Two random questions

[ItsOverZyvox]

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exactly. So cefotaxime + flagyl is an option as well, and while the flagyl is q6h it's nice that ceftriaxone is q24h. The less frequent the dosing (hopefully) the fewer doses to be missed...

ahhhh...I love you... Cefotaxime and flagyl...we sued to mix them together and call it Clafgyl. We can do Rocephin + Flagyl also..much cheaper..

But consider this... if you miss a dose for a drug given 4 times a day..no big deal. But if you miss a drug that's given once a day...it's a big deal. So once a day drug doesn't alway mean it's better because of a less chance of missing a dose... Think about it.

 

[ItsOverZyvox]

How is Cefotaxime's anaerobe coverage?

Zosyn is an option but cheaper is either Cipro/Flagyl or Ceftriaxone/Flagyl. Those are the two I see the most empirically.

My understanding is that Cefotetan and Cefoxitin have unreliable availability but are also have shorter half lives and require more frequent dosing.

Another great response!!! Ok...cefotetan and cefoxitin supply is reliable... so don't worry about it.

Cipro 400mg bag is now $1.98.... Ceftriaxone 1gram can be had for less than $3. Zosyn 3.375gram is around $15...multiply by 4...it's $60 per day.

Though..we have generic Zosyn getting ready to launch very soon.

 

[ItsOverZyvox]

0 bacteroides, 0 clostridium...it's for peritoneal infections without perforation...oops

You need to add Flagyl...the gold standard for anaerobes.
things get screwey when enterococcus and pseudomonas come into play with intra-ab infection though.

 

[Moxxie]

You need to add Flagyl...the gold standard for anaerobes.
things get screwey when enterococcus and pseudomonas come into play with intra-ab infection though.

So am I correct in thinking that flagyl has no activity against aerobic gram (+)/gram (-)? What about the enterobactericiae (facultative anaerobes?) I'm going off of my notes and the Sanford guide, but I don't see why flagyl wouldn't work in some of the g (-) GI bugs.

Edit: Nevermind, I think that I figured it out. O2 is a better substrate than metronidazole for reduction, so the flagyl wouldn't really be active if there was any amount of O2 in the environment.

 

[ItsOverZyvox]

So am I correct in thinking that flagyl has no activity against aerobic gram (+)/gram (-)? What about the enterobactericiae (facultative anaerobes?) I'm going off of my notes and the Sanford guide, but I don't see why flagyl wouldn't work in some of the g (-) GI bugs.

Edit: Nevermind, I think that I figured it out. O2 is a better substrate than metronidazole for reduction, so the flagyl wouldn't really be active if there was any amount of O2 in the environment.

Alrighty then!

 

[Moxxie]

Alrighty then!

But am I right? Our ID prof is a little looney at times (he constantly refers to "the voices" that tell him what to lecture on), so I wasn't sure.

 

[ItsOverZyvox]

enterobacter is not the only facultative anaerobe... staph and e.coli can be also. Hence, we consider enterobacter species as aerobes and don't use flagyl to to treat them. Flagyl is an anaerobic drug.... and anti-protozoan.

Why you asking these stuff...I'm not a clinician!

 

[njac]

ahhhh...I love you... Cefotaxime and flagyl...we sued to mix them together and call it Clafgyl. We can do Rocephin + Flagyl also..much cheaper..

But consider this... if you miss a dose for a drug given 4 times a day..no big deal. But if you miss a drug that's given once a day...it's a big deal. So once a day drug doesn't alway mean it's better because of a less chance of missing a dose... Think about it.

you need another ID pharmacist anytime soon?

But there's more leeway with a Q24H drug - if it's given 2 hours late it isn't the end of the world - especially with cephalosporins. Even with Q6H it isn't terrible if timing gets fudged up a bit but sometimes then the nurses want to reschedule all future doses and it becomes ridiculous.

 

[WVUPharm2007]

WVU may not need them but the rest of the world does. I hope they try to explain the nephrotoxicity issue further.

They'll say that in and of itself, Vanc isn't as bad as it used to be thanks to manufacturing improvements. It might potentiate the nephrotoxicity of other drugs like gent, tob, and ampho.

And that increasing interval increases trough.

Um.....

And that we really do not give a flying kite about the peak.

I'm pretty sure everyone has come to this conclusion. Hence all monitoring adjustments are always based upon trough/infection/MIC. Do you know someone who actually bases adjustments off of peak?

 

[njac]

They'll say that in and of itself, Vanc isn't as bad as it used to be thanks to manufacturing improvements. It might potentiate the nephrotoxicity of other drugs like gent, tob, and ampho.




Um.....



I'm pretty sure everyone has come to this conclusion. Hence all monitoring adjustments are always based upon trough/infection/MIC. Do you know someone who actually bases adjustments off of peak?

I've run into lots of nurses who think they should pull peaks and younger docs who want to as well. An ID doc on my last rotation was convinced that vanco eats kidneys for breakfast and wanted troughs of like 10. I agree that it can potentiate nephrotoxicity of other medications, but used alone is not likely to be nephrotoxic.

And by increasing interval I meant increasing frequency... Giving it more often increases the trough while giving higher doses increases the peak. Hence the ridiculousness of the 1750mg Q12H on our pre-digested (aka transfer) patient.

 

[ItsOverZyvox]

you need another ID pharmacist anytime soon?

Well, maybe. You just never know. But to manage antimicrobial stewardship at a larger institution, we would expect a PGY1 and 2. If you're willing to locate to a smaller facility as a do it all clinician, you could do that without a residency.

But there's more leeway with a Q24H drug - if it's given 2 hours late it isn't the end of the world - especially with cephalosporins. Even with Q6H it isn't terrible if timing gets fudged up a bit but sometimes then the nurses want to reschedule all future doses and it becomes ridiculous.

Ahhh...youngin. You'll come across drug reps marketing their drugs being much better than your tried and true generics..and the argument they'll use to get a buyin from physicians and nursing is "once daily" factor and how your generic drug requires q6h dosing...which means more chance of missing dose + increased cost of nursing.

Then you'll look back and say... "hmmmm...well, what happens if we miss your once daily dose and patient goes without the drug for 48 hours... and also, do we pay nurses more money when they hang a drug once vs 4 times a day???? They're sitting on their butt munching on donuts you brought...it would help them to get up and do some work!"

 

[ItsOverZyvox]

Don't buy into the hype of "we don't need no peak." Getting the peak once in a while will allow you to predict the trough more accurately and also calculate Ke and t1/2. Also, have you forgotten about ototoxicity? At what level does that occur? And if you're soley worried about trough and not look at the peak... who's liable when patient comes back deaf?

I personally know a physician who got sued and lost due to ototoxicity from Vancomycin.

I know...I'm one of the few who preach "get the peak also" but at the same time, I'm not going to join the hype of your typical clinician who are myopic. See what everyone does...then go the other way.

 

[ItsOverZyvox]

That's what I said. Oh well. I'm trying not to ruffle too many feathers my first few months there. We still are capping Lovenox at 150mg, too...despite the fact that I provided a copy of what the latest ASHP position paper said...which was do anti-Xa labs in those > 190kg...and if that's not available, give it to 'em anyway until they bruise...I kinda got the brush off. I didn't push it any further. It's really inconsequential...until someone gets HIT and sues us for not using a LMWH...

It's a weird place...I think the hospitalists there respect me more than the other pharmacists there do. Perhaps because I'm the first new grad they've had there in 10+ years and they associate new grad with "no idea what he's doing" because back in their day they really didn't.

wooo...didn't read this.

Well, here the deal. You can use 0.9L which will exaggerate the VD which will calculate out higher dosing regimen... and this..probably inaccuarte will still result in better levels... What mg/kg are you guys using? I recommend 20 to 25mg/kg...but if you're using 0.9L..you could get away with 15 to 20mg/kg.

HIT is whole another topic...