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psurocks

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this is just a disgrace....at this hospital, e coli is more resistant to cipro when compared to Ancef....and now, in the last 6 weeks, all the zosyn sensitivities are coming back with a MIC of <16 (this is due to the MDs writing for zosyn like its free candy)


does anyone have any ideas how we can address this? 2 of our big guns are becoming more vulnerable, and its really scary
 
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Priapism321

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this is just a disgrace....at this hospital, e coli is more resistant to cipro when compared to Ancef....and now, in the last 6 weeks, all the zosyn sensitivities are coming back with a MIC of <16 (this is due to the MDs writing for zosyn like its free candy)


does anyone have any ideas how we can address this? 2 of our big guns are becoming more vulnerable, and its really scary

When you make this statement, I am uncertain you fully understand exactly what you are trying to say (if that makes sense). First, you may be confusing the concepts of susceptibility breakpoints with minimum inhibitory concentrations. If the MIC of piperacillin/tazobactam was <16 mcg/mL for a Pseudomonas isolate, this would be a good thing, and indicate the bacteria was sensitive to the medication. When you comment on all of the "sensitivities are coming back with a MIC of <16," the information really means nothing unless you give us a corresponding pathogen.

There has been controversy over the past couple years regarding the appropriateness of the CLSI breakpoint for piperacillin/tazobactam against, in particular, Pseudomonas isolates. Some clinicians feel a susceptibility breakpoint of 64 mcg/mL (which it officially is/was) is too high, and a group of pharmacists from Houston published a paper suggesting a higher rate of mortality in bacteremic patients who's Pseudomonas isolate had an MIC of 32 or 64 (retrospective analysis, compared to the patients with Pseudomonas blood stream isolates with MIC's of <32 mcg/mL).

This paper was published in CID, and caused some to believe this may lead to an official revision of the breakpoints by the CLSI (which is rare, but the last two revisions were recent and notable, for vancomycin and ceftriaxone). Your hospital's microbiology director may have decided, based on the available evidence, to revise the breakpoints him/herself, in an effort to prevent the prescribing of piperacillin/tazobactam when there may indeed be reduced susceptibility. So in reality, to answer your question regarding how to address the overprescribing of a broad spectrum agent, revising the breakpoints to make therapeutic expectations more "reasonable" (ie, if the MIC is >16, piperacillin/tazobactam will no longer be listed as "sensitive") will actually help with the issue, and may be in the best interest of the patients with Pseudomonal bacteremia.
 

psurocks

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when i started here, sensitivies of most bugs use to come in at < 4 or so.....then we saw it to trend up to <8 and now for different bugs it consistently is coming at <16

and this is peak COPD exacebration season, which the PCP diagnose as pnemonia and throw on zosyn and never streamline down

(and dont let me tell you about our C diff rates, which are way out the roof, and have increased each month of this year)
 

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Your microbiology reference lab could have simply changed the MIC susceptibility breakpoints 6 weeks ago.

Bugs don't suddenly become resistant over 6 weeks. Otherwise, you got an epidemic ...better call the CDC.

And again...Ancef over Cipro for ecoli is no big deal.
 
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psurocks

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i checked a proteus report today, and it showed zosyn to be < 16

we went back on a few from 2 months ago, t hey were at <4


again, small sample size but its telling enough for me


nothing in micro lab has changed reporting wise
 
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i checked a proteus report today, and it showed zosyn to be < 16

we went back on a few from 2 months ago, t hey were at <4


again, small sample size but its telling enough for me


nothing in micro lab has changed reporting wise

Hmmm, you really want to go with induced resistance after only 2 months?

Take a look at the rest of a C&S report...is Pip/Tazo the only one with a noticeable change? If so, what does/doesn't this tell you?
 

psurocks

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Hmmm, you really want to go with induced resistance after only 2 months?

Take a look at the rest of the C&S report...is Pip/Tazo the only one with a noticeable change? If so, what does/doesn't this tell you?

well yea, simply b.c its used like water at the hospital...every copd exacebration (And the fall months are peak for that) get dx as pnemonia, and they all get zosyn, and then mds dont streamline down....even after sensitivities come back, (say its sensitive to zosyn and rocephin), they wont streamline down...

we are trying to devise a research method that would best help us analyse this, but there are a lot of factors to look at
 

Priapism321

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well yea, simply b.c its used like water at the hospital...every copd exacebration (And the fall months are peak for that) get dx as pnemonia, and they all get zosyn, and then mds dont streamline down....even after sensitivities come back, (say its sensitive to zosyn and rocephin), they wont streamline down...

we are trying to devise a research method that would best help us analyse this, but there are a lot of factors to look at

Sounds like a hospital with a weak Division of Pharmacy
 
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Priapism321

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nope, we can only make recommendations, which we do

the md dont make any changes, we cant help it, pharmacy doesnt write orders

You make my point. Where I come from, MD/DO/Midlevel/Janitor/Intern writes for piperacillin/tazobactam, they don't get it unless the ID PharmD or an ID Physician says yes.
 

psurocks

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You make my point. Where I come from, MD/DO/Midlevel/Janitor/Intern writes for piperacillin/tazobactam, they don't get it unless the ID PharmD or an ID Physician says yes.

well maybe its just the way it came off...the clinical guys repeatedly plead to get zosyns change but cant, they really try every day, i can vouch for them

i think we have to make it restricted, which requires ID consult....but even the ID docs have their own agenda too (ie, they hardly go against other mds cuz they dont want to lose future consults (this is from what I have seen, btw))
 

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i checked a proteus report today, and it showed zosyn to be < 16

we went back on a few from 2 months ago, t hey were at <4


again, small sample size but its telling enough for me


nothing in micro lab has changed reporting wise

Proteus?? Man, you can spit on it to kill that bug...

cephalosporin will do just fine for Proteus.
 

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You make my point. Where I come from, MD/DO/Midlevel/Janitor/Intern writes for piperacillin/tazobactam, they don't get it unless the ID PharmD or an ID Physician says yes.

really? I haven't been anywhere yet where Zosyn is on ID restriction. I don't necessarily think it's a bad idea, but I haven't seen that in practice at all.
 

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really? I haven't been anywhere yet where Zosyn is on ID restriction. I don't necessarily think it's a bad idea, but I haven't seen that in practice at all.


You're showing your age.. Oh wait, I'm showing my age. When Zosyn first came out, it was heavily restricted...heck Rocephin used to be restricted.
 

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thats the point....such a big gun like zosyn shouldnt have trouble with it


Sigh.. why do I bother with this...

OK, what abx is recommended for CAP with Ps A risk, HAP, and VAP??
Should those patients be treated empirically or wait until culture comes back positive? What say you?
 

Priapism321

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really? I haven't been anywhere yet where Zosyn is on ID restriction. I don't necessarily think it's a bad idea, but I haven't seen that in practice at all.

You speak like you have a vast amount of experience, though you are listed as a student (and believe me, I don't have much experience, and will admit it in most instances). Potentially contradictory. You don't "necessarily" think piperacillin/tazobactam should be restricted. Why not? Has it been proven to be more effective empirically than a 4th generation cephalopsorin? And, I don't want to hear about Pseudomonas "always" being sensitive to piperacillin/tazobactam, please refer to my earlier posts about the well over-stretched susceptibility breakpoints.
 

Priapism321

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You're showing your age.. Oh wait, I'm showing my age. When Zosyn first came out, it was heavily restricted...heck Rocephin used to be restricted.

Piperacillin/tazobactam still restricted where I come from; not sure it offers any benefit over cheaper empirically employed anti-pseudomonal agents.
 
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ItsOverZyvox

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Piperacillin/tazobactam still restricted where I come from; not sure it offers any benefit over cheaper empirically employed anti-pseudomonal agents.

Well grasshopper... in Academic settings with ID Fellows and ID pharmacist on call 24/7, I would restrict ampicillin.

In a community setting (large or not) without ID fellowship or medical residency, ID is handled by private ID physicians on referral basis. It's virtually impossible to implement antibiotic restrition/approval program.
We can however restrict certain Abx to ID only.
 

njac

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You speak like you have a vast amount of experience, though you are listed as a student (and believe me, I don't have much experience, and will admit it in most instances). Potentially contradictory. You don't "necessarily" think piperacillin/tazobactam should be restricted. Why not? Has it been proven to be more effective empirically than a 4th generation cephalopsorin? And, I don't want to hear about Pseudomonas "always" being sensitive to piperacillin/tazobactam, please refer to my earlier posts about the well over-stretched susceptibility breakpoints.

no, I said that I don't "necessarily" think it's a bad idea to restrict pip/tazo. It's been overused in the 6 hospitals I've rotated through, in the southwest and the midatlantic USA. I commented that I have not seen it restricted at any of these places.

Simmer down.
 

Priapism321

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no, I said that I don't "necessarily" think it's a bad idea to restrict pip/tazo. It's been overused in the 6 hospitals I've rotated through, in the southwest and the midatlantic USA. I commented that I have not seen it restricted at any of these places.

Simmer down.

So, you may be old. I only wanted you to clarify what you mean when you say that you don ot necessarily think it is a bad idea to restrict the drug. I think it should be a no-brainer, unless you can provide evidence to the contrary.

I will now simmer young one.
 
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well yea, simply b.c its used like water at the hospital...every copd exacebration (And the fall months are peak for that) get dx as pnemonia, and they all get zosyn, and then mds dont streamline down....even after sensitivities come back, (say its sensitive to zosyn and rocephin), they wont streamline down...

we are trying to devise a research method that would best help us analyse this, but there are a lot of factors to look at

I'm still confused though. You're concerned about Zosyn resistance based on proteus sensitivity? Have you noticed the pseudomonas sensitivity change drastically? And are they combining with Cipro or Levofloxacin for empiric and then just not adjusting?
 

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Hey rep, where is Lady Lake? Oh...I have the 100-400 in my gold box.. not sure I'll pull the trigger or not..
 
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Hey rep, where is Lady Lake? Oh...I have the 100-400 in my gold box.. not sure I'll pull the trigger or not..

Lady Lake? As in near The Villages where all of my Dad's buddies retire and go to golf heaven? That's closer to Pri's home turf! I'm from SoFla where the youngins live.

I've got junk in my gold box today...like battery grip, which I'm not interested in. 100-400? You ever get the 2x extender? I got the 1.4...works nice!
 

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Lady Lake? As in near The Villages where all of my Dad's buddies retire and go to golf heaven? That's closer to Pri's home turf! I'm from SoFla where the youngins live.

I've got junk in my gold box today...like battery grip, which I'm not interested in. 100-400? You ever get the 2x extender? I got the 1.4...works nice!

2X is useless, so I read.

Chit.. The villages is near Lady Lake?? I'll be there for 2 days before ASHP..

200mm doesn't give me enough reach.. and I'll primarily use 100-400 on the crop body..and outdoors.
 
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2X is useless, so I read.

Chit.. The villages is near Lady Lake?? I'll be there for 2 days before ASHP..

200mm doesn't give me enough reach.. and I'll primarily use 100-400 on the crop body..and outdoors.

I think it's near the villages...you going to golf? (Do I even need to ask...)

Really? You'd use the 100-400 on the crop? I've actually been leaning more towards the 400 prime for that distance. With the 70-200, I don't really need the overlap.
 

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I think it's near the villages...you going to golf? (Do I even need to ask...)

Really? You'd use the 100-400 on the crop? I've actually been leaning more towards the 400 prime for that distance. With the 70-200, I don't really need the overlap.

What are you going to do...carry the 70-200 and 400mm prime and swap the lens out back and forth??? what if you need something between 300 and 400? I just feel like 400 prime won't be flexibile enough... unless I'm trying to do sports photography in low light with f2.8, I would stick with 100mm - 400mm. Isn't 400mm f2.8 like over $5,000?

That's a lot of weight!

Of course I would use it on the crop.. imagine the reach.
 

psurocks

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I'm still confused though. You're concerned about Zosyn resistance based on proteus sensitivity? Have you noticed the pseudomonas sensitivity change drastically? And are they combining with Cipro or Levofloxacin for empiric and then just not adjusting?

sensitivities to various bugs have become from <4 or < 8 to now consistently coming back < 16.

and yes, the mds for any condition throw on the broad spectrum ABs, and never stream line down
 
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psurocks

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Sigh.. why do I bother with this...

OK, what abx is recommended for CAP with Ps A risk, HAP, and VAP??
Should those patients be treated empirically or wait until culture comes back positive? What say you?

i know what the HAP and VAP txs are, we dont see much of those....we have a lot of COPD exacebrations in our area that get dx with CAP and zosyn gets thrown on and never streamlined down, tats the problem
 

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Ok, then what do you treat COPD ex and CAP for those patients coming in from nursing homes.. and I bet you have some of those patients.
 
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What are you going to do...carry the 70-200 and 400mm prime and swap the lens out back and forth??? what if you need something between 300 and 400? I just feel like 400 prime won't be flexibile enough... unless I'm trying to do sports photography in low light with f2.8, I would stick with 100mm - 400mm. Isn't 400mm f2.8 like over $5,000?

That's a lot of weight!

Of course I would use it on the crop.. imagine the reach.

No, you're right. I think I was just arguing with you for argument's sake. And I'm coming from a time when primes are tack sharp, and zoom telephotos are just, ehhhh. But that's not the case any more and the 100-400 would be far more convenient. For now, I'm getting enough reach with the 70-200 and 1.4x combo. Next May, I'll probably look at the 100-400 in Japan. Heck, I may even just leave the 70-200 home since I've got the 85 f/1.8 (another sweet one).

How's an ultra-wide look on the FF??? :love:
 
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I can always add or take vignette out with photoshop... My middle school buddy who I intruduced photography to whe we were kids went to http://www.brooks.edu/ to study photography... I should look him up..

It would been a fun profession.

Cool! I know someone that went there too.

You should look him up; who knows...you may be in the intro to one of his books, thanking zpacksux for introducing him to his passion. :p

Your guy FreddyCr hasn't been showing too many location shots lately. I'm loving M Powered & Kagemaru's work.
 

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Cool! I know someone that went there too.

You should look him up; who knows...you may be in the intro to one of his books, thanking zpacksux for introducing him to his passion. :p

Your guy FreddyCr hasn't been showing too many location shots lately. I'm loving M Powered & Kagemaru's work.

Those guys are good... but this guy is much better..check ur pm.
 

Priapism321

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Alright guys, enough of this. My cellular telephone camera has 2 megapixels with an optional flash.
 

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Nice...love the natural lighting, and not overly processed. The fireplace shot is stunning...and "Solar Bath". Actually, they all are.

Look at the 2006 album, 2nd row from the bottom, 3rd picture to the right...that's my favorite pose. Genius!
 
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Look at the 2006 album, 2nd row from the bottom, 3rd picture to the right...that's my favorite pose. Genius!

The one in the field? Looks like she may be pregnant...wow it's a beautiful shot.

Wait...you mean the red one with boots? Oooh...that one's too cool too.

Hard to pick a fave on this site.
 
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