ID Question

[Sparda29]

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We had an assessment today, so when I compared answers after the exam with my classmates, we had a few differences.

Here's the question:

A 35 year old female who is pregnant for 32 weeks is in the hospital. During her stay while catheterized, she contracts an infection. Cultures show it is a gram negative bacteria (most likely Pseudomonas aer. IMO). Due to concerns for side effects due to the gentamicin, the MD decides to change the therapy and calls you the pharmacist for a recommendation. What would be the drug of choice with a similar spectrum of activity?

A. Ciprofloxacin
B. Penicillin
C. Aztreonam
D. Bactrim DS
E. Vancomycin

I eliminated Vanco and Penicillin since they wouldn't affect gram negative organisms. And I also eliminated Bactrim DS and Ciprofloxacin due to pregnancy factor. So I chose Aztreonam.

Some of my classmates think I'm wrong and say that Bactrim would be the best option.

 

[RxWildcat]

Where was the cx from? SMX-TMP + pregnancy = kernicterus = bad

 

[WVUPharm2007]

I'd go with your answer...

 

[StaviZFingerZ]

iv or foley catheter?
what kind of culture? how about sensitivity? urine? iv catheter site? blood? sputum? wound?
infection or colonization? wbc? simple or complex uti? cellulitis? why pseudomonas and not e coli?

who wrote the question?

more info dood.

 

[StaviZFingerZ]

and pt was already on gent? was pregnancy a new info that prompted the doc to change abx? i think not if shes 32 weeks pregnant. also how long was she on gent??? how do we know infection didnt already clear after 3 doses of gent? was culture done before gent and does she still have an active infection? if so...mrsa or s epi could be the culprit if its iv catheter.....

 

[naseuy]

Aztreonam

 

[njac]

my first inclination was ceftriaxone, but that wasn't one of your options.

we don't know how long she's been hospitalized, what she's hospitalized for, if she's in the ICU or not, etc etc.

 

[PharmDstudent]

If the point of the question is to apply pregnancy categories, then aztreonam is preferred over bactrim. Aztreonam is cat B, while bactrim is cat C.

 

[Sparda29]

iv or foley catheter?
what kind of culture? how about sensitivity? urine? iv catheter site? blood? sputum? wound?
infection or colonization? wbc? simple or complex uti? cellulitis? why pseudomonas and not e coli?

who wrote the question?

more info dood.

Don't have any of that info, it was a question on a test.

 

[b1234]

wouldn't the term catheterized imply foley not iv...

 

[RxWildcat]

wouldn't the term catheterized imply foley not iv...

no...

 

[KARM12]

Bactrim would be a poor choice for empiric coverage of a GNR. I usually wouldn't reach for aztreonam either unless the patient was a true PCN allergy.

Personally, I don't see the issue with the gent. Why does the MD want to change? Why do they suspect it is pseudomonas? Why is this woman catheterized? Not your typical candidate... What a bad question!

 

[Sparda29]

Bactrim would be a poor choice for empiric coverage of a GNR. I usually wouldn't reach for aztreonam either unless the patient was a true PCN allergy.

Personally, I don't see the issue with the gent. Why does the MD want to change? Why do they suspect it is pseudomonas? Why is this woman catheterized? Not your typical candidate... What a bad question!

I don't know, I think it was aiming for what is the best alternative to gentamicin in a pregnant patient. The question was from our once every 2 years assessment. It was just a cumulative test of everything we learned in the last 2 years, since it doesn't count in any grading, it's just determining how well the curriculum is in educating us.

 

[Priapism321]

wouldn't the term catheterized imply foley not iv...

No.

 

[StaviZFingerZ]

What a bad question!

It's a stupid question.

 

[njac]

why wouldn't you want to use gent in a pregnant woman?

 

[StaviZFingerZ]

why wouldn't you want to use gent in a pregnant woman?

typically pregnancy is an exclusion criteria for ODA, so we just do conventional dosing. Especially if it's UTI, then low dose gent should take care of it. There's no way a question can be that vague.

 

[njac]

typically pregnancy is an exclusion criteria for ODA, so we just do conventional dosing. Especially if it's UTI, then low dose gent should take care of it. There's no way a question can be that vague.

right, that's why I don't get why they were so gung-ho to get her off the gent.

Although all I need to know anymore is 5 mg/kg x1 and a level in about 12 hours

yay for trauma patients!! 😍

 

[StaviZFingerZ]

right, that's why I don't get why they were so gung-ho to get her off the gent.

Although all I need to know anymore is 5 mg/kg x1 and a level in about 12 hours

yay for trauma patients!! 😍

And a nomogram.

There's not a whole lotta difference between 5 and 7mg/kg ODA as far as clearance but 7mg/kg does attain a much better peak hence more cidal.

 

[StaviZFingerZ]

right, that's why I don't get why they were so gung-ho to get her off the gent.

Because the person who wrote the test probably isn't a very knowledgeable ID pharmacist.

 

[njac]

And a nomogram.

There's not a whole lotta difference between 5 and 7mg/kg ODA as far as clearance but 7mg/kg does attain a much better peak hence more cidal.

they aren't my problem after dose #1. I'll just order that level as a favor to whoever is taking care of them on the floor

 

[Its Z]

they aren't my problem after dose #1. I'll just order that level as a favor to whoever is taking care of them on the floor

May the Medication Reconciliation Gods have mercy on your soul!

 

[Its Z]

it's just determining how well the curriculum is in educating us.

Quality! 👍

 

[Sparda29]

Only reason I can come up with for not using gentamicin is the side effects associated with aminoglycosides. Hearing problems, balance, etc. But how high of a dose would be required to cause those side effects?

One thing about this assessment was that the questions were ridiculously easier than the questions we saw on the exams during the last 2 years.

 

[Praziquantel86]

Only reason I can come up with for not using gentamicin is the side effects associated with aminoglycosides. Hearing problems, balance, etc. But how high of a dose would be required to cause those side effects?

One thing about this assessment was that the questions were ridiculously easier than the questions we saw on the exams during the last 2 years.

This hasn't been taught to you yet? Don't you have a 2+2 program?

 

[Sparda29]

This hasn't been taught to you yet? Don't you have a 2+2 program?

We did ID during the 1st semester of P1, I'm gonna have to go back and brush up.

 

[njac]

We did ID during the 1st semester of P1, I'm gonna have to go back and brush up.

so the way the program at Touro is set up - the first, and only, time you see ID therapeutics is the very first semester of pharmacy school? 😱

I can't say that I agree with that philosophy. ID is one of the greatest areas where we as pharmacists can make an impact. And to address it at the very beginning and then never again? Of course you'll see it some on rotations, but I've done clinical rotations - I am fully aware of the joke rotations that are available, and can only imagine what the case is for a new school.

 

[Its Z]

We did ID during the 1st semester of P1, I'm gonna have to go back and brush up.

I don't think so..

You may have done a little pharmacology or medicinal chem of some antimicrobials but you didn't do "ID" during the P1, first semester.

How can you do ID without having completed pathology and/or microbio.... I can see microbio may be a pre req...but it needs to be taught with patho emphasis... also ID requires understanding of therapeutics...

 

[njac]

I don't think so..

You may have done a little pharmacology or medicinal chem of some antimicrobials but you didn't do "ID" during the P1, first semester.

How can you do ID without having completed pathology and/or microbio.

Z - we just got old.

"Back in my day, we learned ID in patho, pharmacology, med chem, kinetics, and THEN we did it in therapeutics"

 

[Praziquantel86]

so the way the program at Touro is set up - the first, and only, time you see ID therapeutics is the very first semester of pharmacy school? 😱

I can't say that I agree with that philosophy. ID is one of the greatest areas where we as pharmacists can make an impact. And to address it at the very beginning and then never again? Of course you'll see it some on rotations, but I've done clinical rotations - I am fully aware of the jokes that are available, and can only imagine what the case is for a new school.

Agree completely.

Half the stuff I get asked is related to ID (the other half is formulary) - that and oncology are the two places that I feel specialty pharmacists may legitimately know more about the drugs and how to use them than their physician counterparts.

 

[Its Z]

Z - we just got old.

"Back in my day, we learned ID in patho, pharmacology, med chem, kinetics, and THEN we did it in therapeutics"

I think we had ID every semester for 3 years...in some form or fashion.

 

[njac]

Agree completely.

Half the stuff I get asked is related to ID (the other half is formulary) - that and oncology are the two places that I feel specialty pharmacists may legitimately know more about the drugs and how to use them than their physician counterparts.

I get asked a lot about electrolyte replacements - and that is something I felt we were very poorly taught in school and on rotations.

 

[Praziquantel86]

I get asked a lot about electrolyte replacements - and that is something I felt we were very poorly taught in school and on rotations.

Good call. I don't know the first thing about that stuff. I'm hoping my transplant rotation will help out with that, but who knows.

 

[Its Z]

I get asked a lot about electrolyte replacements - and that is something I felt we were very poorly taught in school and on rotations.

There's only about 10 electrolytes...how hard is that??

 

[RX CARE]

This just goes back to the difference between academics and real life scenarios. I feel like in academics, a lot of questions are randomly put together and asked just to prove a point. Clearly in this case it was the pregnancy issue and the gram negative bacteria. That's why I hardly try to answer questions based on how realistic they are, but as to what the professor is trying to get at, and I've been quite successful at that. The real skills come on the job IMO.

 

[njac]

Good call. I don't know the first thing about that stuff. I'm hoping my transplant rotation will help out with that, but who knows.

they didn't teach us in school, but an easy one to remember is that 10 mEq of KCl will raise the K+ ~ 0.1 Obviously you want to be on the conservative side for patients with crappy kidneys. You can always give more, but it's not as easy to get it back out!

so if their K+ is 3.4 and you want it >4 because they're on the vent, you would want to give 60 mEq



I've got a cheat sheet I've made for myself, but that's one thing they never handed to us in school!

 

[njac]

There's only about 10 electrolytes...how hard is that??

hush office boy.

you're one of the carpet dwellers now!

(that doesn't work at my current hospital because there is some carpet in the pharmacy, but where I used to work there was carpet in the administrative area and not in the pharmacy itself. Hence administration = carpet dwellers)

 

[Praziquantel86]

they didn't teach us in school, but an easy one to remember is that 10 mEq of KCl will raise the K+ ~ 0.1 Obviously you want to be on the conservative side for patients with crappy kidneys. You can always give more, but it's not as easy to get it back out!

so if their K+ is 3.4 and you want it >4 because they're on the vent, you would want to give 60 mEq



I've got a cheat sheet I've made for myself, but that's one thing they never handed to us in school!

Some handy hints...I'll keep them in mind.

Thanks!

 

[Sparda29]

so the way the program at Touro is set up - the first, and only, time you see ID therapeutics is the very first semester of pharmacy school? 😱

I can't say that I agree with that philosophy. ID is one of the greatest areas where we as pharmacists can make an impact. And to address it at the very beginning and then never again? Of course you'll see it some on rotations, but I've done clinical rotations - I am fully aware of the joke rotations that are available, and can only imagine what the case is for a new school.

What I meant by ID was, the microbiology/antibiotic pharmacology and then after that we just got lectures on the infectious diseases (TB, HIV, Respiratory Tract, Urinary Tract, Skin/Soft Tissue, etc)

Since our class is the 1st class, we are the guinea pigs for the curriculum. The P1 curriculum we got was a bit different than what the 2013 class is getting.