_____________________________________________________________________________________________________ VOLUME 14.1 March 2010 EDITORS: Alina Lopo, M.D., Ph. D Susan Wee, Pharm.D. http://www.tarzanameded.com/pharmacy/pharmacy.html PHARMACY AND THERAPEUTICS Vancomycin Trough Value Revision COMMITTEE ACTIONS
nearly 50 years and has been a treatment of
FORMULARY:
choice for MRSA. Due to gradual development of resistant strains and limited
Additions: Micafungin (Micamine) Deletions: Caspofungin (Cancidas)
tissues, current guidelines published by the
POLICY UPDATE:
(IDSA), and the American Society of Health
Therapeutic Substitution Policy When Ordered Substituted With
targeting higher trough values for specific
Micamine
A target trough value of 15-20 mcg/ml is Metamucil
recommended for indications such as: (1)
pneumonia, (2) meningitis, (3) endocarditis,
Novolin (insulin regular)
(4) osteomyelitis, and (5) bacteremia. Trough
Phenergan
values of 10-15 mcg/ml may be sufficient for
(promethazine) IM
other indications. These higher trough values
for these indications have been shown to
have a better clinical outcome and less emergence of resistance2, 3. Heparin IV Protocol Medication Utilization Evaluation (MUE):
vancomycin monotherapy is rare (<1%) but
The MUE found that the revised protocol of
that risk is approximately 3 – 4 times higher
60 units/kg bolus and 12 unit/kg/hr initial
infusion achieved the target goal aPTT in 24
correlation between higher trough values (of
revision) with less patients exceeding facility
15-20 mcg/ml) and nephrotoxicity, however, it
upper therapeutic aPTT value of greater than
insufficiency since vancomycin is eliminated
Fewer patients were prescribed warfarin on
the first day of heparin IV protocol (33%
compared to 60% of pre-revision) for those
REFERENCES 1. Rybak M, Lomaestro B, et al. AJHP 2009. 66;82-
who could take oral medications. Physicians
are recommended to initiate warfarin on the
2. Howden BP, et al. Clin Infect Dis. 2004; 38:521-8.
first day of heparin or enoxaparin (Lovenox)
3. Sakoulas G J Clin Microbiol. 2004; 42:2398-402.
4. Zimmermann et al Pharmacotherapy.1995;15:85-
Antimicrobial Stewardship Report ADVERSE DRUG REACTIONS
76 year old female was started on Sotalol
changes of antibiotic based on culture and
80mg bid for a-fib and rapid ventricular rate.
sensitivity results and de-escalation of
(Baseline Scr = 1.41; CrCl = 36). The patient
diaphoresis, and renal insufficiency (Scr =
2.71; CrCl = 17). Sotalol was put on hold and
the patient was admitted inpatient for three
(metronidazole). Pip/tazo and metronidazole
both have an excellent anaerobic coverage
The manufacturer recommends that in order
and the prescribing both of the antibiotics
to minimize the risk of induced arrhythmia,
is unnecessary unless the patient is NPO
patients initiated or re-initiated sotalol should
be placed for a minimum of three days in a
INSTITUTE for SAFE MEDICATION PRACTICES (ISMP) UPDATE: 4th Quarter 2009 ADR Report: Is the figure below Provera, Prozac, or Proscar?
Analgesics and antibiotics continue to be the medication classes most frequently associated with ADR.
(medroxyPROGESTERone) 10 mg po daily. L2 enoxaparin and warfarin - severe epistaxis L2 linezolid IV – thrombocytopenia PROZAC (FLUoxetine) 10 mg po daily. The
L2 enalapril – bronchospasm & swelling
nurse did not detect the error when verifying
in the medication administration record.
MEDICATION UPDATE
The patient received one dose of Prozac.
Morphine Epidural in Cesarean Delivery:
The physician discovered the error the next
Observation studies report that the frequency
day while he was reviewing the patient’s
of respiratory depression ranges from 0.08%
to 3% when single-injection epidural morphine
are administered. 1 The studies also report
detected many errors). The handwritten order
that doses larger of 3.75mg did not further
was shown to several nurses, pharmacists,
increase analgesia.2 For cesarean delivery,
and physicians and some interpreted the
intrathecal doses of morphine greater than
order as Prozac, Provera or PROSCAR.
100 – 200 mcg and epidural doses greater
Poor handwriting was a contributing factor,
as was the fact that Provera is infrequently
It is recommended that initial dose of epidural morphine be less than 4 mg for
prescribed drug, perhaps biasing the reader’s
interpretation as “Prozac” on the handwritten
1. Horlocker TT et al. Anesthe 2009;110:218-230
2. Palmer CM et al. Anesth Analg 2000;90:887-91
3. Carvalho B. anesth Analg 2008; 107-956-61
DIRECTOR, PHARMACY SERVICES
CURRICULUM VITAE ROBERTO OGGERO , nato a Torino il 18/7/1947. Diploma di maturità classica presso il Liceo Classico "Cavour" di Torino nel Luglio Diploma di Laurea in Medicina e Chirurgia conseguito presso l'Università degli Studi di Torino il 13/7/1973 a pieni voti legali (100/110), con tesi di Laurea in Clinica Pediatrica dal titolo: "Le Mucopolisaccaridosi nel ' infanzia.&#
Philippa Levine, « Gendering Decolonisation », Histoire@Politique . Politique, culture, société , N°11, mai-août 2010, www.histoire-politique.fr Gendering Decolonisation Philippa Levine In the past twenty years or so, something of a revolution has occurred in the writing of British Empire history. Once the exclusive province of economic and of diplomatic and political history,
Antimicrobial Stewardship Report