l******k
发帖数: 27533 | 1 师姐有空来教教呀～
1. UTI: 如果culture sensitive to cefazolin, 决定给keflex，是 500 mg BID 还是
TID OR QID for 7 days or 5 days？今天一个PA说她学的是QID. 但uptodate 和
micromedex都是BID,快速看了idsa uti guideline，没提到keflex dosing，只有
提到证据不充分，也不知道是resistance problem 还是 lack of efficacy...
2. 今天进来那个巨臭的人，在床上躺了半年没人管，背上ulcer流得稀里哗啦，一想到
就噁心。。。anyway，admitted for hyperkalemia, renal failure, sepsis,
hyponatremia. 然后呢，allergic to penicillin, cipro. 病人无法说话，不知道具
体是啥allergic reactions. 在ED就得上ABX了，preceptor就问我啦，该用啥呢，我觉
得vanco加aztreonam不错呀，但preceptor说vanco起效慢，得用个beta lactam. 不能
用zosyn啦，该挑啥呢？carbapenem 吧，可惜有restriction, preceptor觉得不如用
cefepime，然后狂找penicillin allergy cross-reaction with cephalosporins and
carbapenem，很想找个clinical trial 看看，但大多数都是review，我会继续找，请
师姐推荐比较好的paper吧～
我们还没找到完美方案呢，病人被抬到ICU了，明天可以看看到底ICU的医生给她用了啥
抗生素。
后来跟co-residents聊起这个问题，他们都做过ICU rotation了，都觉得该用vanco+
aztreonam，原因是起效太快的抗生素大量分解毒素会反而对病人不利。。。
唉～问题越堆越多，周末还要staffing，时间太不够啦！ | f****o
发帖数: 2770 | 2 1. 1g Q12h or 500mg Q6h都没关系吧。。。keflex应该是time dependent killing
当然q6h compliance会有影响
而且这个case是uncomplicated UTI还是complicated uti?
2. penicillin allergy cross-reaction with cephalosporins and
carbapenem----概率不是很高啦，只要病人对pcn不是anaphylaxis，试一下cefepime也
无妨啊，如果allergic反正在医院可以抢救。aztreonam超贵的，而且只cover gram
negative,现在为了省钱自然就不用啦
cefepime coverage和zosyn差不多啊，除了anaerobes少了很多，你要cover anaerobe
可以加flagyl | l******k
发帖数: 27533 | 3 是的， 你说的没错
Keflex是500 mg，给qid也不会有啥伤害，但想找到最合理的regimen for best
practice嘛，这就比较time consuming了，周末我们的ID pharmacist 不在，我有一
堆ED的作业，所以来问问
用aztreonam是为了pseudomonas，这个case的问题是septic shock pt到底该用fast
killer 还是slow killer
Cross reaction 我查到的是1% for both，但是again,是基于理论，review，和一些
retrospective 的data，想问问是否我的research不够，有更好的evidence我没找到
★ 发自iPhone App: ChineseWeb 8.6
【在 f****o 的大作中提到】
: 1. 1g Q12h or 500mg Q6h都没关系吧。。。keflex应该是time dependent killing
: 当然q6h compliance会有影响
: 而且这个case是uncomplicated UTI还是complicated uti?
: 2. penicillin allergy cross-reaction with cephalosporins and
: carbapenem----概率不是很高啦，只要病人对pcn不是anaphylaxis，试一下cefepime也
: 无妨啊，如果allergic反正在医院可以抢救。aztreonam超贵的，而且只cover gram
: negative,现在为了省钱自然就不用啦
: cefepime coverage和zosyn差不多啊，除了anaerobes少了很多，你要cover anaerobe
: 可以加flagyl
| a*****8
发帖数: 2115 | 4 第一个问题：What is the mic to cefazolin? Like fiorio said, beta-lactam PD
is time above MIC which means the longer time above MIC the better efficacy.
That being said, in general, if the target attainment is approximately 50%,
it will have a good efficacy. Based on the PK data, in average person, Cmax
after 250 or 500 mg dose is 9 and 15 respectively, and it will decline to 1
.6 and 3.4 mg/L after 3 hour of the dosing. Since I am not sure what bug it
is, and whether it is cystitis or uncomplicated UTI or complicated and MIC,
it hard to make a solid recommendation. But if MIC is <0.5, I would say
either q12 or q6 would have the same effect, but if MIC is approximately 1-2
, you may have better efficacy with q6 dosing. On the other hand, since it
is UTI and given the high concentration of urinary concentration of
cefazolin, either interval should be ok. Taking into consideration of
patient's compliance issue, social issue, whether patient can tolerate q6
dosing etc.
The reason that cephalexin is not recommended in the IDSA guideline is due
to increase resistance in E coli. it is not considered as empiric therapy
for UTI but if you have culture directed information and it is sensitive, it
can be used as oral option for outpatient. | a*****8
发帖数: 2115 | 5 for your second questions:
Lets put aside the fast kill or slow kill issue.
1. we are treating potential sepsis right, but where is the source, is it
skin-soft tissue or osteo, or bacteremia or pneumonia, cause the organisms
you want to cover may be different.
2. I am assuming pt has been in the hospital or LTCF for a long time, in
that case we do want to cover broadly
3. If we are treating skin and soft tissue infection due to his ulcer, it
usually gram positive directed, but if he is at a higher risk of developing
MDR organisms, gram negative should also be considered.
4. Therefore, regardless whether you pick azetreonan or beta-lactam, you
should have good gram positive coverage. yes, beta-lactam especially first
generation of cephlosporins and nafacillin had great activity against MSSA,
but you may want to cover MRSA as well, which you will need to use
vancomycin anyway.
5. cross reactivity of betalactam are highly depend on their side chains at
3, 6,and 7 positions. Cefepime dose have very limited cross reactivity
against penicillins and can be used to cover pseudomonas. Same as azetreonam
.
Couples articles I think is pretty good reviewing the cross reactivity are:
J Am Pharm Assoc (2003). 2008 Jul-Aug;48(4):530-40.
Cephalosporin use in treatment of patients with penicillin allergies
Ann Pharmacother. 2009 Feb;43(2):304-15. doi: 10.1345/aph.1L486. Epub 2009
Feb 3.
Allergic cross-sensitivity between penicillin, carbapenem, and monobactam
antibiotics: what are the chances?
and
J Emerg Med. 2012 May;42(5):612-20. Epub 2011 Jul 13.
The use of cephalosporins in penicillin-allergic patients: a literature
review. Campagna JD, Bond MC, Schabelman E, Hayes BD.
【在 l******k 的大作中提到】
: 师姐有空来教教呀～
: 1. UTI: 如果culture sensitive to cefazolin, 决定给keflex，是 500 mg BID 还是
: TID OR QID for 7 days or 5 days？今天一个PA说她学的是QID. 但uptodate 和
: micromedex都是BID,快速看了idsa uti guideline，没提到keflex dosing，只有
: 提到证据不充分，也不知道是resistance problem 还是 lack of efficacy...
: 2. 今天进来那个巨臭的人，在床上躺了半年没人管，背上ulcer流得稀里哗啦，一想到
: 就噁心。。。anyway，admitted for hyperkalemia, renal failure, sepsis,
: hyponatremia. 然后呢，allergic to penicillin, cipro. 病人无法说话，不知道具
: 体是啥allergic reactions. 在ED就得上ABX了，preceptor就问我啦，该用啥呢，我觉
: 得vanco加aztreonam不错呀，但preceptor说vanco起效慢，得用个beta lactam. 不能
| a*****8
发帖数: 2115 | 6 Also if you think about it, who would do a clinic trial on beta lactam cross
reactivity. you won't find good solid trial for that. mostly are from case
series or report, maybe retrospective study and from chemistry journal. | a*****8
发帖数: 2115 | 7 with regard to fast kill and slow kill issue, honestly I have never
encounter that I need to base on fast kill and slow kill to make antibiotics
selection, Oncology maybe. I will need to look into that. Vancomycin is
slower bacterial killing when compared to nafacillin in MSSA infection.
Therefore, when someone is having S aureus endocarditis pending
susceptibility,some of the physician will use both vanc and nafacillin to
cover MSSA and MRSA. | l******k
发帖数: 27533 | 8 谢谢师姐！
麻烦你周末一大早来教我
We give keflex based on culture susceptibility. Most cultures grow E.coli.
Sometimes it grows Klebsiella. And they are sensitive to cefazolin. Dosing
based on MIC makes sense.
Thanks again :)
efficacy.
%,
Cmax
1
★ 发自iPhone App: ChineseWeb 8.6
【在 a*****8 的大作中提到】
: 第一个问题：What is the mic to cefazolin? Like fiorio said, beta-lactam PD
: is time above MIC which means the longer time above MIC the better efficacy.
: That being said, in general, if the target attainment is approximately 50%,
: it will have a good efficacy. Based on the PK data, in average person, Cmax
: after 250 or 500 mg dose is 9 and 15 respectively, and it will decline to 1
: .6 and 3.4 mg/L after 3 hour of the dosing. Since I am not sure what bug it
: is, and whether it is cystitis or uncomplicated UTI or complicated and MIC,
: it hard to make a solid recommendation. But if MIC is <0.5, I would say
: either q12 or q6 would have the same effect, but if MIC is approximately 1-2
: , you may have better efficacy with q6 dosing. On the other hand, since it
| l******k
发帖数: 27533 | 9 Will read the articles
Love love love... A LOT! :)
★ 发自iPhone App: ChineseWeb 8.6
【在 a*****8 的大作中提到】
: for your second questions:
: Lets put aside the fast kill or slow kill issue.
: 1. we are treating potential sepsis right, but where is the source, is it
: skin-soft tissue or osteo, or bacteremia or pneumonia, cause the organisms
: you want to cover may be different.
: 2. I am assuming pt has been in the hospital or LTCF for a long time, in
: that case we do want to cover broadly
: 3. If we are treating skin and soft tissue infection due to his ulcer, it
: usually gram positive directed, but if he is at a higher risk of developing
: MDR organisms, gram negative should also be considered.
| l******k
发帖数: 27533 | 10 The pt is treated by clindamycin, vanco, and cefepime now. May I assume that
the concomitant use of clindamycin and vanco is for the slow killing
affects from vanco?
antibiotics
★ 发自iPhone App: ChineseWeb 8.6
【在 a*****8 的大作中提到】
: with regard to fast kill and slow kill issue, honestly I have never
: encounter that I need to base on fast kill and slow kill to make antibiotics
: selection, Oncology maybe. I will need to look into that. Vancomycin is
: slower bacterial killing when compared to nafacillin in MSSA infection.
: Therefore, when someone is having S aureus endocarditis pending
: susceptibility,some of the physician will use both vanc and nafacillin to
: cover MSSA and MRSA.
| a*****8
发帖数: 2115 | 11 Not exactly, sometime for those community acquired MRSA or toxin producing
organisms, clindamycin has some effect agaings reduction toxin production. | l******k
发帖数: 27533 | 12 对对对
把clinda的这个特点给忘了。。。
【在 a*****8 的大作中提到】
: Not exactly, sometime for those community acquired MRSA or toxin producing
: organisms, clindamycin has some effect agaings reduction toxin production.
| l******k
发帖数: 27533 | 13 晕～
这三篇我都没法打开全文
求助求助～～
developing
【在 a*****8 的大作中提到】
: for your second questions:
: Lets put aside the fast kill or slow kill issue.
: 1. we are treating potential sepsis right, but where is the source, is it
: skin-soft tissue or osteo, or bacteremia or pneumonia, cause the organisms
: you want to cover may be different.
: 2. I am assuming pt has been in the hospital or LTCF for a long time, in
: that case we do want to cover broadly
: 3. If we are treating skin and soft tissue infection due to his ulcer, it
: usually gram positive directed, but if he is at a higher risk of developing
: MDR organisms, gram negative should also be considered.
| a*****8
发帖数: 2115 | 14 IM me your email address |
|
