Guess how many patients are at my new rotation..?

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WVUPharm2007

WVUPharm2007

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11. Yes, 11. In a hospital. The cart fill for 2 days took 10 minutes.

All of them are on gent, too. This is like having an ID course with a professor and one other student. I've learned more today about aminoglycoside dosing than I ever could in a classroom. Thank God I'm away from retail. Thank God I'm away from academia. This rotation **** has renewed my non-dislike of pharmacy. In one day.
 
WVUPharm2007 said:
11. Yes, 11. The cart fill for 2 days took 10 minutes.

All of them are on gent, too. This is like having an ID course with a professor and one other student. I've learned more today about aminoglycoside dosing than I ever could in a classroom. Thank God I'm away from retail. Thank God I'm away from academia. This rotation **** has renewed my non-dislike of pharmacy. In one day.
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I could have learnt you everything there is to know about Aminoglycoside in 5 minutes.

What's the Vd of Aminoglycoside..and at 7mg/kg, what is the extrapolated Cmax and at what times the MIC is aminoglycoside most bacteriocidal. Why is conventional dosing more nephrotoxic than once daily at 5-7mg/kg?
 
You must be at an LTAC..
 
It's not a jcoha-accredited joint, I know that. They were talking about swing patients and this and that. They said it wasn't important to know, so I didn't remember.
 
WVUPharm2007 said:
11. Yes, 11. In a hospital. The cart fill for 2 days took 10 minutes.

All of them are on gent, too. This is like having an ID course with a professor and one other student. I've learned more today about aminoglycoside dosing than I ever could in a classroom. Thank God I'm away from retail. Thank God I'm away from academia. This rotation **** has renewed my non-dislike of pharmacy. In one day.
Click to expand...

Sweet! After nearly six years in Pharmacy school the only place you are happy is in a hospital with 11 patients. Good luck finding a job.

One other question. You have a blog spot titled "The Apathetic Pharmacist." How can you be an apathetic Pharmacist when you are still in school? Just wondering, wishfull thinking I suppose. I think I would wait until I had my license hanging on the wall....just me I guess.
 
Good for you WVU!!!!! Have fun & learn lots....branch out when you get a chance.

Are there any opportunities for JCAHO accreditation? Perhaps you could get involved in some administrative stuff in that area...or start something new.

Good luck!
 
sdn1977 said:
Good for you WVU!!!!! Have fun & learn lots....branch out when you get a chance.

Are there any opportunities for JCAHO accreditation? Perhaps you could get involved in some administrative stuff in that area...or start something new.

Good luck!
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I'm still waiting for him to answer my short aminoglycoside quiz....
 
ZpackSux said:
I'm still waiting for him to answer my short aminoglycoside quiz....
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Daaa....this is his first day! He's still brushing off his grey matter from all those months doing nothing. Give him time to do the math!:meanie:
 
sdn1977 said:
Daaa....this is his first day! He's still brushing off his grey matter from all those months doing nothing. Give him time to do the math!:meanie:
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You know what's funny is that...there haven't been a single pharmacist or pharmacy student who correctly answered that same question without having to look it up.. except for some of my fellow SC grads... we had an awesome antimicrobial program.
 
ZpackSux said:
I could have learnt you everything there is to know about Aminoglycoside in 5 minutes.

What's the Vd of Aminoglycoside..and at 7mg/kg, what is the extrapolated Cmax and at what times the MIC is aminoglycoside most bacteriocidal. Why is conventional dosing more nephrotoxic than once daily at 5-7mg/kg?
Click to expand...

Z - be nice, I'm a first year. I'll take a shot at part of this:

Aminoglycoside nephrotoxicity is cumulative but reversible. So by dosing once daily you give the kidneys a bit of time to "recover" if you will, before the next dose.

For p. aerug you want 10 times the MIC for qd dosing.

The extended interval dosing is superior due to less toxicity but also because of extended post-antibiotic effect. Once daily dosing may avoid some adaptive resistance (ribosomal changes) in the bacteria. With traditional dosing the second daily dose was always less effective due to these adaptive changes. Since the changes are non-persistant, daily dosing can overcome them.

I tried!🙂
 
All4MyDaughter said:
Z - be nice, I'm a first year. I'll take a shot at part of this:

Aminoglycoside nephrotoxicity is cumulative but reversible. So by dosing once daily you give the kidneys a bit of time to "recover" if you will, before the next dose.

For p. aerug you want 10 times the MIC for qd dosing.

The extended interval dosing is superior due to less toxicity but also because of extended post-antibiotic effect. Once daily dosing may avoid some adaptive resistance (ribosomal changes) in the bacteria. With traditional dosing the second daily dose was always less effective due to these adaptive changes. Since the changes are non-persistant, daily dosing can overcome them.

I tried!🙂
Click to expand...

Excellent. But tell me...how is 5mg/kg once a day safer than 1.5-2mg/kg three times a day...when the total daily dose is the same?

You didn't answer the Vd and Cmax question..😛
 
Sweet! After nearly six years in Pharmacy school the only place you are happy is in a hospital with 11 patients. Good luck finding a job.
Click to expand...

Eh, just "not retail" in general seems ok for now.

One other question. You have a blog spot titled "The Apathetic Pharmacist." How can you be an apathetic Pharmacist when you are still in school? Just wondering, wishfull thinking I suppose. I think I would wait until I had my license hanging on the wall....just me I guess.
Click to expand...

Eh, close enough. What's a year.
 
ZpackSux said:
Excellent. But tell me...how is 5mg/kg once a day safer than 1.5-2mg/kg three times a day...when the total daily dose is the same?

You didn't answer the Vd and Cmax question..😛
Click to expand...

I thought I did address the safety issue - the avoidance of cumulative nephrotoxicity and letting the kidney rest... I'm thinking...
 
All4MyDaughter said:
I thought I did address the safety issue - the avoidance of cumulative nephrotoxicity and letting the kidney rest... I'm thinking...
Click to expand...


Yes..you're right. But how does the kidney rest when the total daily dose is the same amount in both regimen... How could giving 3 times the amount of dose at once be safer than dividing it into 3 doses? I'm playing devil's advocate here....
 
ZpackSux said:
What's the Vd of Aminoglycoside
Click to expand...

I got that written down somewhere...but it ain't in my head.

and at 7mg/kg, what is the extrapolated Cmax
Click to expand...

I must not understand the question, wouldn't that depend on infusion rate..?

and at what times the MIC is aminoglycoside most bacteriocidal.
Click to expand...

I wanna say 4? Or is that vanc? If it's not 4, it's 25. I get those backwards.

Why is conventional dosing more nephrotoxic than once daily at 5-7mg/kg?
Click to expand...
I knew this at one point but have since forgotten. I know it has something to do with the drug accumulating in the tubules over time vs. over a shorter time with qd dosing. the spike in Cp allows for a shorter duration of nephrotoxic level..somthing along those lines. The exact mechanism...yeah, kinda hazy..

As '79 pointed out. I got to shake the dust off my brain. I was bloody lost today. It's rough to go 6 months without talking about any of this stuff, then to just hop back into the saddle.
 
ZpackSux said:
You know what's funny is that...there haven't been a single pharmacist or pharmacy student who correctly answered that same question without having to look it up.. except for some of my fellow SC grads... we had an awesome antimicrobial program.
Click to expand...

I didn't realize you were "testing" me too😱 ! Oooops....I'll respond back if you want, but I'm fixing dinner.....& there is that bottle of wine my husband just opened....do you want me back boss???

Oh...btw....is your chips/beer diuresis over:laugh: ?
 
ZpackSux said:
Yes..you're right. But how does the kidney rest when the total daily dose is the same amount in both regimen... How could giving 3 times the amount of dose at once be safer than dividing it into 3 doses? I'm playing devil's advocate here....
Click to expand...



Hmmmm, that's a good question...
There there would be one large peak instead of three small ones that...
So levels would steadily decrease over time instead of staying a somewhat higher, more constant level...
The therapeutic window is narrow....
I say extended interval dosing keeps patients near the "toxic" end of the therapeutic window for a shorter period of time...

This is probably beyond my (limited) schooling at this point!
 
sdn1977 said:
I didn't realize you were "testing" me too😱 ! Oooops....I'll respond back if you want, but I'm fixing dinner.....& there is that bottle of wine my husband just opened....do you want me back boss???

Oh...btw....is your chips/beer diuresis over:laugh: ?
Click to expand...

Oh...I'm not testing you. Go take care of your hubby...

no chips and beers over the weekend...👍
 
All4MyDaughter said:
Hmmmm, that's a good question...
There there would be one large peak instead of three small ones that...
So levels would steadily decrease over time instead of staying a somewhat higher, more constant level...
The therapeutic window is narrow....
I say extended interval dosing keeps patients near the "toxic" end of the therapeutic window for a shorter period of time...

This is probably beyond my (limited) schooling at this point!
Click to expand...


Excellent try... at least you're thinking! 👍

This question encompasses 2nd year pharmacotherapy and antimicrobials and 3rd year therapeutics.... something WVU should be able to recite without even blinking an eye...:meanie:
 
WVUPharm2007 said:
I got that written down somewhere...but it ain't in my head.



I must not understand the question, wouldn't that depend on infusion rate..?



I wanna say 4? Or is that vanc? If it's not 4, it's 25. I get those backwards.


I knew this at one point but have since forgotten. I know it has something to do with the drug accumulating in the tubules over time vs. over a shorter time with qd dosing. the spike in Cp allows for a shorter duration of nephrotoxic level..somthing along those lines. The exact mechanism...yeah, kinda hazy..

As '79 pointed out. I got to shake the dust off my brain. I was bloody lost today. It's rough to go 6 months without talking about any of this stuff, then to just hop back into the saddle.
Click to expand...


Dood....👎
 
ZpackSux said:
Excellent try... at least you're thinking! 👍

This question encompasses 2nd year pharmacotherapy and antimicrobials and 3rd year therapeutics.... something WVU should be able to recite without even blinking an eye...:meanie:
Click to expand...

It was a welcome distraction from my OTC assignment for tomorrow: contact lens care....

We just finished block exams today. 7 exams over Fri, Sat, Mon. I did really well last block, not so sure about this one.

When are you going to share the answer?
 
ok....he just poured the wine....dinner's not ready yet...can I give a hint???

for the students.....look at the proximal renal tubular epithelial cells & the maximal renal uptake....


then......have a discussion with Zpak......😉
 
oh....also ....as a student - its ok to look it up - just don't "forget"!
 
According to WVUPharm2007 one year from graduation is close enough to call himself a Pharmacist. You'd think he have all the answers then. Hmmmm...might want to rethink the title of your blog.
 
According to WVUPharm2007 one year from graduation is close enough to call himself a Pharmacist. You'd think he have all the answers then. Hmmmm...might want to rethink the title of your blog.
Click to expand...

God, and I didn't think I had a life. It's not like I proclaim I've graduated already.
 
The Vd of Aminoglycoside is 0.25L/kg

The dosing weight of Aminoglycoside in obese pt is IBW + 0.4X(Actual weight - IBW)..this assumes 40% absorption of drug into adipose tissues.

If Pt weighs 50kg, the Vd (volume of distribution) = 12.5 liters.

So the size of bucket (compartment where drug distributes) is 12.5 liters.

At 7mg/kg, this pt receives 350mg of Gent or Tobra. 350mg of Gent in 12.5liter compartment (350mg/12.5L) results in absolute extrapolated Cmax of 28 ug/ml. Which is about 10 to 15 times the MIC (2ug/ml).

T1/2 of Aminoglycoside varies...but usually ranges from 2 to 4 hours. Let's pick 3 hours. So in 3 hours, the conc = 14ug/ml, in 6 hours 7, in 9 hours 3.5, in 12 hours 1.75, in 15 hours 0.9, in 18 hours 0.45, in 21 hours 0.2 and in 24 hours 0.1. Basically after 12th hour...the level is below 2ug/ml for the rest of 12 hours.

If pt received 120mg q8h, the peak is at about 9 to 10ug/ml, in 3 hours 4.5, in 6 hours 2.25, and in 8th hour...about 1.5..then pt gets another dose of 120mg where the level goes up to about 10...then it cycles.

Basically with conventional q8h dosing, renal system never gets a break from Aminoglycoside.

Remember, renal toxicity of Aminoglycodise results from sustained trough. Therefore conventional dosing tends to result in more renal damages.

Your explanation of post antibiotic effect is dead on.
 
WVUPharm2007 said:
God, and I didn't think I had a life. It's not like I proclaim I've graduated already.
Click to expand...

Awwwww just busting your balls. I thought it was funny in your signature you state you are a pharmacy student and under it you have a link to a blog which states you are the Apathetic Pharmacist. Don't know why I felt the need to point it out but I did.

Zpack - tell me you don't have all that in your head. I thought you were the director of pharmacy? Directors don't actually practice pharmacy do they? I thought you guys sat around all day planning where your next golf game will be? :meanie:
 
ZpackSux said:
The Vd of Aminoglycoside is 0.25L/kg

The dosing weight of Aminoglycoside in obese pt is IBW + 0.4X(Actual weight - IBW)..this assumes 40% absorption of drug into adipose tissues.

If Pt weighs 50kg, the Vd (volume of distribution) = 12.5 liters.

So the size of bucket (compartment where drug distributes) is 12.5 liters.

At 7mg/kg, this pt receives 350mg of Gent or Tobra. 350mg of Gent in 12.5liter compartment (350mg/12.5L) results in absolute extrapolated Cmax of 28 ug/ml. Which is about 10 to 15 times the MIC (2ug/ml).

T1/2 of Aminoglycoside varies...but usually ranges from 2 to 4 hours. Let's pick 3 hours. So in 3 hours, the conc = 14ug/ml, in 6 hours 7, in 9 hours 3.5, in 12 hours 1.75, in 15 hours 0.9, in 18 hours 0.45, in 21 hours 0.2 and in 24 hours 0.1. Basically after 12th hour...the level is below 2ug/ml for the rest of 12 hours.

If pt received 120mg q8h, the peak is at about 9 to 10ug/ml, in 3 hours 4.5, in 6 hours 2.25, and in 8th hour...about 1.5..then pt gets another dose of 120mg where the level goes up to about 10...then it cycles.

Basically with conventional q8h dosing, renal system never gets a break from Aminoglycoside.

Remember, renal toxicity of Aminoglycodise results from sustained trough. Therefore conventional dosing tends to result in more renal damages.

Your explanation of post antibiotic effect is dead on.
Click to expand...

Thanks! Now I want to see my score on my antibiotics test...
 
Well...I could just go look up the answers and make you think I'm smart. I'm not gonna lie though, I freely admit I barely have an idea what I'm doing.....now.

I actually asked my preceptor to do some stuff with glycoside antibiotics/kinetics right off the bat because I know it is a weakness of mine I desperately need to work on. It is my goal for the week. Next week I'm doing tx of MRSA/VRSA. Then I'm doing clotting disorders. All the **** I know I need work on. I'd do some stuff on oncology drugs, something else I need to work on.. but...yeah...that isn't exactly something I can get at this hospital.

She actually has this Gent dosing thing going on that uses this chart she conjured up to guess maintenence dose based on percentage of loading dose and Crcl.
 
MountainPharmD said:
Zpack - tell me you don't have all that in your head. I thought you were the director of pharmacy? Directors don't actually practice pharmacy do they? I thought you guys sat around all day planning where your next golf game will be? :meanie:
Click to expand...

Sad as it may sound...that's all from my head.. I've been known to do kinetics in my head...both vanc and aminoglycosides... I wasn't always a director...

Actually I haven't been planning golf...getting little chilly. But I spent all day today on www.rennlist.com because Mrs. Zpack said I can buy a 911 before I turn 40... 8 months. I actually had my office door closed researching and reading about the 996... even went to a dealer for a test drive.. but they had sold the one I was looking at.
 
WVUPharm2007 said:
Well...I could just go look up the answers and make you think I'm smart. I'm not gonna lie though, I freely admit I barely have an idea what I'm doing.....now.

I actually asked my preceptor to do some stuff with glycoside antibiotics/kinetics right off the bat because I know it is a weakness of mine I desperately need to work on. It is my goal for the week. Next week I'm doing tx of MRSA/VRSA. Then I'm doing clotting disorders. All the **** I know I need work on. I'd do some stuff on oncology drugs, something else I need to work on.. but...yeah...that isn't exactly something I can get at this hospital.

She actually has this Gent dosing thing going on that uses this chart she conjured up to guess maintenence dose based on percentage of loading dose and Crcl.
Click to expand...

That chart you talking about is called the "Nomogram" where the random level drawn 6 to 14 hours after the start of infusion is plugged into determine the frequency of dosing. tx of MRSA is easy.. Vanco. But there are 2 types of MRSAs... community acquired which is resistant to beta lactams but susceptible to many other drugs... hospital acquired will require Vanco.. or some IDs wanna get fancy and use Tygacil, Zyvox, Cubicin..Synercid etc.

If you have VRSA in the hospital..u got issues. Call the CDC. I think you're referring to VRE... Vanco resistan Enterococcus..which are streptococcus species. Most of VRE may not require a treatment..many times colonization.

But if treatment is warranted, Zyvox, Cubicin, or Tygacil can be used.

Aint this stuff interesting... actually use the knowledge learned in school...

Not.
 
ZpackSux said:
Sad as it may sound...that's all from my head.. I've been known to do kinetics in my head...both vanc and aminoglycosides... I wasn't always a director...

Actually I haven't been planning golf...getting little chilly. But I spent all day today on www.rennlist.com because Mrs. Zpack said I can buy a 911 before I turn 40... 8 months. I actually had my office door closed researching and reading about the 996... even went to a dealer for a test drive.. but they had sold the one I was looking at.
Click to expand...

My pops has a '56 Porsche 356.
 
so what's our dad doing this weekend??
 
ZpackSux said:
so what's our dad doing this weekend??
Click to expand...

Ahhhh!! It's the big 2-5 anniversary!! He's taking mom out and buying her some more jewelry. It'll keep her happy for another couple of years.
 
ZpackSux said:
tx of MRSA is easy.. Vanco. But there are 2 types of MRSAs... community acquired which is resistant to beta lactams but susceptible to many other drugs... hospital acquired will require Vanco.. or some IDs wanna get fancy and use Tygacil, Zyvox, Cubicin..Synercid etc.
Click to expand...
That's what i'm doing.

If you have VRSA in the hospital..u got issues. Call the CDC. I think you're referring to VRE... Vanco resistan Enterococcus..which are streptococcus species. Most of VRE may not require a treatment..many times colonization.

But if treatment is warranted, Zyvox, Cubicin, or Tygacil can be used.
Click to expand...

I meant VRE....doh....

Aint this stuff interesting... actually use the knowledge learned in school...

Not.
Click to expand...
Yeah...I doubt any of those drugs were out yet back when you were in school. But, hey, you have a cool lawnmower. I sure don't.
 
cycloketocaine said:
Ahhhh!! It's the big 2-5 anniversary!! He's taking mom out and buying her some more jewelry. It'll keep her happy for another couple of years.
Click to expand...

I think mom has too much jewelry... but if she stays happy, it's all good.
I think I'll send dad a couple of blue diamonds.. it might make boff of em kinda happy..while I take a ride in my 356.
 
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