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RE: Curbside Consult Case for July

 
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RE: Curbside Consult Case for July - July 30, 2008 12:26:07 PM   
SJBird55

 

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I would tend to believe that there have been all sorts of antibiotics around for pneumonia.  First off, prevention is probably better than the actual disease.  The older population should probably receive the vaccine.  Second of all, when the FDA happens to suggest caution with 65+ folks, there's a good reason for that caution.  Their data is coming also from post-marketing.  (Think of how many tendon ruptures aren't reported!)  Medscape doesn't recommend the quinolones for 60+ year olds.  If there is a different option than the quinolones, that's the better option.  Better yet, communicate the side effect potential for tendon ruptures in that population - I highly doubt anyone 60+ (or anyone for that matter) is interested in a tendon rupture - their independence will be risked AND there will be an additional financial cost to society that probably could have been avoided.

(in reply to Dr.Wagner)
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RE: Curbside Consult Case for July - July 30, 2008 4:33:50 PM   
Dr.Wagner


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I appreciate your insight, but it should be noted that all medications warrent close observation and monitoring in patients over the age of 65, from Lipitor, to ASA, to insulin, to antibiotics...there are many complications and interactions.  Also, the FDA does not serve as a clinical policy maker, respective colleges and researchers  do (there are many examples of nonFDA approved uses of medications that are used thousands of times a day).  Example of the ACEP (American College of Emergency Physicians) clinical policy on management and treatment of CAP...borrowed from the American College of Chest Physicians.  Sometimes there are few effective choices due to allergies, interactions, or effectiveness in the face of co-morbidities (COPD, CAD, DM, Tobacco use, debility, PVD, CHF etc)
Outpatients
Generally preferred are (not in any particular order): doxycycline, a macrolide, or a
fluoroquinolone.
Selection considerations (see text, Management of Patients Who Do Not Require
Hospitalization).
These agents have activity against the most likely pathogens in this setting, which
include Streptococcus pneumoniae, Mycoplasma pneumoniae, and Chlamydia
pneumoniae.
Selection should be influenced by regional antibiotic susceptibility patterns for S
pneumoniae and the presence of other risk factors for drug-resistant S pneumoniae.
Penicillin-resistant pneumococci may be resistant to macrolides and/or doxycycline.
For older patients or those with underlying disease, a fluoroquinolone may be a
preferred choice; some authorities prefer to reserve fluoroquinolones for such
patients.

Hospitalized patients
General medical ward
Generally preferred are: an extended spectrum cephalosporin combined with a
macrolide or a ?-lactam/?-lactamase inhibitor combined with a macrolide or a
fluoroquinolone (alone).
Intensive care unit
Generally preferred are: an extended-spectrum cephalosporin or ?-lactam/?-
lactamase inhibitor plus either fluoroquinolone or macrolide.
Alternatives or modifying factors (see text, Management of Patients Who Are
Hospitalized, Special Considerations).
Structural lung disease: antipseudomonal agents (piperacillin, piperacillintazobactam,
carbapenem, or cefepime) plus a fluoroquinolone (including
high-dose ciprofloxacin).
?-Lactam allergy: fluoroquinolone±clindamycin.
Suspected aspiration: fluoroquinolone with or without clindamycin, metron

Now of course the overuse of fluoroquinolones has created resistance patterns, this is something that really causes problems.  Further, any antibiotic or drug needs to be CLOSELY watched for interactions and side effects.  Absolutely absolutely.  I see interactions every day, they can be anything from mildly annoying to life threatening...

I Love immunizations...if you can only get people to get them.  The CDC notes that 1. only 60% or so older than 65 get the pneumococcal vaccine and may only be 50% effective per the article Policies to increase influenza and pneumococcal immunizations in chronically ill and institutionalized settings .  The American Journal of Infection Control




< Message edited by Dr.Wagner -- July 30, 2008 4:40:15 PM >


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Dr. Wagner DO
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(in reply to SJBird55)
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RE: Curbside Consult Case for July - July 30, 2008 4:38:37 PM   
Dr.Wagner


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From: Indianapolis
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Please note the above is only an example of "why" a certain class of drug is used in a specific situation/disease state. 


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RE: Curbside Consult Case for July - July 30, 2008 5:31:15 PM   
SJBird55

 

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I'll disagree Wags.. the FDA has some heavy clout.  They can take a med right off the shelf.  ;)

In light of the new labeling by the FDA, I would be surprised that what you put in bold, italic, underlined text would be a current recommendation.  What is the date of that recommendation?

(in reply to Dr.Wagner)
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RE: Curbside Consult Case for July - July 30, 2008 7:15:40 PM   
buckeye

 

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sjbird - Appreciate the offer to send information. I do not send my email out over a forum and never the use the PM.

I notice the FDA information on fluoroguinolones states there are occurrences of spontaneous ruptures several months after the antibiotic was stopped. I also recall reading about one spontaneous that happened nine months after stopping the antibiotic.

It looks like we need to follow good precautions - unload the Achilles and gradual progressions with exercises. The article in PT Journal several years ago has some good information. It is available free at the APTA web site.

Vol. 82, No. 12, December 2002, pp. 1224-1231





 
Physical Therapist Management of Fluoroquinolone-Induced Achilles Tendinopathy
Brenda L Greene

(in reply to SJBird55)
Post #: 25
RE: Curbside Consult Case for July - July 30, 2008 7:52:52 PM   
Dr.Wagner


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Joined: January 25, 2003
From: Indianapolis
Status: offline
I think you unfortunately are falling into a medicolegal trap SJ...the FDA approves drugs, but does not create or set practice patterns...this is a VERY IMPORTANT POINT.  The FDA moves based upon clinical data and experimental data given to them.  There are VERY VERY few absolutes and MANY  MANY  WARNINGS.

Example: Zyvox is a new antibiotic used for complicated skin and soft tissue infections particularly by CA-MRSA.  Lets say it's $150 for 1 week usage.  Similarly BACTRIM DS is an antibiotic used and recommended by all authorities for soft tissue infections caused by CA-MRSA it costs $4 for 1 week usage.
Bactrim does not have FDA approval for use in skin infections caused by CA-MRSA.

Bactrim has a tremendous track record and is used daily and is affordable to the entire population; and is recommended by leaders in the field of infectious disease for treatment.

What do you do?


Well, the FDA does not create the clinical guidelines for treatment for professions, though they do state drug approved uses...each respective college and academic body attempts to move with the quick and ever changing practice patterns. 

The FDA is a governmental body and while they hold "power", sometimes their usefullness is questioned due to timeliness and relevance. 

The case presented was an example of simply a new "warning" not new information.  I read a case report about Cipro and achilles tendon rupture 10 years ago...this is not new information.

As for the Fluoroquinolone group, it is an exceedingly important drug group based upon class alone...but resistance patterns have changed practice patterns.

Once again, the group of drugs is VERY VERY useful...but as with any, there are warnings and things we need to watch. 

Perhaps pharmacology and side effects is something that we can focus on in future cases.


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Dr. Wagner DO
Moderator of Medical Complexity Forum

(in reply to buckeye)
Post #: 26
RE: Curbside Consult Case for July - July 30, 2008 9:15:37 PM   
buckeye

 

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Dr. Wagner - Pharmacology and its relevance to physical therapy sounds like a great idea.

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Post #: 27
RE: Curbside Consult Case for July - July 31, 2008 6:37:21 PM   
buckeye

 

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How about a patient with ACL reconstruction using patellar tendon graft who develops UTI about two weeks after surgery and is placed on Cipro? At this point, the patient is still early in the rehab - protective phase. But will the Cipro put the patellar tendon graft at risk?

(in reply to buckeye)
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