Notes from Merck conference on Antimicrobial Stewardship 2013


Metropolitan Hotel: Vancouver


No Boundaries for Disease or Education

Click to access if-hp-antimicrobial-assessment-stewardship-resources-provincial.pdf

Click to access Antimicrobial%20Stewardship.pdf

Click to access pneumonia-timing-antiobiotic-administration-131120-en.pdf

Drug, dose, timing and duration
50% of use inappropriate
ID specialist + Director of Pharmacy: leverage on something that has gone bad and create a business case

Chloramphenicol PO: higher availability
T > MIC 50% of time, predictive of antibacterial effect

Early ART decreases inflammation
CMV, EBV and HCV co-infections
monocytes inflammation emerging as a new contributor for CV
The Berlin Patient: New York Times

80% of strokes can be decreased by lifestyle changes/management

Inspire action to address challenges and leverage opportunities for accelerating improvement in quality of care

Dr. Rolando Barrios:


John Kotter: Why do change efforts fail?

The 8-Step Process for Leading Change

Leveraging client voice for improvement

BPMH: collect, clarify and reconcile

Feb 16 2015: Interesting poster read: The Use of Self-Administered Medicinal Cannabis For Cystic Fibrosis Symptom Management: Patient Reported Experiences by Kathleen MN Lee, Pat MacDiarmid, Stephen Shalansky, Pearce Wilcox

Click to access pneumonia-timing-antiobiotic-administration-131120-en.pdf

insertion, removal or presence of a catheter in selected sites can place an anticoagulated pt at some risk for local bleeding, complications leading to neurologic injury and paraplegia by causing a spinal hematoma. Removal of catheter must occur when the pt has minimal amount of anticoagulant in their blood.
You can give anticoagulant 4 hrs after removal or 20 hrs after dose

Causes of mesenteric vein thrombosis: appendicitis, cancer, diverticulitis, liver disease with cirrhosis, pancreatitis

Angiodysplasia (swollen, fragile blood vessels in the colon that occasionally result in blood loss from the GI tract mostly related to aging and degeneration of the blood vessels.

Normal pressure hydrocephalys (NPH): Clinical symptom complex characterized by abnormal gait, urinary incontinence, dementia. Potentially reversible cause of dementia
Hydrocephalus: Disturbance of formation, flow or absorption of CSF (cerebrospinal fluid) that leads to an increase in volume occupied by this fluid in the CNS.

“In hereditary hemorrhagic telangiectasia, some arterial vessels flow directly into veins rather than into the capillaries. These abnormalities are called arteriovenous malformations. When they occur in vessels near the surface of the skin, where they are visible as red markings, they are known as telangiectases (the singular is telangiectasia).
Without the normal buffer of the capillaries, the blood moves from the arteries at high pressure into the thinner walled, less elastic veins. The extra pressure tends to strain and enlarge these blood vessels, and may result in compression or irritation of adjacent tissues and frequent episodes of severe bleeding (hemorrhage). Nosebleeds are very common in people with hereditary hemorrhagic telangiectasia, and more serious problems may arise from hemorrhages in the brain, liver, lungs, or other organs.”

May 21, 2016

Antimuscarinic agent (M3 selective) Dose 7.5 to 15 mg PO daily
Peak serum levels are attained 7 hours post dose
Half life 13-19 hours

10 Secrets to Success


Came across this while cleaning my room today:

1. Mentality: How you think is everything

Success is 98% mental, 2% physical

Most people expect to fail, but hope to surprise themselves and win.

Attitude is everything.

Always be positive

Never look at the downside.

Face adversity – don’t be a mental sissy!

Challenges should make you better, not bitter. 

Think long-term.

Mentally sell out.

Get excited and show it!

You must expect to win.

Be Persistent – Work Hard

Develop a great work ethic. Success is a marathon. Develop discipline and mental toughness. Keep regular hours of operation. Attitude alone is not enough – you must work hard and be persistent. 





What is currently happening with the proposed prohibition of inducements/loyalty point bylaw change?

What sort of changes do I want to make in my career as a pharmacist?

After several months of working, I believe as pharmacists our biggest task is to problem solve. I need to focus on the kind of questions I should ask every time I am faced with a problem. Am I making an effort to collect all the pieces of the puzzle or am I taking shortcuts?

I should endeavor to do the best that I can at the task at the hand. I need to commit to doing the best job I can.

Two of the basic principles that made a significant difference to Bob Nakagawa: Take the Initiative to Make Things Better and Lead by Example. “Taking the initiative to make things better is what I think about when I encounter a challenging situation. I think  about my mentors who served as great examples for me to emulate as I advanced” 

In the Drug Schedules, a Schedule 2 Vaccine is defined as follows:


vaccines which are a part of routine immunization program

vaccines requiring special enhanced public access due to disease outbreaks

cholera vaccine (oral, inactivated) when used for prophylaxis against traveler’s diarrhea due to enterotoxigenic escherichia coli (ETEC)

For example: Zostavax is presently not part of the BC’s publicly funded program, however the BCCDC does recommend Zostavax for individuals over 50 for the prevention of herpes zoster in patients with prior chickenpox infection. Therefore, it could be considered Schedule 2 for this indication. 

Therapeutics Letter: July/August 2012

Because of the lack of effect on mortality and total SAEs (serious adverse events) there is no net health benefit from prescribing high dose statins over standard dose statins. 

Neat quote I found:
“I never think anything will be done for me (unless I do it for myself) and I’m fiercely determined. I carved my way into the hip-hop music industry at a time when it was unreceptive to white girls (mid-’90s) and against my father’s furiously expressed wishes. What my father’s lack of nurturing taught me is that underestimating myself is far better than overestimating myself. I tend to assume that I won’t land an exciting new client, which means that I’m thrilled when it actually happens. But mostly, when things don’t go my way, I know how to pick myself up and try again, on my own.” Nicole Balin

Antibiotic Abyss


This is a summary of the presentation one of the pharmacists at the hospital shared with me:

Antibiotic resistance is increasing, so we have the same bugs but new drugs. Do all infections need antibiotics?
presentation by Fredrick M. Abrahamian. Associate Professor of Medicine, UCLA School of Medicine

Antibiotics are not indicated for simple, first time, uncomplicated cases. Indications:
1. Surrounding cellulits
2. Signs of systemic toxicity
3. Immunocompromised host
4. High-risk locations (hands, face)
5. recurrent abscesses or lack of response to I&D
6. Multiple or large abscess ( greater or equal to 5 cm)

In vitro CA-MRSA is susceptible to TMP/SMX, Rifampin, Vancomycin and Linezolid
variable to Clindamycin 300-600 mg PO TID or QID (94%): Covers staphylococci, streptococci, anaerobes. Inducible resistance ( D-zone disk-diffusion test)
doxycycline (100%) 100 mg PO BID excellent tissue penetration, levofloxacin (45%), erythromycin (10%)
Rifampin 300 mg PO BID: Numerous drug interactions, risk-to-benefit ration does not justify routine use, best reserved for decolonization purposes

Rifampin drug interactions: decreases the effect or levels of beta-blockers, digoxin, ACE-inhibitors, diltiazem, nifedipine, corticosteroids, methadone, oral anticoagulants, phenytoin, sulfonlyureas, oral contraceptives
Linezolid inhibits toxin production. Tigecycline: First dose ( 100 mg IV then 50 MG IV q12 H) also covers gram negative and anaerobes, does not cover Pseudomonas plus minus Proteus. Complicated SSTIs, intra-abdominal infections, CAP (not for DRSP)

New FDA approved antimicrobial therapies: Telavancin (10 mg/kg day), Ceftaroline 600 mg q12hrs (given over 60 min)

Complicated infections: more likely mixed aerobic and anaerobic infections
Consider in patients with chronic infections, peri-rectal infections, wounds involving lower extremities (e.g. feet), vascular insufficiency (venous stasis ulcers), immunocompromising conditions example diabetes mellitus, bite-related wounds, post-operative wounds, infected burns
Evernote 20130313 15-11-15

What works on Pasteurella or E corrodens

Necrotizing skin and soft tissue infections:
Vanco + Pip/tazo + Clinda

Alternative: Linezolid + Pip/taz

First generation cephalosporins are inactive against Pasteurella or Eikenella

2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections

Click to access 2012%20Diabetic%20Foot%20Infections%20Guideline.pdf

HIV/AIDS Final Week


Drug Interactions with HCV medicationsTasks performed:

Worked up patients
Attended educational session on Drug Interactions by Dr. Tseng from Toronto
hepatitis cases_Vancouver_handout_May12

Nursing In Service: Drug Interactions
Other health care professionals present: Dietitian, Social worker
Discussed topics: Opportunisitic Infections (CMV, Toxoplasmosis)

Last day: Mock oral Exam
Great practice before I step into the real world

Final evaluation:

– good interactions with patients – empathetic and caring
– extremely receptive to feedback
– has shown great improvement overall
– good literature searching skills and evaluation
– helpful and accessible to team members, always polite and professional

FOCUS AREAS for improvement:
– time management with patient workups and drug information response time can be improved, need to “whittle down” the most important info
– remember to relay your recommendation/bottom line when answering drug info requests (more succinct)
– knowledge base – ongoing process – do not rely on single sources. Evaluate the sources you are using.
– remember to keep things on a practical basis versus theory – will be helpful in work ups/communications with pts and health care teams. know your audience.
– remember to look for the answers you seek – do not expect answers to come to you or that the chart is “complete” – always question things
– always remember SEAMLESS CARE!

Overall, this rotation was a great end to my residency career. I am glad I got a chance to experience this and meet people from different walks of life. I got rid of lot of stereotypes and it was definitely an eye opening experience. Overall, I wish I was a bit more motivated in during the month of February but at the same time it was a blessing in disguise as the feedback received during that month really opened my eyes and helped me focus on things I needed to work on especially questioning things. Further on, the emergency and neurology rotations reinforced these focus areas and helped me become a better resident and a better pharmacist in the future.

I am excited and scared to enter the real work force but at one thing I need to keep in mind is to make sure I provide the best pharmaceutical care to my patients. They are MY patients!

HIV/AIDS Discussions and Pearls


Topics reviewed today:

Which medications to start and how to pick one from the other?

Nucleoside/Nucleotide RTIs: Abacavir (300 mg po BID or 600 mg po once daily), Didanosine, Emtricitabine (200 mg po once a day), Lamivudine (150 mg po BID or 300 mg po once daily), Stavudine, Tenofovir (300 mg once daily), Zidovudine

Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)

Efavirenz (Dose: 600 mg daily), Etravirine, Nevirapine, Rilpivirine

Multi-class combination drugs: Efavirenz/Emtricitabine/tenofovir (600/200/300 mg tablet)

Protease Inhibitors: The 3 main ones that are used:
Darunavir 600 mg + 100 mg ritonavir BID or 800/100 mg QD for naive subjects
Atazanavir 400 mg QD or 300 mg with 100 mg ritonavir QD
Lopinavir/ritonavir (Kaletra) 400/100 mg BID or 800/200 mg QD (has good CNS penetration)
Kaletra + Phenytoin drug interaction: Usually phenytoin is switched to Levetriacetam (normal dose: 500 mg BID or 1000mg BID) . If not possible, frequency of Kaletra usually has to be increased from 2 tabs BID to 3 tabs BID due to enzyme induction effect of phenytoin and monitor using therapeutic drug monitoring to adjust the dose of phenytoin.

Picking between Truvada and Kivexa
Tenofovir: can lead to renal failure, osteoporosis (Choose based on renal function and bone mass density)
Some evidence that it is more effective if viral load is high
Tenofovir and Lamivudine (brand name Heptovir): Also works against Hepatitis B, patient could be HIV -ve and still be on Tenofovir

Cryptosporidosis: protozoa infects small bowel mucosa, immunosuppressed persons, the large bowel and extra-intestinal sites. Person-to-person transmission is common, especially among MSM. Most commonly presents with acute or subacute onset of profuse, nonbloody, watery diarrhea, accompanied often by nausea, vomiting and lower abdominal cramping.
Interesting fact: HIV-infected persons should avoid eating raw oysters because cryptosporidial oocysts can survive in oysters taken from certain commercial oyster beds.

Abacavir: Check for HLAB5701 hypersensitivity
Efavirenz: CNS side effects

Risk factors for PCP: CD4% <14%, previous episode of PCP, oral thrush, recurrent bacterial pneumonia, unintentional weight loss, higher plasma HIV RNA
Treatment dose for Septra: 1 DS tab PO TID or TMP-SMX (15-20 mg TMP and 75-100 SMX)/kg/day IV administered q6h or q8h
duration of treatment: 21 days
duration of primary prophylaxis: continue for adult and adolescent patients whose CD4+ count has increased from 200 cells/microL for >3 months as a result of ART. for secondary prophylaxis it can extend up to 6 months

Make sure you provide seamless care to your patient
Once treatment is finished, they should go home on a prescription for prophylaxis for Septra (1 DS tab daily or 1 SS tab daily) or 1 DS tab 3 times/week

An Immune reconstitution syndrome (IRIS) has been associated with initiation of ART in the presence of underlying OIs.
IRIS is characterized by fever and worsening of OI manifestations in the initial weeks after ART. An ART associated rapid-onset immune reconstitution against the OI pathogen is thought to be the mechanism of IRIS.
Three main OIs: PCP, MAC and cytomegalovirus retinitis

Therapy for cryptococcal meningitis: amphotericin B 0.7 mg per kg per day IV for a minimum of 2 weeks with or without flucytosine 100 mg per kg per day in 4 divided doses followed by fluconazole 400 mg per day for 8 weeks or until CSF cultures are negative

Toxoplasmosis gondii Encephalitis: Seroprevalence varies
Greatest risk among patients with CD4+ count less than 50 cells per microliter.
Primary infection occurs after eating undercooked meat containing tissue cysts or ingestion of oocytes that have been shed in cat feces and have sporulated in the environment. No transmission of the organism occurs by person-to-person contact.

Most common clinical presentation: headache, confusion, motor weakness and fever
Physical examination might show neurological abnormalities. If there is no treatment it can progress to seizures, stupor and coma. CT scan or MRI of the brain will typically show multiple contrast-enhance lesions often with associated with edema but can manifest as single lesions as well.

HIV/AIDS Week 2 and 3


Nursing Inservice
Hepatitis C Virus Treatment Management of Side Effects

Feedback received:

Well organized
Right amount of information
Good slides

This week I would be presenting on the second part: Drug Interactions and management. I would continue to work-up patients and improve my skills.

Looking forward to this!