Why would this patient need Zyvox?

[pharaday]

The mother of an 8 year old boy came into the pharmacy tonight with a prescription for Zyvox suspension. The child only had prescription coverage from an out-of-state Medicaid plan, so would have to pay cash. The medication was not in stock, and even if it was, the family could not afford it. I asked the doctor about switching, and he said no. The patient MUST have Zyvox. When I explained that they couldn't afford it, he still refused to change it. The mother left in tears with nothing. She said the child had been stung by a hornet near his wrist, and that his arm had swollen up to his shoulder. Would the doctor be thinking MRSA? Mother had no idea. And if it was MRSA, couldn't he have been given Bactrim instead? I read that Bactrim may not be as effective for MRSA in children, but certainly better than leaving the pharmacy empty handed, right? Or maybe it wasn't even really an infection at all?

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[Sparda29]

The mother of an 8 year old boy came into the pharmacy tonight with a prescription for Zyvox suspension. The child only had prescription coverage from an out-of-state Medicaid plan, so would have to pay cash. The medication was not in stock, and even if it was, the family could not afford it. I asked the doctor about switching, and he said no. The patient MUST have Zyvox. When I explained that they couldn't afford it, he still refused to change it. The mother left in tears with nothing. She said the child had been stung by a hornet near his wrist, and that his arm had swollen up to his shoulder. Would the doctor be thinking MRSA? Mother had no idea. And if it was MRSA, couldn't he have been given Bactrim instead? I read that Bactrim may not be as effective for MRSA in children, but certainly better than leaving the pharmacy empty handed, right? Or maybe it wasn't even really an infection at all?

If it's MRSA, it would probably be cheaper for her to take the kid to ER where they can re-evaluate, check if it's really MRSA, and then go with IV vanco.

 

[pharaday]

If it's MRSA, it would probably be cheaper for her to take the kid to ER where they can re-evaluate, check if it's really MRSA, and then go with IV vanco.

I did suggest that she go to the ER if things worsened. The child had been treated with something in the hospital, but the mother didn't know what it was. I wondered if maybe it was Vanco.

 

[WVUPharm2007]

Perhaps the hornet was in a LTC facility and had a foley catheter in its stinger.

...

We'd need more info...

 

[johnep34]

In the Uk would probably be treated locally with Fucibet (fusidic acid/betamethasone) cream. If allergic reaction, then adrenaline via an Epipen.
Cost would be free under NHS.
johnep

 

[group_theory]

The mother of an 8 year old boy came into the pharmacy tonight with a prescription for Zyvox suspension. The child only had prescription coverage from an out-of-state Medicaid plan, so would have to pay cash. The medication was not in stock, and even if it was, the family could not afford it. I asked the doctor about switching, and he said no. The patient MUST have Zyvox. When I explained that they couldn't afford it, he still refused to change it. The mother left in tears with nothing. She said the child had been stung by a hornet near his wrist, and that his arm had swollen up to his shoulder. Would the doctor be thinking MRSA? Mother had no idea. And if it was MRSA, couldn't he have been given Bactrim instead? I read that Bactrim may not be as effective for MRSA in children, but certainly better than leaving the pharmacy empty handed, right? Or maybe it wasn't even really an infection at all?

In this situation, I would not use Bactrim. I would have admitted the kid, started broad spectrum IV antibiotics (including vanc) pending culture/sensitivity, with low threshold for surgical consult. Given the extent of his infection, I would be hesitant to use oral bactrim or oral clinda unless the infection responded well to several doses of IV antibiotics and I know exactly what I'm treating and the sensitivities of what I'm treating.

For patients whom I'm discharging home with Linezolid, I usually make sure care coordinator and social workers work with the patient and obtain prior authorization from whatever insurance company they have prior to discharge. If no prior auth, then I don't discharge and keep the patient for the full length of treatment.

For those who think it's just an allergic reaction - are you willing to gamble with this child's arm and life (and your checkbook) with that diagnosis?

 

[Its Z]

Zyvox for hornet's sting? WTF.

There are 2 types of MRSA... Community Acquired MRSA and Nosocomial MRSA and they are different strains.

For CA-MRSA, Zyvox is not necessary except it's available in PO form...then again so are other non-beta lactam abx...except this being a kid.. quinolone is not recommended. And it being a nosocomial MRSA is highly unlikely and it's highly unlikely it's VRE.

Freaking Zyvox is no more effective than Vanco for nosocomial MRSA... another large meta-analysis published last week...I bet Pfizer isn't too happy.



The bottom line is do we know that the swelling is from an infection or and inflammatory response from the venom...or both?

Kid needs to be admitted for further test and treated properly.

 

[pharaday]

Perhaps the hornet was in a LTC facility and had a foley catheter in its stinger.

Ha! I love it. 😀

Seems like they should have kept this kid in the hospital until arrangements were made for medication that they could realistically afford. I couldn't see how this could be a nosocomial infection, although I certainly don't know all the details. Just seemed like there had to be other options here.

 

[Quiksilver]

Why this kid was sent home is beyond me. I would have wanted answers. Any steroid or diphenhydramine given?

 

[ucrx]

For patients whom I'm discharging home with Linezolid, I usually make sure care coordinator and social workers work with the patient and obtain prior authorization from whatever insurance company they have prior to discharge. If no prior auth, then I don't discharge and keep the patient for the full length of treatment.

For those who think it's just an allergic reaction - are you willing to gamble with this child's arm and life (and your checkbook) with that diagnosis?

Sounds like poor discharge planning. Nobody should be discharged with a prescription for an expensive medication without making sure that it is covered and in stock somewhere. I'm assuming they have some reason for linezolid over just the CYA method of therapy (although I would need more info for preference over other abx). I would have sent that mother back to the hospital.

 

[Rebel78]

Out of curiosity, was the prescriber an ER doc, family med, or something else?

 

[J ROD]

Bee sting is more an allergic/inflammatory response.....I would have given IV steroids and some type of antihistamine......

 

[pharaday]

Out of curiosity, was the prescriber an ER doc, family med, or something else?

I looked him up, and he appears to be a pediatric critical care physician. Unfortunately, I don't know a lot of other details since the mother did not know anything at all about what he was treated with in the hospital.

 

[eeyore spice]

Perhaps the hornet was in a LTC facility and had a foley catheter in its stinger.

...

We'd need more info...

I lol'd. And then I stopped, because this situation really isn't funny. I was asking myself earlier today why a patient needed Zyvox, and this was for an infected knee replacement.

Did you ask about cultures? Of what I'm not sure, but if they didn't have cultures, I would have wanted to hear some kind of reasonable suspicion that made Zyvox an absolute necessity.

"Well, Doctor, it's just that I've never seen Zyvox for a hornet sting...is this some new indication I haven't heard about?"

And if there was no reasonable suspicion, I'd tell them to get a 2nd opinion.

It is possible the mom was mistaken about a hornet sting, or that did happen a while ago and got infected but she's not too bright and doesn't realize what's going on...but still, even then the doc should have been able to explain why he's insisting on Zyvox.

 

[Ackj]

Oddly enough, we also had a pt with an rx faxed in for Zyvox today. They got a prior auth, but the copay was still in the ballpark of $500. This was right at the end of my shift so I'm not sure what ended up happening. I'll see if I can report back tomorrow.

 

[pharaday]

It is possible the mom was mistaken about a hornet sting, or that did happen a while ago and got infected but she's not too bright and doesn't realize what's going on...but still, even then the doc should have been able to explain why he's insisting on Zyvox.

This is kind of what I was thinking too. Perhaps the child did originally have a hornet sting, and then scratched it and it became infected (possibly with MRSA). Or, perhaps it was initially an infection, and the mother just thought it was a hornet sting. Don't people often mistake MRSA infections for spider bites? I was off today, but I am going to see if I can find out any additional information tomorrow. I hope the mother was able to find a doctor willing to help her.

 

[group_theory]

I looked him up, and he appears to be a pediatric critical care physician. Unfortunately, I don't know a lot of other details since the mother did not know anything at all about what he was treated with in the hospital.

Everyone seems to be focused on the sting. My concern (as you can see what I bolded and underlined in my first response) is the rapid swelling of the entire arm from wrist to shoulder. My guess is that there was also erythema and edema involved too. It could be cellulitis, but it can also be necrotising fasciitis, osteomyelitis, septic joint, etc. with the sting being the point of entry (hence why my low threshold for surgical consult). The choice of antibiotics probably wasn't made at a whim (especially if the child was in the pediatric ICU). Several posters have suggested steroids and antihistamines - but unless you are certain it isn't anything that is potentially life or limb threatening, you treat under the assumption that it is a potentially serious infection.

And I've seen MDR organisms in kids. They are not limited to elderly nursing home patients with multiple admissions. Believe it or not, kids do get exposed to all type of bugs from all type of sources (kids do visit sick grandparents in hospitals/nuring homes, or have a sick sibling that requires frequent hospitalizations, etc). I've seen MDR-TB, ESBL Klebsiella, MRSA, resistent strep pneumo, etc in kids. Heck, I've seen NICU babies who after a few days would have positive MRSA swabs (either from family members visiting/touching, or healthcare workers) Don't rule out resistant organisms just because the patient is a kid.

It appears this kid was in the pediatric ICU. It also appears that mom is an extremely poor historian. Most PICUs usually have good social workers and care coordinators. A lot of PICU also have a dedicated Peds ICU Pharmacist as part of the team. I wonder if in this case linezolid was already prior auth and a pharmacy was already picked (such as the hospital's outpatient pharmacy) and the mom just didn't understand (or ignored what she was told) and went to her default pharmacy to get the meds?

We don't know what this child had (however it was bad enough to require a peds ICU stay).

 

[All4MyDaughter]

I don't think anyone doubts that the doctor was treating an INFECTION with the Zyvox, only that Zyvox was the ONLY choice available. We just don't have enough information about this situation to be able to determine that.

I'm not really surprised that the mother understood so little about what happened to the child. From her view, the kid got stung by a hornet and ended up in the hospital. I see people discharged from the hospital ALL THE TIME without really understanding what happened to them while they were inpatients. If we are talking about a mother with low literacy, it's totally understandable. Or maybe the doctors didn't really bother to explain much to her. I've seen that too. Who knows?

The doctor compounded things by refusing to even discuss other options, even when told that the patient was going to get NOTHING b/c they couldn't afford the Zyvox. I doubt it was a prior auth issue, b/c those are usually good for any pharmacy. It's possible that the patient was approved to get the Zyvox through a specific pharmacy through a patient assistance program, but if that was the case, wouldn't the doctor have mentioned it when the pharmacist called?

 

[Its Z]

I've seen MDR-TB, ESBL Klebsiella, MRSA, resistent strep pneumo, etc in kids. Heck, I've seen NICU babies who after a few days would have positive MRSA swabs (either from family members visiting/touching, or healthcare workers) Don't rule out resistant organisms just because the patient is a kid.

Zyvox is not a broad spectrum antibiotic. And it's a bacteriostatic agent to boot.

It certainly won't work against MDR gram negative bugs and superiority of Zyvox over Vanco is questionable.

Of course IV vanco probably wasn't an option for this kid in outpatient basis and nosocomial MRSA- cellulitis is the most logical infection if Zyvox was insisted upon. Since there are alternative ABX for CA-MRSA.

 

[Quiksilver]

Everyone seems to be focused on the sting. My concern (as you can see what I bolded and underlined in my first response) is the rapid swelling of the entire arm from wrist to shoulder. My guess is that there was also erythema and edema involved too. It could be cellulitis, but it can also be necrotising fasciitis, osteomyelitis, septic joint, etc. with the sting being the point of entry (hence why my low threshold for surgical consult). The choice of antibiotics probably wasn't made at a whim (especially if the child was in the pediatric ICU). Several posters have suggested steroids and antihistamines - but unless you are certain it isn't anything that is potentially life or limb threatening, you treat under the assumption that it is a potentially serious infection.

And I've seen MDR organisms in kids. They are not limited to elderly nursing home patients with multiple admissions. Believe it or not, kids do get exposed to all type of bugs from all type of sources (kids do visit sick grandparents in hospitals/nuring homes, or have a sick sibling that requires frequent hospitalizations, etc). I've seen MDR-TB, ESBL Klebsiella, MRSA, resistent strep pneumo, etc in kids. Heck, I've seen NICU babies who after a few days would have positive MRSA swabs (either from family members visiting/touching, or healthcare workers) Don't rule out resistant organisms just because the patient is a kid.

It appears this kid was in the pediatric ICU. It also appears that mom is an extremely poor historian. Most PICUs usually have good social workers and care coordinators. A lot of PICU also have a dedicated Peds ICU Pharmacist as part of the team. I wonder if in this case linezolid was already prior auth and a pharmacy was already picked (such as the hospital's outpatient pharmacy) and the mom just didn't understand (or ignored what she was told) and went to her default pharmacy to get the meds?

We don't know what this child had (however it was bad enough to require a peds ICU stay).

I am at a loss here. Perhaps the OP is a poor storyteller but I was under the assumption this was completely outpatient and the timeline of events seems fairly short- perhaps over the course of a few hours. That this patient was never admitted. Perhaps we are seeing things differently. From a purely outpatient perspective, Zyvox in this patient is absurd. That was my interpretation of the story.

Necrotizing fasciitis is not likely and if you suspected this, you certainly wouldn't send a patient home with PO Zyvox. By the time the Zyvox would do anything, you wouldn't have an arm left. But thanks to you and Z for painting a clearer picture.

 

[Praziquantel86]

I'm just going to echo that there seems to be a huge chunk of this story missing. Was the kid admitted, to what service, and what was done? Linezolid is almost never an appropriate empirical antibiotic choice as an initial outpatient oral medication. The prescribing physician also bothers me - why would a peds ICU doc be writing for this if the kid hadn't been hospitalized to his service?

Maybe this is D-test positive MRSA nec fasc stepdown therapy? The arm swelling certainly gives me concern for that. There is some in-vitro evidence showing that linezolid inhibits toxin production, but no good in vivo outcomes data. If the kid is sulfa allergic or the bug is resistant, then linezolid may be the only option. However, nec fasc is an emergent condition and would never be treated outpatient.

I'm sure there's a good reason, and I don't think linezolid has reached the point where it's being prescribed without a pretty decent reason (or at least vaguely justifiable). Maybe the mother's an awful historian and the covering resident was contacted.

We need more info.

 

[group_theory]

Zyvox is not a broad spectrum antibiotic. And it's a bacteriostatic agent to boot.

It certainly won't work against MDR gram negative bugs and superiority of Zyvox over Vanco is questionable.

Of course IV vanco probably wasn't an option for this kid in outpatient basis and nosocomial MRSA- cellulitis is the most logical infection if Zyvox was insisted upon. Since there are alternative ABX for CA-MRSA.

Wasn't trying to imply that linezolid is a broad spectrum drug. Was just pointing out that just because the patient is a child doesn't mean that he/she doesn't have a multidrug resistent infection.

I am at a loss here. Perhaps the OP is a poor storyteller but I was under the assumption this was completely outpatient and the timeline of events seems fairly short- perhaps over the course of a few hours. That this patient was never admitted. Perhaps we are seeing things differently. From a purely outpatient perspective, Zyvox in this patient is absurd. That was my interpretation of the story.

Necrotizing fasciitis is not likely and if you suspected this, you certainly wouldn't send a patient home with PO Zyvox. By the time the Zyvox would do anything, you wouldn't have an arm left. But thanks to you and Z for painting a clearer picture.

Nec fasciitis is in the differential but it isn't the only thing in the differential. We don't know what the diagnosis is, what the tests/studies show, if the patient went to the OR, etc.

I'm just going to echo that there seems to be a huge chunk of this story missing. Was the kid admitted, to what service, and what was done? Linezolid is almost never an appropriate empirical antibiotic choice as an initial outpatient oral medication. The prescribing physician also bothers me - why would a peds ICU doc be writing for this if the kid hadn't been hospitalized to his service?

Maybe this is D-test positive MRSA nec fasc stepdown therapy? The arm swelling certainly gives me concern for that. There is some in-vitro evidence showing that linezolid inhibits toxin production, but no good in vivo outcomes data. If the kid is sulfa allergic or the bug is resistant, then linezolid may be the only option. However, nec fasc is an emergent condition and would never be treated outpatient.

I'm sure there's a good reason, and I don't think linezolid has reached the point where it's being prescribed without a pretty decent reason (or at least vaguely justifiable). Maybe the mother's an awful historian and the covering resident was contacted.

We need more info.

We definately need more information ... otherwise it's pure speculation on what this child had. And it's the mom who is the poor historian, not the OP 😛

From what I can tell, there was a bee/wasp sting involve. At some point (related or unrelated), there was massive swelling of the entire arm. The kid was admitted, and was in the PICU. The kid was discharged directly from the PICU (hence why the script was written by a PICU doc). When the OP looked up the doc's info and found out the doc is Peds CCM, then most likely the person he/she talked to is either a PICU fellow or attending.

We don't know what the final diagnosis is, what cultures/sensitivies showed, what operative procedure (if any), what imaging modalities were done, etc. We don't even know how long the kid was hospitalized.

And why is everyone suddenly fixated on nec fasciitis after I mentioned it in my differential. It's on the differential but it's not the only one on the differential diagnosis. Common things being common, it's more likely to be a bad erysipelas or cellulits from MRSA, than VRE septic joint or nec fasciitis.


*just providing a clinical/diagnostic perspective

 

[VA Hopeful Dr]

We definately need more information ... otherwise it's pure speculation on what this child had. And it's the mom who is the poor historian, not the OP 😛

From what I can tell, there was a bee/wasp sting involve. At some point (related or unrelated), there was massive swelling of the entire arm. The kid was admitted, and was in the PICU. The kid was discharged directly from the PICU (hence why the script was written by a PICU doc). When the OP looked up the doc's info and found out the doc is Peds CCM, then most likely the person he/she talked to is either a PICU fellow or attending.

We don't know what the final diagnosis is, what cultures/sensitivies showed, what operative procedure (if any), what imaging modalities were done, etc. We don't even know how long the kid was hospitalized.

And why is everyone suddenly fixated on nec fasciitis after I mentioned it in my differential. It's on the differential but it's not the only one on the differential diagnosis. Common things being common, it's more likely to be a bad erysipelas or cellulits from MRSA, than VRE septic joint or nec fasciitis.


*just providing a clinical/diagnostic perspective

First off, I'm good to doubt the hornet story just a little. Every abscess I've ever seen in a child presented as a "spider bite". If it is an MRSA abscess, a) I wouldn't use zyvox b) if its just an abscess then all that arm is very worrisome, that kid isn't leaving the hospital.

If that is in fact a hornet sting that swelled like that, even if I were to let the kid leave, it would be with prednisone and lots of it.

 

[FruitFly]

First off, I'm good to doubt the hornet story just a little. Every abscess I've ever seen in a child presented as a "spider bite". If it is an MRSA abscess, a) I wouldn't use zyvox b) if its just an abscess then all that arm is very worrisome, that kid isn't leaving the hospital.

If that is in fact a hornet sting that swelled like that, even if I were to let the kid leave, it would be with prednisone and lots of it.

Funny thing is, most professionals don't even know what a so-called 'spider bite' even looks like, and -fact- most spiders cannot even pierce human skin with their chelicerae. Furthermore, there is so much misinformation about spiders that some even think the 'daddylonglegs' is the most venomous spider on earth only it cannot bite 🙂rolleyes:🙄). Spiders get a bad rap for what mostly amounts to misdiagnosis and misadventures in pharmacotherapies.