Would you have filled this?

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Silvermist

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I came across this blog post ... the mother feels as if the pharmacist had no choice but to dispense the drug as ordered. Obviously hindsight is 20/20 - but in this situation, would you have dispensed it knowing the baby had an adverse reaction?

http://www.lawyersandsettlements.com/articles/14266/interview-stevens-johnson-syndrome-sjs-5.html

Physician and Pharmacist Discrepancy over Stevens Johnson Syndrome

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June 1, 2010. By Jane Mundy
San Francisco, CA: Ellen says that her son’s Stevens Johnson Syndrome (SJS) could have been avoided if his pediatrician had listened to the pharmacist and prescribed a different antibiotic. "The good thing is that Connor was only two years old, so he doesn't remember suffering."
interview-stevens-johnson-syndrome-sjs-5.jpg

Connor was only seven weeks old when he developed an ear infection. He was given amoxicillin but the infection continued and he had an adverse reaction to the drug. "He had mottling over his entire body; it looked like someone had beaten him up," says Ellen. The pharmacist knew about Connor's adverse reaction, but the doctor prescribed him yet another penicillin.

"Why would the pediatrician give him this?" Ellen asked her pharmacist. She phoned the pediatrician right away and told him the drug he prescribed was a third-generation penicillin and Connor already had a reaction to penicillin. "Do not question me, I won't give him anything else," he replied.

"When a physician argues about the classification of a drug with a pharmacist, that is a huge arrogance issue with me," says Ellen. "There is no way a doctor can be knowledgeable and aware of side effects and classifications of so many new drugs. That is why they should be consulting the pharmacist—they should both be on the same page.

"My pharmacist dispensed the medication—she had no choice—and told me to watch Connor closely. The pediatrician told me to give him a second course because the infection didn’t go away. On the third day of the second course, I was at work and I got a phone call from the babysitter.

"'Something is very wrong,' she said. I could hear my son crying in the background.

"She drove him to my work at the Fire Station (I'm a firefighter) about 10 minutes later. Blisters had popped all over his lower body. There was skin from his feet on her car floor. Right away we called an ambulance and treated him as a burn victim.

"The ambulance transferred us to Childrens' Hospital Oakland, which had a new pediatric burn unit. Connor was in hospital for 11 days and had skin grafts, taken from his thigh, from hip to hip. He ended up with second degree burns over 25 percent of his body. We were fortunate enough to have an extremely bright doctor who diagnosed SJS, but not before some people thought my son had been burned, either by me or the babysitter!

"The pediatrician never documented that my son had an allergy or any adverse reactions to antibiotics. I tried to sue him for malpractice—not for the money but for public awareness about SJS.

"But no one would take the case because it was over the statute of limitations. And nobody wanted to take on a case that would only compensate 25 percent for a minor with a cap of $250,000. If I had gone to an attorney in the first six months and sued on behalf of Connor and me, there is no cap on pain and suffering and you can get 40 percent in California. Frankly, I find this cap appalling. I have records from the pharmacist and the hospital that proves he had a reaction, and proves malpractice by the pediatrician.

"When Connor came home and the SJS had subsided, we went to a homeopathic MD who put him on mineral supplements to build his immune system. And of course we changed pediatricians. Connor is now 17 and still has scars from SJS. Fortunately he doesn't remember like I do."​

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Eh, I am no pharmacist but I have seen pharmacists refuse to dispense something. If it was me, I would have told the patient to seek a second opinion. She could have easily taken her child to an urgent care instead of going back to the doctor. If it was my child, I certainly would have done so.
 
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I don't understand how anyone could give a child the same medication after an effect such as the one above occurred. The pharmacist should've refused to fill and like somone previously mentioned, recommended that the patient see another doctor. Fluoroquinolones not recommended for children (I believe Cipro would be the safer one to use if a particular situation called for a quinolone in the ped. population since it has less side effects among - at least that what I got from my research), but I would look at azithromycin, but I'm not a pediatric specialist so I'd check on that.
 
The mom says the pharmacist had "no choice", but did the mother not chose to give the child the medication that was prescribed by the doctor and dispensed by the pharmacist? Not trying to blame the mother, but if she knew about the previous reaction, she should have demanded to see another doctor if he refused to change the prescription. If I was in that situation, as either the pharmacist or a parent, I would refuse to dispense, or tell the parent not to give the medication to the child, or not give the medication to my child if I was the parent.
 
I don't understand how anyone could give a child the same medication after an effect such as the one above occurred. The pharmacist should've refused to fill and like somone previously mentioned, recommended that the patient see another doctor. Fluoroquinolones not recommended for children (I believe Cipro would be the safer one to use if a particular situation called for a quinolone in the ped. population since it has less side effects among - at least that what I got from my research), but I would look at azithromycin, but I'm not a pediatric specialist so I'd check on that.

What is the most common bug to cause ear infections?

Why would Cipro not be a good option empirically?
 
The mom kinda lost my sympathy here:

"When Connor came home and the SJS had subsided, we went to a homeopathic MD who put him on mineral supplements to build his immune system."

Clarithromycin or azithromycin would be alternatives to the beta lactams, but the cross-allergenicity of cephs and pens isn't all that high; ie, < 10%. It's reasonable to give a ceph to pts with documented pen allergies. This poor little guy suffered the perfect storm of medical rarities: a cross-allergenicity of pens and cephs, and SJS.

After years of listening to babies scream in pain while I filled their scripts for otitis media, I breast-fed my kids when I had 'em. Wonder if wonder mom, who takes her kid to alternative quacktitioners, bothered to do this simple thing.
 
The mom kinda lost my sympathy here:



Clarithromycin or azithromycin would be alternatives to the beta lactams, but the cross-allergenicity of cephs and pens isn't all that high; ie, < 10%. It's reasonable to give a ceph to pts with documented pen allergies. This poor little guy suffered the perfect storm of medical rarities: a cross-allergenicity of pens and cephs, and SJS.

After years of listening to babies scream in pain while I filled their scripts for otitis media, I breast-fed my kids when I had 'em. Wonder if wonder mom, who takes her kid to alternative quacktitioners, bothered to do this simple thing.

He was 2 at the time, not sure how long passive immunity lasts or immune benefits of breast feeding, but most people stop at or before 1. I agree though, alternative quacktitioner for "immune building" is a joke. Even more so when it was an immune-system mediated problem in the first place.
 
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What is the most common bug to cause ear infections?

Why would Cipro not be a good option empirically?

Is it Strep. pneumoniae? (If I make an ass of myself, my bad, but obviously I'm learning and getting ready for rotations here). So with that
Cipro from the second generation wouldn't be good as it works better for gram - organisms or has less efficacy...?
 
I question the source... a 3rd generation PCN?
 
Clarithromycin or azithromycin would be alternatives to the beta lactams, but the cross-allergenicity of cephs and pens isn't all that high; ie, < 10%. It's reasonable to give a ceph to pts with documented pen allergies. This poor little guy suffered the perfect storm of medical rarities: a cross-allergenicity of pens and cephs, and SJS.

I was also told that information at work (hospital) that just because a patient has an allergy to PCNs doesn't mean you can't give cephalosporins. So what would a Rph do in the retail setting? Do you all just automatically go to a macrolide or does it depend?
 
Is it Strep. pneumoniae? (If I make an ass of myself, my bad, but obviously I'm learning and getting ready for rotations here). So with that
Cipro from the second generation wouldn't be good as it works better for gram - organisms or has less efficacy...?

The bug wasn't killed with the cillin...
 
I would have convinced the mom that it likely did not even need an ABX depending on how bad the infection was. or if she cried about NEEDING an ABX, I'd use Azith
 
That's right, but the gram (+) and the gram (-) activity is associated with cephalosporins, isn't it?

there is some generation-ality with the FQs, but we don't talk about it like we do with the cephalosporins.

Cipro is an excellent gram negative agent. It does not cover strep pneumo, unlike Levofloxacin and Moxifloxacin, your respiratory FQs.

There is lots of Azithro resistance in S.pneumo. Go do a pub med search on it.

Personally, if they had written for a 3rd gen Ceph I probably would've filled it, after advising the physician of the possible interaction. The cross-reactivity is so low (~10%, if that, for a 3rd gen) that I would just warn mom to keep an eye out and have benadryl on hand.
 
I think the cross sensitivity data between penicillin and cephalosporins may not be entirely accurate. We learned that a lot of the data came from early uses of first generation cephalosporins which had a high probability of contamination with penicillin during manufacturing.
The cephalosporin ring also fragments in different ways than the penicillin beta-lactam ring during metabolism and formation haptens. Hence cross reactivity between the rings are fairly low. I think the more important determinant is the similarity in side chain structure between the offending drugs. I think this even plays a bigger role in T-cell mediated allergic reactions such as SJS/TENS.
That being said, it's probably better to play it safe, especially in retail where you can't readily follow-up/monitor.
 
Students - give an example of cross-reactivity (abx - I'm thinking of a specific example) due to similar side chains?
 
He was 2 at the time, not sure how long passive immunity lasts or immune benefits of breast feeding, but most people stop at or before 1. I agree though, alternative quacktitioner for "immune building" is a joke. Even more so when it was an immune-system mediated problem in the first place.

Oh right; I got confused because it said how he got an ear infection at 7 weeks old.

When a kid has an ear infection, you can wait 48-72 h to see if it resolves on its own. (My youngest would have been on ABs continuously from about 10 to 15 months old if I didn't follow this guideline - the ear infections started when I began to phase out the breast-feeding.)

Personally, if they had written for a 3rd gen Ceph I probably would've filled it, after advising the physician of the possible interaction. The cross-reactivity is so low (~10%, if that, for a 3rd gen) that I would just warn mom to keep an eye out and have benadryl on hand.

I have filled cephs in pts with documented pen allergies, and I basically explain it to them, saying there's a chance of cross-allergenicity, and I let them choose whether they want me to phone the doc and get a non-beta-lactam alternative. Mainly it was adults, though; if it was my kid, I don't know if I'd want to chance it. And the petechiae the kid had from the 1st dose at only 7 wks old would make me kinda leery...it didn't sound like run-of-the-mill hives.
 
The cross-reactivity is so low (~10%, if that, for a 3rd gen) that I would just warn mom to keep an eye out and have benadryl on hand.

While I agree that the cross reactivity is low but why take the risk?
 
crossreactivity to cephs is low. it is higher for carbapenems though. also the reported cross-rx of carbs is a range due to the number of people examined at the time.


cross reactivity with Cephs isn't that high especially 3rd generation.

we are hearing a report from lawyers here.... you really gonna believe any of that? they are the lowest form of life...
 
crossreactivity to cephs is low. it is higher for carbapenems though. also the reported cross-rx of carbs is a range due to the number of people examined at the time.


cross reactivity with Cephs isn't that high especially 3rd generation.

we are hearing a report from lawyers here.... you really gonna believe any of that? they are the lowest form of life...

I have to agree with PharmaTope ... I have never seen any studies that have shown 3rd generations to have any sort of cross reactivity with PCN allergies.
 
This is my cheat sheet for PCN and Ceph allergy. I have dispensed 3rd gen Cephs many times to PCN allergy pts just fine. It comes down chemical structure and severity of IgE rxn, and I find it helpful to look at sheet for quick reference of side chains.

*****
Cephalosporins are often safe in patients with reported penicillin allergy

Cross reactivity risk between penicillins and cephalosporins is limited and is far less than the historically quoted 10%. Both cephalosporins and penicillins have similar chemical structures containing a highly substituted beta-lactam ring, but data suggests it is not the beta lactam ring but the presence of a similar side chain in the 7-position which confers true cross reactivity risk. For first-generation cephalosporins, the increased risk of cross-reactivity is about 0.5%. In second and third generation cephalosporins, evidence is lacking to support presence of any significant cross-reactivity risk. Below is a table outlining the groups of antibiotics that could confer cross-reactivity based on the presence of specific side-chains: **see attachment**

In conclusion:
· Overall risk is lower with 2nd and 3rdgeneration cephalosporins compared to 1st generation members.
· If a patient has experienced a non-IgE mediated allergic reaction, then the culprit antibiotic as well as related antibiotics are safe.
· If a patient has a history of severe IgE-mediated reaction to penicillin, then cephalosporins with the corresponding similar 7-position side chain (cephaloridine, cephalothin, cefoxitin) should be used cautiously.
· If the reported IgE-mediated reaction was to amoxicillin or ampicillin, then cephalosporins containing the corresponding similar 7-position side chain (cefaclor, cephalexin, cephradine, cefprozil, cefatrizine, and cefadroxil) should be regarded with care.
 

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What is the most common bug to cause ear infections?

Virus.

Why would Cipro not be a good option empirically?

Hmmmm... remember 15 years ago, Cipro's coverage against Strep Pneumo wasn't always bad....
 
This is my cheat sheet for PCN and Ceph allergy. I have dispensed 3rd gen Cephs many times to PCN allergy pts just fine. It comes down chemical structure and severity of IgE rxn, and I find it helpful to look at sheet for quick reference of side chains.

*****
Cephalosporins are often safe in patients with reported penicillin allergy

Cross reactivity risk between penicillins and cephalosporins is limited and is far less than the historically quoted 10%. Both cephalosporins and penicillins have similar chemical structures containing a highly substituted beta-lactam ring, but data suggests it is not the beta lactam ring but the presence of a similar side chain in the 7-position which confers true cross reactivity risk. For first-generation cephalosporins, the increased risk of cross-reactivity is about 0.5%. In second and third generation cephalosporins, evidence is lacking to support presence of any significant cross-reactivity risk. Below is a table outlining the groups of antibiotics that could confer cross-reactivity based on the presence of specific side-chains: **see attachment**

In conclusion:
· Overall risk is lower with 2nd and 3rdgeneration cephalosporins compared to 1st generation members.
· If a patient has experienced a non-IgE mediated allergic reaction, then the culprit antibiotic as well as related antibiotics are safe.
· If a patient has a history of severe IgE-mediated reaction to penicillin, then cephalosporins with the corresponding similar 7-position side chain (cephaloridine, cephalothin, cefoxitin) should be used cautiously.
· If the reported IgE-mediated reaction was to amoxicillin or ampicillin, then cephalosporins containing the corresponding similar 7-position side chain (cefaclor, cephalexin, cephradine, cefprozil, cefatrizine, and cefadroxil) should be regarded with care.

Excellent post :)
 
Virus.



Hmmmm... remember 15 years ago, Cipro's coverage against Strep Pneumo wasn't always bad....

Nope! 15 years ago I was in middle school. :smuggrin:
 
Well, 20 years ago, Quinolone was considered a big gun. Required ID approval....
 
Well, 20 years ago, Quinolone was considered a big gun. Required ID approval....

as they still should.

they still have potential if we don't continue to overuse them.
 
Not necessarily. http://www.ncbi.nlm.nih.gov/pubmed/15620440 There are several studies like this one that have shown increasing FQ susceptibilities when they take them away and put them on ID restriction.

There is hope!

But what's going to stop the community docs from prescribing Cipro, Levaquin and Avelox for nearly everything?
 
But what's going to stop the community docs from prescribing Cipro, Levaquin and Avelox for nearly everything?

we can only hope for education. If we can stop using it in the hospital as empiric treatment for everything that rolls in, we can at least hopefully reduce the resistance of the more hospital-associated gnarly gram negatives that they tend to pick up while admitted.
 
yeah..too late.. as I see many places with Quinolone susceptibility against E. coli around 50%.
 
But what's going to stop the community docs from prescribing Cipro, Levaquin and Avelox for nearly everything?

and if you see a community doc prescribing Cipro for CAP, let me in on that lawsuit...

What do you call a patient with community acquired pneumonia on Cipro?

dead patient.
 
and if you see a community doc prescribing Cipro for CAP, let me in on that lawsuit...

What do you call a patient with community acquired pneumonia on Cipro?

dead patient.

Cheap patient!

I've seen an NP-in-a-box do that, but not an MD. I don't work retail anymore...so hopefully I won't.
 
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