answer.
 

ItsOverZyvox

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1. Be a jerk like your teacher and fight it out. It's Over Zyvox (An excellent teacher by the way) gave you enough information for you to make a reasoned argument that would give you a chance to raise your grade.
Did you just call me a jerk? :smuggrin: j/k

I can relate to this young man because I was one question away from 4.0 during my first semester P1 year. It was Pharmaceutics. I argued my case why I was right but the prof wouldn't budge. Still to date, I know I was right, though I don't remember what it was about. He was a d i c k and I acted the same way.. if I kissed his ass, it would have been different. But today...what does it matter? I'm no less of a pharmacist because of it..

To OP: Have you written up a PK analysis? If I was the prof, I would actually give you an opportunity to convince me why you're right. I would expect a full bore detailed analysis.
 
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RxWildcat

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I've pretty much decided to just drop the argument at this point. I still believe I could prove myself correct with the PK analysis, but regardless of what proof I show all she is going to say if that I wasn't the most correct. Her last e-mail to me, after I had shown her several of the studies posted earlier on here, was that if the dose achieves T>MIC 99% of the time that is better than a dose that achieves it 95% of the time. Well DUH! Basically no matter what I show or prove she is going to sidestep my logic and play the "this is more correct because of this" card. If you guys know the teacher you'd understand. She grades tough and doesn't waver, A4MD can attest to that.

As far as the A vs. the B goes, I'm not a whiny student who has to get all As every semester, I don't really care. The only reason I'm making a huge fuss is because it was so close to the A and I feel like a had a legitimate argument. I'm gonna rock someone on rotations with all this VAP and cefepime knowledge, thats for sure.
 

ItsOverZyvox

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I've pretty much decided to just drop the argument at this point. I still believe I could prove myself correct with the PK analysis, but regardless of what proof I show all she is going to say if that I wasn't the most correct. Her last e-mail to me, after I had shown her several of the studies posted earlier on here, was that if the dose achieves T>MIC 99% of the time that is better than a dose that achieves it 95% of the time. Well DUH! Basically no matter what I show or prove she is going to sidestep my logic and play the "this is more correct because of this" card. If you guys know the teacher you'd understand. She grades tough and doesn't waver, A4MD can attest to that.

As far as the A vs. the B goes, I'm not a whiny student who has to get all As every semester, I don't really care. The only reason I'm making a huge fuss is because it was so close to the A and I feel like a had a legitimate argument. I'm gonna rock someone on rotations with all this VAP and cefepime knowledge, thats for sure.
I prefer Pip/Tazo over cefepime.. in VAP/HAP
 

njac

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Can you find a different point to *rgue? I never argued poiints in rx school but I was also queen of the 88-89. Maybe if I'd argued even some my gpa would be better. But when/if I teach I'm grading like a hardass.
 

RxWildcat

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I prefer Pip/Tazo over cefepime.. in VAP/HAP
Why? Just curious for my own sake. At UK we have a bunch of cefepime fanboys, they preached it a lot during our ID modules.
 

RxWildcat

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Can you find a different point to *rgue? I never argued poiints in rx school but I was also queen of the 88-89. Maybe if I'd argued even some my gpa would be better. But when/if I teach I'm grading like a hardass.
I think the problem is no matter what point I argue and how well I prove it, she's not going to budge. Don't grade like that, nobody likes professor hardass :D
 

ItsOverZyvox

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Why? Just curious for my own sake. At UK we have a bunch of cefepime fanboys, they preached it a lot during our ID modules.
Evidently your fanboys haven't read the meta-analysis from last year...well, they probably did and the analysis was questionable... still.

The reason Pip/Tazo would have been the mo better answer ?

1. more than likely better coverage against Pseudomonas.. look at the antibiogram.

2. less likely to induce resistant Enterococcus.
 

njac

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The fact is that she's right. In a pt with more or less normal renal function go for the high dose. You've likely got a bug with some resistance and the lungs get poor penetration anyway.
 

RxWildcat

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Evidently your fanboys haven't read the meta-analysis from last year...well, they probably did and the analysis was questionable... still.

The reason Pip/Tazo would have been the mo better answer ?

1. more than likely better coverage against Pseudomonas.. look at the antibiogram.

2. less likely to induce resistant Enterococcus.
Got a link to the meta-analysis? If not I can look it up myself, no biggie.
 

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send me ur email addy.
 

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