Infectious Disease Question

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soccerfreak

soccerfreak

Cubs 2007.. Please....
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So I was going through my kinetics notes and stumbled upon the following question to which I didn't write down the answer (I was daydreaming I guess) Anyways, what would you do in the following situation.

Sputum culture with P. aeruginosa --------

(WBC >25, epithelial cells <10 per microscopic evaluation)
Clinically, the patient has pneumonia

Drug MIC (mg/L) Interpretation
Piperacillin 128 R
Piperacillin/Tazo 128 R
Ceftazidime 32 R
Cefepime 32 R
Amikacin 32 R
Tobramycin 8 R
Gentamicin 16 R
Cipro 2 R

Which antibiotic would you choose for treatment?
 
soccerfreak said:
So I was going through my kinetics notes and stumbled upon the following question to which I didn't write down the answer (I was daydreaming I guess) Anyways, what would you do in the following situation.

Sputum culture with P. aeruginosa --------

(WBC >25, epithelial cells <10 per microscopic evaluation)
Clinically, the patient has pneumonia

Drug MIC (mg/L) Interpretation
Piperacillin 128 R
Piperacillin/Tazo 128 R
Ceftazidime 32 R
Cefepime 32 R
Amikacin 32 R
Tobramycin 8 R
Gentamicin 16 R
Cipro 2 R

Which antibiotic would you choose for treatment?
Click to expand...

Imipenem?
 
soccerfreak said:
So I was going through my kinetics notes and stumbled upon the following question to which I didn't write down the answer (I was daydreaming I guess) Anyways, what would you do in the following situation.

Sputum culture with P. aeruginosa --------

(WBC >25, epithelial cells <10 per microscopic evaluation)
Clinically, the patient has pneumonia

Drug MIC (mg/L) Interpretation
Piperacillin 128 R
Piperacillin/Tazo 128 R
Ceftazidime 32 R
Cefepime 32 R
Amikacin 32 R
Tobramycin 8 R
Gentamicin 16 R
Cipro 2 R

Which antibiotic would you choose for treatment?
Click to expand...

The patient is screwed unless imipenem, doripenem, or meropenem works.
 
anybody care to summarize for a lowly P2 who hasnt had ID yet?

Are the MIC's greater than toxic levels for the drugs?
 
NormalSaline said:
anybody care to summarize for a lowly P2 who hasnt had ID yet?

Are the MIC's greater than toxic levels for the drugs?
Click to expand...

Given that this was from a kinetics class, I think that might be the question they wanted to ask. See which drug they would push the limit on.

Patient's still **** out of luck, though.
 
ItsOverZyvox said:
The patient is screwed unless imipenem, doripenem, or meropenem works.
Click to expand...

Agreed. Start him on imipenem. Isolate the guy and case report it (contact CDC maybe). For dosing, start low and keep on increasing the dose until you see him seizing. Subtract 500 mg from the dose that you saw him seizing at and keep him on that. You have to kill those bugs or else. Also consider adding Levo for some syngerism.
 
Last edited:
Aznfarmerboi said:
Agreed. Start him on imipenem. Isolate the guy and case report it (contact CDC maybe). For dosing, start low and keep on increasing the dose until you see him seizing. Subtract 500 mg from the dose that you saw him seizing at and keep him on that. You have to kill those bugs or else. Also consider adding Levo for some syngerism.
Click to expand...


Aint you a retail druggist?
 
Aznfarmerboi said:
Agreed. Start him on imipenem. Isolate the guy and case report it (contact CDC maybe). For dosing, start low and keep on increasing the dose until you see him seizing. Subtract 500 mg from the dose that you saw him seizing at and keep him on that. You have to kill those bugs or else. Also consider adding Levo for some syngerism.
Click to expand...

Why start low? I don't think that makes any sense at all, actually.
 
Minimum Inhibitory Concentration (MIC) has little to do with toxic effects of the drug.
 
Priapism - I haven't had a ton of experience using carbapenems. Why did you pick meropenem rather than imi/cil or dori?

I know about the sz risk with imipenem, and dori is new. Anything else?
 
Sparda29 said:
Why isn't aztreonam on the list?
Click to expand...

What does your institution's most recent antibiogram indicate regarding Pseudomonal isolates and sensitivity to aztreonam? Might be an option.
 
njac said:
Priapism - I haven't had a ton of experience using carbapenems. Why did you pick meropenem rather than imi/cil or dori?

I know about the sz risk with imipenem, and dori is new. Anything else?
Click to expand...

Probably institution bias; I think they are all relatively interchangeable outside of access to local microbiological data. Seizure risk and imipenem/cilastatin do not bother me too much.
 
Ok, that's what I figured. Just didn't know if I had a gap there.

Like in an interview where I recommended cefepime for a febrile neutropenia pt and didn't know about the meta-analysis showing increased all cause mortality compared to other beta-lactams. I looked it up when I got home, but it had never come up in class, at work, or on rotations.
 
njac said:
Ok, that's what I figured. Just didn't know if I had a gap there.

Like in an interview where I recommended cefepime for a febrile neutropenia pt and didn't know about the meta-analysis showing increased all cause mortality compared to other beta-lactams. I looked it up when I got home, but it had never come up in class, at work, or on rotations.
Click to expand...

Controversial meta-analysis, still waiting for the next FDA update, 13 months and counting I believe. Cefepime was the work horse at my previous institution, so I may have a bias when it comes to this issue as well.
 
How often do you see aztreonam reported on a c+s? Without specifically requesting it?
 
Sparda29 said:
My institution? I have no idea, but I found this on PubMed about Pseudomonas and Aztreonam.

http://www.ncbi.nlm.nih.gov/pubmed/10802265
Click to expand...

A supplement in a low-level journal? That's what you got? Like I said, aztreonam may be an option, a little over 70% Pseudomonal isolates are susceptible at my institution. Not good enough for empiric coverage in my opinion, but a highly active drug nonetheless. Nothing in that article would alter my opinion of aztreonam.
 
njac said:
How often do you see aztreonam reported on a c+s? Without specifically requesting it?
Click to expand...

It is routine with Pseudomonas (I think), but I typically just track the antibiogram over time.
 
soccerfreak said:
So I was going through my kinetics notes and stumbled upon the following question to which I didn't write down the answer (I was daydreaming I guess) Anyways, what would you do in the following situation.

Sputum culture with P. aeruginosa --------

(WBC >25, epithelial cells <10 per microscopic evaluation)
Clinically, the patient has pneumonia

Drug MIC (mg/L) Interpretation
Piperacillin 128 R
Piperacillin/Tazo 128 R
Ceftazidime 32 R
Cefepime 32 R
Amikacin 32 R
Tobramycin 8 R
Gentamicin 16 R
Cipro 2 R

Which antibiotic would you choose for treatment?
Click to expand...

So what if the breakpoint for cipro was 8mg/L? I know that if it's sensitive then the drug with the greatest breakpoint/MIC ratio exhibits the best effect. Since the bacteria is resistant would it even matter?
 
soccerfreak said:
So what if the breakpoint for cipro was 8mg/L? I know that if it's sensitive then the drug with the greatest breakpoint/MIC ratio exhibits the best effect. Since the bacteria is resistant would it even matter?
Click to expand...

If the breakpoint was 8, would the isolate be resistant to ciprofloxacin? The report would be wrong if that were the case. And, what do you mean "if"? The breakpoints are set, and rarely change.
 
RxWildcat said:
If the infection was resistant to carbapenems would it be reasonable to start inhaled tobramycin?
Click to expand...

Depends. Person is resistant in this case. There are also a lot of COPD patients out there that might have gotten the thing via ventilators. There is also the risk of bronchospasm.
 
Aznfarmerboi said:
Depends. Person is resistant in this case. There are also a lot of COPD patients out there that might have gotten the thing via ventilators. There is also the risk of bronchospasm.
Click to expand...

I thought the TOBI formulation eliminated the additional bronchospasm risk. I'm not too familiar with it, so there's a good chance I'm wrong.
 
Praziquantel86 said:
I thought the TOBI formulation eliminated the additional bronchospasm risk. I'm not too familiar with it, so there's a good chance I'm wrong.
Click to expand...


It's not the formulation per se...rather lack of preservatives. But TOBI is not free of bronchospasm.
 
Praziquantel86 said:
Once daily isn't going to keep the troughs anywhere near where they need to be. Plus, resistance to amikacin seems to eliminate parenteral tobra as an option.
Click to expand...


With Aminoglycoside, you don't want to to keep any troughs... after all, it's the sustained high trough that's nephrotoxic.

Also, AG exhibit PAE.
 
soccerfreak said:
So I was going through my kinetics notes and stumbled upon the following question to which I didn't write down the answer (I was daydreaming I guess) Anyways, what would you do in the following situation.

Sputum culture with P. aeruginosa --------

(WBC >25, epithelial cells <10 per microscopic evaluation)
Clinically, the patient has pneumonia

Drug MIC (mg/L) Interpretation
Piperacillin 128 R
Piperacillin/Tazo 128 R
Ceftazidime 32 R
Cefepime 32 R
Amikacin 32 R
Tobramycin 8 R
Gentamicin 16 R
Cipro 2 R

Which antibiotic would you choose for treatment?
Click to expand...

So I guess this scenario assumes all abx are resistant with no other option. My instructor said that he would most likely maximize the ceftaz to 30g/day. Is this even feasible? He said that we'd prolly get sued but if no other choice then pick ceftaz and hit hard. What do you guys think?
 
soccerfreak said:
So I guess this scenario assumes all abx are resistant with no other option. My instructor said that he would most likely maximize the ceftaz to 30g/day. Is this even feasible? He said that we'd prolly get sued but if no other choice then pick ceftaz and hit hard. What do you guys think?
Click to expand...

Your instructor is an idiot.

As Njac said.. Colistin will work. Also, your instructor should know that Ceftaz is an easy inducer of resistance of Pseudomonas..

Good Lord...what kind instructors are out there teaching our yutes.. 👎
 
ItsOverZyvox said:
Your instructor is an idiot.

As Njac said.. Colistin will work. Also, your instructor should know that Ceftaz is an easy inducer of resistance of Pseudomonas..

Good Lord...what kind instructors are out there teaching our yutes.. 👎
Click to expand...

Told you!! It would be really useful...


Posted via Mobile BlackBerry Device
 
SpirivaSunrise said:
Told you!! It would be really useful...


Posted via Mobile BlackBerry Device
Click to expand...


If I wrote it, it'll have to be a text book like volume.. with pharmacoeconmics consideration on top of the pharmacology, pharmacotherapy, and Pharmacokinetics.

They might as well read DiPiro or Koda-Kimble.
 
1. Cut off the patients distal limbs and try to drain that booger out! (kidding, of course). This patient is screwed. or 2. Possibly consider introducing a bacteria that might be harmful to P. Aeru but is susceptible to the listed agents (that's my House, MD answer), that way once the battle is done you can vanquish the victor-- assuming its the one you introduced. This sounds eerily similar to that south american supermodel case, oh, a month ago. But she succumb to her resistant P. Aeruginosa infection. 🙁

soccerfreak said:
So I was going through my kinetics notes and stumbled upon the following question to which I didn't write down the answer (I was daydreaming I guess) Anyways, what would you do in the following situation.

Sputum culture with P. aeruginosa --------

(WBC >25, epithelial cells <10 per microscopic evaluation)
Clinically, the patient has pneumonia

Drug MIC (mg/L) Interpretation
Piperacillin 128 R
Piperacillin/Tazo 128 R
Ceftazidime 32 R
Cefepime 32 R
Amikacin 32 R
Tobramycin 8 R
Gentamicin 16 R
Cipro 2 R

Which antibiotic would you choose for treatment?
Click to expand...
 
themorphinerule said:
1. Cut off the patients distal limbs and try to drain that booger out! (kidding, of course). This patient is screwed. or 2. Possibly consider introducing a bacteria that might be harmful to P. Aeru but is susceptible to the listed agents (that's my House, MD answer), that way once the battle is done you can vanquish the victor-- assuming its the one you introduced. This sounds eerily similar to that south american supermodel case, oh, a month ago. But she succumb to her resistant P. Aeruginosa infection. 🙁
Click to expand...


Colistin !!!!
 
ItsOverZyvox said:
If I wrote it, it'll have to be a text book like volume.. with pharmacoeconmics consideration on top of the pharmacology, pharmacotherapy, and Pharmacokinetics.

They might as well read DiPiro or Koda-Kimble.
Click to expand...

So do it already!

Mmmm...DiPiro & KK don't have the unique spin you'd put on it.

Seriously though, there's no reason you can't start small, and work up.
 
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