Vre uti

[njac]

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Hey kids (I can say that now! and I'm being nice - I call my students "minions" - thankfully the two I have this month have a good sense of humor)

I was doing culture reviews this am, HIV+ HepC+ noncompliant pt who was in for a headache. Of course they did a urine culture, and we grew E. faecium resistant to vanco, FQ and tetracyclines. Susceptible to Synercid, linezolid, and nitrofurantoin. Called the lab for the MIC for ampicillin, resistant >8 (lots of help, I know).

I was thinking Fosfomycin, but I don't know if that is covered on public aid here, I didn't see it on the preferred drug formulary. In all honesty, this is an exercise in futility, the patient doesn't ever pick up any of her meds. But now I am on a mission to find data for oral monotherapy for high-dose ampicillin or amoxicillin. Anyone know of anything?

 

[WVUPharm2007]

Hey kids (I can say that now! and I'm being nice - I call my students "minions" - thankfully the two I have this month have a good sense of humor)

I was doing culture reviews this am, HIV+ HepC+ noncompliant pt who was in for a headache. Of course they did a urine culture, and we grew E. faecium resistant to vanco, FQ and tetracyclines. Susceptible to Synercid, linezolid, and nitrofurantoin. Called the lab for the MIC for ampicillin, resistant >8 (lots of help, I know).

I was thinking Fosfomycin, but I don't know if that is covered on public aid here, I didn't see it on the preferred drug formulary. In all honesty, this is an exercise in futility, the patient doesn't ever pick up any of her meds. But now I am on a mission to find data for oral monotherapy for high-dose ampicillin or amoxicillin. Anyone know of anything?

No idea...but make your students do it.

 

[Its Z]

If it is UTI VRE susceptible to Nitrofurantoin, what's wrong with Macrobid..... CrCL too low?

 

[Its Z]

And what is the typical urine/blood concentration ratio for renally cleared drugs? 25:1?

Can Karm interject here?

 

[njac]

oh yeah, forgot that CrCl ~44mL/min. So depending where you look - most places, nitrofurantoin is CI.

 

[PharmaTope]

medicaid will most likely cover zyvox. they cover everything.

 

[Its Z]

oh yeah, forgot that CrCl ~44mL/min. So depending where you look - most places, nitrofurantoin is CI.

Well... thanks for nothing!!!

 

[njac]

No idea...but make your students do it.

the minions were helping. We're finding tons for endocarditis and added to AGs, but nothing published for high-dose oral amino penicillin for VRE UTI even though we know everyone does it.

 

[Its Z]

medicaid will most likely cover zyvox. they cover everything.

If inpatient, it's a moot point. For outpatient, pfizer has an indigent program for Zyvox.

 

[njac]

medicaid will most likely cover zyvox. they cover everything.

do we want to give zyvox to someone who, if she picks it up, won't take them all?

 

[njac]

If inpatient, it's a moot point. For outpatient, pfizer has an indigent program for Zyvox.

it's outpt.

Think about where I work now, and that I'm doing culture review. This is also hinging on the idea that I can get a hold of her...

 

[Its Z]

do we want to give zyvox to someone who, if she picks it up, won't take them all?

What makes you think she'll take anything she gets? But at least if Zyvox is recommended, you know if she takes it, it will work. But the question will always remain if high dose amp fails or not.

Do the right thing and treat the patient best you can. Remember, this pt has potential to become very immunocompromised.

 

[njac]

where are the minions?!?!?! I don't want to hear from the grown ups!

 

[Its Z]

where are the minions?!?!?! I don't want to hear from the grown ups!

aight! I take back everything I said!!! 😡

 

[rph3664]

I was initially going to suggest checking for ceftriaxone sensitivity, but chances are, fosfomycin's gonna work and the patient won't be sore afterwards.

http://jac.oxfordjournals.org/cgi/content/full/43/1/137?ck=nck

 

[Its Z]

I was initially going to suggest checking for ceftriaxone sensitivity, but chances are, fosfomycin's gonna work and the patient won't be sore afterwards.

http://jac.oxfordjournals.org/cgi/content/full/43/1/137?ck=nck

Well, you can't contribute cuz you aint a minion... but that article is questionable since the topic of VRE has taken a turn for the worse in last half decade...that study is 11 years old and as predicted, it states MIC for faecium is higher.. Ceftriaxone certainly won't hit VRE.. not so certain about fosfomycin.

 

[KARM12]

Linezolid....but I would want to know more about her symptoms/CD4 count/VL, etc. You may be able to argue that she does not need treatment if she is asymptomatic and her CD4 count is good.

There is one small study that found no association between asymptomatic bacteriuria and CD4 count in women.

 

[KARM12]

I also wanted to add, you won't find much for high dose oral amp...most patients can't tolerate those doses PO.... I wouldn't use amox.

 

[PharmaTope]

do we want to give zyvox to someone who, if she picks it up, won't take them all?

well if she wont take it, that's her problem. enough of this hand holding in america. women has aids and prob doesnt take hiv medication. at what point do you say, this is the recommendation, take it or leave it.

hep c+ hiv + history of noncompliance..... she a lost cause. she is about to Darwin herself.

 

[rph3664]

I'd go with the Monurol. Are you folks aware that Zyvox is something like $50 a dose - and that's for the oral form? I was shocked to find that out. I'd heard it was expensive but ZOMG I was thinking along the lines of $10 a dose.

OT: I was working in retail when Zyvox came out, and our store's assistant manager stopped by and said, "Hey, I heard there's a new antibiotic coming out. Are we going to stock it?" We told him that this sounded like something we probably wouldn't stock unless we special-ordered it. I left it in 2003 and never saw an RX for it there, and its use was strongly discouraged at the hospital.

 

[ethyl]

I vote for letting the asymptomatic pt keep on trucking with their poor compliance and not treat. Next time they land themselves a free room at the nearby hospital, they can take care of the VRE and everything else (hopefully not fullblown AIDS).

 

[Its Z]

Zyvox oral tablet is $74.31 per dose. Almost $150 per day. And that's cost.

 

[Its Z]

I'd go with the Monurol.

It would be a good choice if susceptible.

 

[njac]

CD4 127, untreated as far as we can tell. Apparently goes to hospitals in a couple states. Even with mild symptoms, I would want to treat it in an AIDS patient. But I guess this begins the jadedness.

 

[PumpkinSmasher]

Monurol always makes me think of the Simpsons "Monorail" episode...

[YOUTUBE]http://www.youtube.com/watch?v=qp8hUmJlUho[/YOUTUBE]

 

[aboveliquidice]

CD4 127, untreated as far as we can tell. Apparently goes to hospitals in a couple states. Even with mild symptoms, I would want to treat it in an AIDS patient. But I guess this begins the jadedness.

Monurol runs for a 3 day treatment... how long is zyvox for VRE UTI? Also with the CRCL, you'll have a build up of both linezolid metabolites - increasing possibility of dyscrasias (2%???)...

 

[PharmaTope]

Monurol runs for a 3 day treatment... how long is zyvox for VRE UTI? Also with the CRCL, you'll have a build up of both linezolid metabolites - increasing possibility of dyscrasias (2%???)...

Dosing: Renal Impairment
No adjustment is recommended. The two primary metabolites may accumulate in patients with renal impairment but the clinical significance is unknown. Weigh the risk of accumulation of metabolites versus the benefit of therapy. Monitor for hematopoietic (eg, anemia, leukopenia, thrombocytopenia) and neuropathic (eg, peripheral neuropathy) adverse events when administering for extended periods.

 

[aboveliquidice]

Dosing: Renal Impairment
No adjustment is recommended. The two primary metabolites may accumulate in patients with renal impairment but the clinical significance is unknown. Weigh the risk of accumulation of metabolites versus the benefit of therapy. Monitor for hematopoietic (eg, anemia, leukopenia, thrombocytopenia) and neuropathic (eg, peripheral neuropathy) adverse events when administering for extended periods.

Yeah - 2% is reported with zyvox across the board... Regardless of renal status.

 

[npage148]

Don't be a puss and use chloramphenicol.

 

[Praziquantel86]

I remember seeing data for one-time dapto at 200mg fixed dose...letter to the editor somewhere. Seemed to work pretty well, and might be an option for a non-compliant outpatient.