Choice PharmD

🌟 Patient Case 🌟 We recently had an interesting patient case highlighting the utility of PCR testing in the clinical setting. A 74 y/o male presented with a chronic, non-healing wound for several months. He had been treated with various oral antibiotics, without any success. Several wound cultures were obtained, which revealed a mixture of gram-positive and gram-negative organisms, but was not able to speciate specific organisms. After several months, a wound specimen was sent for a multiplex PCR test. The following pathogens were detected: Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella pneumoniae, Bacteroides fragilis, Corynebacterium sp, and Enterococcus faecalis. In addition, CTX-M (ESBL), QNR, and vanA resistance genes were detected (among others). Our team of pharmacists reviewed the results and recommended meropenem + linezolid for 2-4 weeks as treatment for this patient's wound infection. The provider was quickly able to arrange administration of meropenem in the outpatient setting. The patient's wound significantly improved in the weeks to come. This was the provider's first experience using PCR for wound infections. She was very grateful for the rapid detection of results and recommendations for therapy! 

"My patient has an allergy to levofloxacin, can I use ciprofloxacin?"    We recently had a provider inquire about a patient, who presented with a chronic wound infection. PCR was performed on the wound specimen and Pseudomonas aeruginosa was detected. The patient had a documented allergy to levofloxacin with a listed reaction of severe rash. Ciprofloxacin was recommended for treatment, but the provider was hesitant, assuming the patient would be allergic to ciprofloxacin as well. Since this was an outpatient setting, an IV medication was not feasible to be utilized for treatment. Therefore, a fluoroquinolone remained the only oral option available for this patient.     Shah et al evaluated rates of fluoroquinolone cross-reactivity in 230 patients across 19 hospitals. Of the 161 patients who received a different fluoroquinolone after a documented allergy, only 6% (all female) experienced a hypersensitivity reaction. Rates of cross-reactivity differed per agent; highest risk with moxifloxacin (9%), followed by ciprofloxacin (6%), and levofloxacin (2%).    This data was relayed to the provider and she felt comfortable prescribing a course of ciprofloxacin to this patient. Diphenhydramine and famotidine PRN was recommended in the case of the patient developing a rash. https://lnkd.in/eag_KMB2

https://lnkd.in/gazJUkPq    Should everyone receive Paxlovid for Covid-19? Based on the EPIC-SR trial, researchers found that there is no benefit (defined as reduction in death, hospitalization, and/or symptom duration) in standard-risk individuals, with nirmatrelvir-ritonavir (Paxlovid) vs placebo. The median time to complete resolution of all signs and symptoms was 12 days in the Paxlovid group and 13 days in the placebo group (P=0.60). It is important to note, Paxlovid is still recommended for high-risk patients who are at risk for progression to severe disease. In this patient population, it has been shown to decrease the risk of hospitalization or death by 89% vs placebo (EPIC-HR). 

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