Wednesday, December 28, 2016

Oral to IV Conversion


  • The optimal time to consider switching a patient to oral therapy is after 2 to 4 days of intravenous therapy.T
  • his period of time allows the clinician to evaluate the patient’s microbiology results and assess their response to treatment. 
  • A large number of clinical trials support the early switching to oral antibiotics after this period of time with equal treatment efficacy and no adverse effects on patient outcome
  • A patient must meet a number
    of criteria prior to switching:
    • Display signs of clinical improvement (Box 1)
    • Able to tolerate oral therapy (Box 2)
    • Not have a condition in which higher concentrations of antibiotic are required in the tissue/prolonged course of IV therapy is essential(Box 4)
  • There are a number of conditions in which a switch to oral therapy should be considered including:
    • Pneumonia
    • Skin and soft tissue infections
    • Urinary tract infections
    • Uncomplicated Gram negative bacteraemia
    • Intra-abdominal infection without deep seated collections



References:
  1. Intravenous to Oral Switch Guideline for Adults Patients –can antibiotics S.T.O.P. South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR)
  2. Focus on Converting from IV to PO Antibiotic Therapy. 

IV to Oral Conversion: Ceftriaxone


Rationale
  • Unnecessarily prolonged courses of IV antibiotics are also associated with increased length of hospital stay, increased costs of nursing, pharmacy and medical time in the insertion of IV lines, preparation, dispensing and administration of IV agents and the increased morbidity and mortality associated with IV line infections
  • To optimise antibiotic use, a switch from IV antibiotics to oral therapy in the appropriate patient has a number of advantages
When to Switch
  • The optimal time to consider switching a patient to oral therapy is after 2 to 4 days of intravenous therapy.
  • This period of time allows the clinician to evaluate the patient’s microbiology results and assess their response to treatment.
  • A large number of clinical trials support the early switching to oral antibiotics after this period of time with equal treatment efficacy and no adverse effects on patient outcome
Agent of Choice
  • Recommendations for oral conversion are provided based on initial IV therapy.
  • The choice of oral antibiotics may be influenced by results of microbiologic studies, favoring more-narrow spectrum agents when possible.
  • Recommendations have been made to convert intravenous ceftriaxone, a third generation cephalosporin, to oral cefuroxime, a second-generation cephalosporin.
  • Intravenous ceftriaxone has no definitive oral equivalent and conversion to cefuroxime (Ceftin®) should be adequate following initial therapy with ceftriaxone.
  • If a specific pathogen is identified, therapy should be modified accordingly.
Pulmonary Infections
  • unstable patients (low severity CAP who require hospital admission for other reasons, such as unstable co-morbid illnesses or social needs) with CAP are suitable candidates for early switch therapy
  • consists of rapid initiation of 1-2 days of intravenous therapy followed by 5 days of oral therapy, with early hospital discharge after the administration of 1-2 doses of oral antibiotic (Augmentin or Cefuroxime)
  • patients treated with Ceftriaxone and Azithromycin can be downgraded to oral Azithromycin if indicated (or Doxycycline).
Intra-Abdominal Infections
  • Conversion to oral therapy with ciprofloxacin/metronidazole was as effective as continued intravenous therapy with ceftriaxone and oral metronidazole in patients who were able to tolerate oral feeding
 IV
 ORAL
Ceftriaxone 1g daily
Amoxycillin-clavulanate 875/125mg 12-hourly
or
Cefuroxime 500mg12-hourly (if respiratoryinfection)
Antimicrobial Stewardship Service, Melbourne Health
Ceftriaxone
1g-2g daily

Amoxycillin 875mg with clavulanic acid
125mg bd*
Intravenous to Oral Switch Guideline for Adults Patient
can antibiotics S.T.O.P.
Ceftriaxone 1 g IV daily 1,5+Azithromycin 500 mg PO x 1, then 250 mg PO daily x 4 more days
Cefuroxime (Ceftin) 500 mg PO Q12h(7 days total) and/or
Azithromycin 250 mg PO daily (5 days total)
Or
Levofloxacin 500 mg PO daily (7 days total)
Guidelines for the Empiric Management of Adult Patients with Community-Acquired Pneumonia (CAP) and IV to PO Conversion
*Consider patient allergy status when converting to a penicillin.
#Some drug doses may need to be reduced with decreased renal function.
References:
  1. Guidelines for the Empiric Management of Adult Patients with Community-Acquired Pneumonia (CAP) and IV to PO Conversion
  2. Intravenous-to-Oral Switch Therapy. http://emedicine.medscape.com/article/237521-overview
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4320166/
  4. ATS/IDSA Guidelines for HAP/VAP: AJRCCM 2005;171:388.
  5. Intravenous to Oral Switch Guideline for Adults Patients –can antibiotics S.T.O.P.
  6. A Quick Guide to Switch. Southern Health Therapeutics Committee

Tuesday, December 27, 2016

Apixaban : Perioperative

1.    Stop apixaban two days before the procedure (off apixaban for one day before the procedure and the day of the procedure).
2.    No bridging.
3.    Resume apixaban the day after the procedure, after at least 24 hours have elapsed when hemostasis secured. If the patient requires polyp removal, delay resumption of apixaban for one to two more days.
4.    Before resume the treatment, PT, APTT, signs and symptoms of bleeding should be monitored and assessed. If there is changes in these parameters delay resumption of apixaban at least 48 hours after the procedure.
5.    Bleeding risk should be assessed before doing any procedure. Table below shows the risk of bleeding for certain procedures :



                                                                                                                         

References
1.   Uptodate.com
2.  Guideline for patients receiving apixaban(eliquis) requiring emergency surgery or treatment for haemorrhage. (Nottingham University Hospital, NHS)

Friday, December 23, 2016

Anti-Tuberculosis: Dosing Adjustment in Obesity





 G Hall II, R. (2015). Evolving Larger: Dosing Anti-Tuberculosis (TB) Drugs in an Obese World. Current pharmaceutical design21(32), 4748-4751.

Pruritus: Differential Diagnosis

Table 1: Historical Findings That Suggest Etiologies for Pruritus

HISTORICAL FINDINGPOSSIBLE ETIOLOGIES
New cosmetics or creams
Allergic contact dermatitis, urticaria, photodermatitis
New medications, supplements, or illicit drugs
Urticaria, fixed drug eruptions
Recent travel
Pediculosis, scabies infestation, photodermatitis, urticaria
Hobby or occupational exposure to solvents, adhesives, cleaners
Irritant contact dermatitis, xerosis, atopic dermatitis, eczema
New animal exposures
Flea infestation, allergic contact dermatitis, urticaria
Sick contacts, especially those with febrile diseases and rashes
Rubeola, mumps, varicella, scarlet fever, cellulitis, fifth disease, folliculitis
Unexplained weight changes, menstrual irregularity, heat/cold intolerance
Thyroid disease with secondary urticaria or xerosis
Unexplained weight loss, night sweats, unexplained fevers, fatigue
Lymphoma with secondary generalized pruritus
Malaise, nausea, decreased urine output
Renal failure with generalized pruritus

Table 2: Dermatologic Etiologies for Pruritus

ETIOLOGYFEATURES
Allergic/irritant contact dermatitis
Sharply demarcated, erythematous lesion with overlying vesicles
Reaction within two to seven days of exposure
Atopic dermatitis
Pruritic area where rash appears when scratched in patients with atopic conditions (e.g., allergic rhinitis, asthma)
Involvement of flexor wrists and ankles, as well as antecubital and popliteal fossae
Bullous pemphigoid
Initially pruritic urticarial lesions, often in intertriginous areas
Formation of tense blisters after urticaria
Cutaneous T-cell lymphoma (mycosis fungoides)
Oval eczematous patch on skin with no sun exposure (e.g., buttocks)
Possible presentation of new eczematous dermatitis in older adults
Possible presentation of erythroderma (exfoliative dermatitis)
Dermatitis herpetiformis
Rare vesicular dermatitis affecting the lumbosacral spine, elbows, or knees
Dermatophyte infection
Localized pruritus and rash characterized by peripheral scaling and central clearing
Can occur on several sites, including the feet, scalp, trunk, and groin
Folliculitis
Pruritus out of proportion to appearance of dermatitis
Papules and pustules at follicular sites on chest, back, or thigh
Lichen planus
Lesions often located on the flexor wrists
Characterized by the six P's (pruritus, polygonal, planar, purple, papules, plaques)
Lichen simplex chronicus
Localized, intense pruritus
Initial erythematous, well-defined plaques with excoriations lead to thickened, lichenified, violaceous patches if scratching continues
Pediculosis (lice infestation)
Occiput in school-aged children; genitalia in adults (sexually transmitted)
Psoriasis
Plaques on extensor extremities, low back, palms, soles, and scalp
Scabies
Burrows in hand web spaces, axillae, and genitalia
Hyperkeratotic plaques, pruritic papules or scales
Face and scalp affected in children but not in adults
Sunburn
Possible photosensitizing cause (e.g., with use of nonsteroidal anti-inflammatory drugs or cosmetics)
Urticaria (hives)
Intensely pruritic, well-circumscribed, erythematous, and elevated wheals
Lesions may coalesce and wax and wane over several hours
Xerosis
Intense pruritus, often during winter months in northern climates
Involvement of back, flank, abdomen, waist, and lower extremities
More common in older persons

Table 3: Systemic Etiologies for Pruritus
Autoimmune
Dermatitis herpetiformis
Dermatomyositis
Linear immunoglobulin A disease
Sjögren syndrome
Hematologic
Hemochromatosis
Iron deficiency anemia
Mastocytosis
Plasma cell dyscrasias
Polycythemia vera
Hepatobiliary
Biliary cirrhosis
Chronic pancreatitis with obstruction of biliary tracts
Drug-induced cholestasis
Hepatitis, particularly hepatitis C
Sclerosing cholangitis
Infectious disease
AIDS
Infectious hepatitis
Parasitic disease (giardiasis, onchocerciasis, schistosomiasis, ascariasis)
Prion disease
Malignancy
Leukemia
Lymphoma
Multiple myeloma
Solid tumors with paraneoplastic syndrome
Metabolic and endocrine
Carcinoid syndrome
Chronic renal disease
Diabetes mellitus
Hyper/hypothyroidism
Hyperparathyroidism
Neurologic
Cerebral abscess
Cerebral tumor
Multiple sclerosis
Stroke
Other
Drug ingestion
Eating disorders with rapid weight loss
Neuropsychiatric disorders
Pregnancy

References:
1. American Family Physician: A Diagnostic Approach to Pruritus 
http://www.aafp.org/afp/2011/0715/p195.html
2. NCBI Chronic Pruritus and Treatment 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3119985/