1 00:00:01,305 --> 00:00:01,345 - 2 00:00:05,935 --> 00:00:09,425 - This is an EM Impulse miniseries Push Dose pearls 3 00:00:09,735 --> 00:00:12,745 with your hosts, Sarah Maderis and Julia Magana. 4 00:00:17,745 --> 00:00:19,275 - Welcome back to EM Impulse. 5 00:00:19,905 --> 00:00:22,835 This is an episode of Push Dose Pearls. 6 00:00:22,835 --> 00:00:25,715 That's our ongoing series of brief podcasts 7 00:00:25,715 --> 00:00:27,715 that address the questions we all have 8 00:00:27,715 --> 00:00:30,595 regarding medications in the emergency department. 9 00:00:31,175 --> 00:00:34,555 And we are here with Chris Adams, our ED 10 00:00:35,075 --> 00:00:36,515 Clinical Pharmacist at uc, Davis, 11 00:00:36,735 --> 00:00:39,235 and our own EM Pulse pharmacist. 12 00:00:39,375 --> 00:00:41,115 I'm just gonna claim you Chris here, . 13 00:00:41,155 --> 00:00:42,995 I love it, . And 14 00:00:42,995 --> 00:00:46,035 - Today we're gonna be talking about antibiotics in the ed. 15 00:00:46,455 --> 00:00:47,715 See if there are any new updates 16 00:00:47,715 --> 00:00:48,875 that we need to be aware of. 17 00:00:49,095 --> 00:00:51,315 So, Chris, what is your favorite new antibiotic 18 00:00:51,375 --> 00:00:52,475 in the ED setting and why? 19 00:00:53,495 --> 00:00:55,775 - I think that the one that comes to mind 20 00:00:55,775 --> 00:00:58,215 that is a little bit more challenging, honestly, 21 00:00:58,715 --> 00:00:59,775 is Doba Vanson. 22 00:00:59,875 --> 00:01:01,775 - Yes, I knew you were gonna say that. . 23 00:01:02,805 --> 00:01:04,335 - It's a really fun idea. 24 00:01:04,595 --> 00:01:06,255 Um, but unfortunately it has a lot 25 00:01:06,255 --> 00:01:07,735 of pitfalls associated with it. 26 00:01:07,755 --> 00:01:11,015 And so we've been trying to find ways to utilize it safely 27 00:01:11,155 --> 00:01:13,895 and effectively, uh, where we're not breaking the bank, 28 00:01:13,955 --> 00:01:15,775 but also ensuring that we're giving it 29 00:01:15,775 --> 00:01:17,455 to the appropriate patients. 30 00:01:18,075 --> 00:01:19,095 - So walk us through that. 31 00:01:19,365 --> 00:01:20,495 What is the right way 32 00:01:20,515 --> 00:01:22,935 to use this really new cool medication? 33 00:01:22,955 --> 00:01:25,055 And remind us like how long it lasts. 34 00:01:25,055 --> 00:01:27,335 What are the indications, kind of how do we use this med? 35 00:01:27,555 --> 00:01:30,015 - So this is an extremely long acting medication. 36 00:01:30,235 --> 00:01:32,135 So you've got a half-life 37 00:01:32,165 --> 00:01:36,135 that provides a single dose regimen, meaning it lasts 38 00:01:36,155 --> 00:01:39,775 so long that generally speaking, only one dose is necessary 39 00:01:40,195 --> 00:01:41,535 for treating skin 40 00:01:41,535 --> 00:01:43,135 and soft tissue infection, simple skin 41 00:01:43,135 --> 00:01:44,615 and soft tissue infections. That's 42 00:01:44,615 --> 00:01:45,615 - So huge, Chris. 43 00:01:45,615 --> 00:01:46,735 Yeah, I mean like, just like, 44 00:01:46,745 --> 00:01:48,175 let's just pause here for a second. 45 00:01:48,575 --> 00:01:51,615 and recognize, let's do a moment of silence 46 00:01:51,875 --> 00:01:55,135 and, uh, recognition of how cool this is . 47 00:01:55,835 --> 00:02:00,175 - It really is a, a very huge potential for benefits here. 48 00:02:00,515 --> 00:02:03,335 And I think that with most emergency medicine, uh, 49 00:02:03,775 --> 00:02:06,855 interventions just a single dose in most cases, 50 00:02:07,355 --> 00:02:08,615 and that fixes the problem. 51 00:02:08,755 --> 00:02:10,895 That's lovely, right? That, that, who doesn't love that? 52 00:02:11,525 --> 00:02:14,535 However, the cost associated with this medication, though, 53 00:02:14,535 --> 00:02:16,815 it shouldn't dictate what therapy options we're using. 54 00:02:16,915 --> 00:02:19,295 It is a problem and that's probably why a lot 55 00:02:19,295 --> 00:02:21,815 of audience members haven't really heard of this before, 56 00:02:22,075 --> 00:02:25,335 or at least not used it before the right way 57 00:02:25,335 --> 00:02:27,695 or at least the, the way that we've found that works 58 00:02:27,715 --> 00:02:29,015 for the use of dovan 59 00:02:29,015 --> 00:02:33,055 or double vanson is by utilizing a three 40 B program. 60 00:02:33,275 --> 00:02:36,215 So that's a program that allows, um, uh, 61 00:02:36,615 --> 00:02:38,895 specific populations to receive or, 62 00:02:38,895 --> 00:02:40,735 and institutions that see those populations 63 00:02:40,735 --> 00:02:43,735 to receive a significantly lower drug cost 64 00:02:43,955 --> 00:02:45,215 for the specific medication. 65 00:02:45,835 --> 00:02:49,975 So the requirements for the population though is outpatient, 66 00:02:50,125 --> 00:02:51,975 meaning that patients that get admitted 67 00:02:52,035 --> 00:02:55,255 or are going to get admitted if you use this medication in 68 00:02:55,255 --> 00:02:58,375 them, then the, that lower cost no longer applies. 69 00:02:58,715 --> 00:03:01,045 So it kind of negates that the potential 70 00:03:01,045 --> 00:03:02,525 for a possible benefit here. 71 00:03:02,905 --> 00:03:05,885 So ensuring that we're utilizing this just in the emergency 72 00:03:05,885 --> 00:03:08,365 department and then discharging patients, that's perfect. 73 00:03:08,825 --> 00:03:10,285 But if they're, if there's a possibility, 74 00:03:10,285 --> 00:03:11,085 this patient's gonna get 75 00:03:11,245 --> 00:03:12,565 admitted and that becomes a problem. 76 00:03:12,755 --> 00:03:16,485 Okay. So first step, ensuring that they are, uh, a candidate 77 00:03:16,485 --> 00:03:18,045 to be immediately discharged 78 00:03:18,045 --> 00:03:20,005 or discharged apps after observation. 79 00:03:20,895 --> 00:03:23,515 - So we do have other treatments, oral treatments, 80 00:03:23,545 --> 00:03:26,315 cheaper treatments for cellulitis 81 00:03:26,335 --> 00:03:27,675 or other soft tissue infections. 82 00:03:28,015 --> 00:03:29,115 So when is the right time 83 00:03:29,135 --> 00:03:31,115 to be choosing dalvance in this patient 84 00:03:31,135 --> 00:03:32,435 or dalbavancin in this patient 85 00:03:32,435 --> 00:03:33,595 that you might be discharging? 86 00:03:34,185 --> 00:03:36,875 - It's situations in which you can't 87 00:03:37,175 --> 00:03:40,075 or won't be able to utilize PO options 88 00:03:40,575 --> 00:03:43,395 or where a patient has potentially failed Those other 89 00:03:43,395 --> 00:03:46,755 options, those situations may include, uh, 90 00:03:46,805 --> 00:03:47,995 where a patient was, 91 00:03:48,055 --> 00:03:50,035 has tried multiple different therapy options 92 00:03:50,095 --> 00:03:53,755 and they're just not working or they saw some benefit 93 00:03:54,055 --> 00:03:56,995 and, um, have had a relapse of their symptoms. 94 00:03:57,545 --> 00:04:01,395 Another common situation is when you have some type 95 00:04:01,395 --> 00:04:04,915 of barrier to therapy, whether that be an inability 96 00:04:05,215 --> 00:04:10,115 to seek therapy or a situation where patients are not able 97 00:04:10,115 --> 00:04:12,555 to be adherent to the therapy that was prescribed to them. 98 00:04:13,255 --> 00:04:15,555 In this situation, you can use a single dose 99 00:04:15,575 --> 00:04:19,235 of this medication and there is no need for adherence 100 00:04:19,295 --> 00:04:22,235 and there is relatively no need for follow up. 101 00:04:22,455 --> 00:04:25,275 And so in those really, really challenging, um, 102 00:04:25,335 --> 00:04:26,475 social situations 103 00:04:26,495 --> 00:04:27,715 or disposition situations, 104 00:04:28,365 --> 00:04:31,045 dalvance may be an appropriate option. 105 00:04:32,585 --> 00:04:34,625 - I love the idea of a single dose. 106 00:04:34,765 --> 00:04:37,945 Um, that's obviously really cool. Can I use this in kids? 107 00:04:39,035 --> 00:04:41,085 - It's looking like, yes. So there's new information 108 00:04:41,085 --> 00:04:44,565 and it looks like there's a new FDA approval for the use 109 00:04:44,665 --> 00:04:47,045 of dovan in a pediatric patient population 110 00:04:47,045 --> 00:04:48,685 for these simple skin soft tissue infections 111 00:04:49,275 --> 00:04:50,965 from a very early age. 112 00:04:51,145 --> 00:04:54,845 Uh, I'm quoting here the from birth, uh, and beyond. 113 00:04:54,865 --> 00:04:56,965 So it sounds like with pediatric patients, 114 00:04:56,975 --> 00:05:00,605 we're gonna be potentially utilizing dovan in appropriate 115 00:05:00,605 --> 00:05:01,725 situations going forward. 116 00:05:02,615 --> 00:05:04,945 - Alright, so let's talk about some other updates. 117 00:05:05,055 --> 00:05:07,145 What about for community acquired pneumonia? 118 00:05:07,175 --> 00:05:08,745 What is our go-to treatment these days? 119 00:05:09,285 --> 00:05:12,265 - So community acquired pneumonia was, uh, 120 00:05:12,405 --> 00:05:13,625 the guideline associated with 121 00:05:13,625 --> 00:05:15,505 that was relatively recently updated. 122 00:05:16,045 --> 00:05:19,305 And so the, the Go-to new option, 123 00:05:19,365 --> 00:05:20,985 and this is not gonna come to a surprise 124 00:05:20,985 --> 00:05:22,665 for any pediatric provider out there, 125 00:05:22,805 --> 00:05:24,545 but amoxicillin has made a comeback here. 126 00:05:25,005 --> 00:05:29,025 It has really dethroned the, uh, macrolides, uh, 127 00:05:29,245 --> 00:05:32,945 and uh, doxycycline as your initial therapy option. 128 00:05:33,285 --> 00:05:35,585 And now in both uncomplicated or 129 00:05:35,605 --> 00:05:37,985 or simple patients as well as uh, patients 130 00:05:37,985 --> 00:05:39,385 with significant comorbidities, 131 00:05:39,735 --> 00:05:41,305 amoxicillin is considered one 132 00:05:41,305 --> 00:05:43,185 of the first-line options for therapy. 133 00:05:44,045 --> 00:05:45,425 - So are the macrolides 134 00:05:45,425 --> 00:05:48,145 and doxycycline still considered first line as well? 135 00:05:48,495 --> 00:05:50,345 - They're considered alternative therapies. 136 00:05:50,405 --> 00:05:52,785 You certainly can turn to them in a situation 137 00:05:52,795 --> 00:05:54,625 where you have a beta-lactam allergy. 138 00:05:55,205 --> 00:05:59,005 Um, and in your patients that have significant comorbidities 139 00:05:59,005 --> 00:06:02,005 that are a little bit more complex, you will add a, uh, 140 00:06:02,075 --> 00:06:05,845 macrolide or um, uh, doxycycline onto them. 141 00:06:06,305 --> 00:06:09,165 Uh, however it is is no longer thought of 142 00:06:09,185 --> 00:06:10,765 as being the first line option 143 00:06:10,825 --> 00:06:12,325 for cap therapy in the community. 144 00:06:13,345 --> 00:06:14,765 - So what about Levofloxacin? 145 00:06:15,215 --> 00:06:18,525 - Great question. Monotherapy is still an acceptable option, 146 00:06:18,785 --> 00:06:20,965 but that's generally gonna be reserved for your, 147 00:06:21,195 --> 00:06:23,445 your patients with significant comorbidities such 148 00:06:23,445 --> 00:06:26,045 as chronic heart failure, lung, liver, renal disease, 149 00:06:26,405 --> 00:06:27,405 diabetes, alcoholism. 150 00:06:27,745 --> 00:06:31,485 In those situations, you, you can to turn to a monotherapy 151 00:06:31,665 --> 00:06:34,525 of a respiratory fluoroquinolone such as, uh, 152 00:06:34,595 --> 00:06:37,565 levo flux moxifloxacin or gemifloxacin. 153 00:06:38,065 --> 00:06:39,925 - And are we still super worried about all the 154 00:06:39,925 --> 00:06:41,125 side effects of quinolones 155 00:06:41,565 --> 00:06:42,565 - Y? 156 00:06:42,565 --> 00:06:44,845 Yeah, that was obviously an in vogue, uh, discussion 157 00:06:44,985 --> 00:06:46,005 and decision point. 158 00:06:46,225 --> 00:06:48,365 Um, but I really feel like the use 159 00:06:48,385 --> 00:06:51,885 of fluoroquinolones is still a very real option, 160 00:06:51,885 --> 00:06:54,445 especially in an appropriate patient population. 161 00:06:54,925 --> 00:06:56,445 I think that, that the majority 162 00:06:56,445 --> 00:06:58,525 of worry should be at least considered, 163 00:06:58,585 --> 00:07:01,405 but I don't think that they should be, um, causing you 164 00:07:01,425 --> 00:07:04,165 to change therapy if these are the appropriate options. 165 00:07:05,035 --> 00:07:07,205 - Okay. So I know how to dose amoxicillin 166 00:07:07,205 --> 00:07:10,685 for pneumonia in peds, but how are we dosing it for adults? 167 00:07:11,155 --> 00:07:13,605 - Amoxicillin in an adult patient population 168 00:07:13,635 --> 00:07:17,445 that does not have major comorbidities is just gonna be one 169 00:07:17,605 --> 00:07:20,805 gram three times daily in a patient population 170 00:07:20,805 --> 00:07:22,885 that has significant comorbidities. 171 00:07:22,975 --> 00:07:25,685 Again, chronic heart failure, lung, liver or renal disease. 172 00:07:25,685 --> 00:07:28,725 In those situations, you flip over into Augmentin 173 00:07:29,025 --> 00:07:33,525 and you dose that the the 500 TID or the 8 75 BID. 174 00:07:33,905 --> 00:07:35,205 - And how many days are we talking about 175 00:07:35,785 --> 00:07:36,785 - In general? 176 00:07:36,785 --> 00:07:38,725 That would be somewhere in the range of five to seven. 177 00:07:38,785 --> 00:07:40,205 And in those patients with significant 178 00:07:40,205 --> 00:07:41,645 comorbidities, you can bump it up to 10. 179 00:07:42,665 --> 00:07:44,115 - Okay. Let's talk about kids in a 180 00:07:44,115 --> 00:07:45,275 community acquired pneumonia. 181 00:07:45,825 --> 00:07:49,355 What is your first line treatment in your preschool patient 182 00:07:50,055 --> 00:07:51,235 - In in those situations? 183 00:07:51,315 --> 00:07:53,995 I don't feel like it changes too much, especially given 184 00:07:53,995 --> 00:07:57,515 that amoxicillin has always been our standby option in 185 00:07:57,515 --> 00:07:58,515 that patient population. 186 00:07:58,775 --> 00:08:01,275 Yep. And so I think that, uh, initiating therapy 187 00:08:01,625 --> 00:08:03,835 with amoxicillin is totally reasonable. Yeah, 188 00:08:04,155 --> 00:08:06,755 - I think that interesting thing in the preschool world is 189 00:08:06,755 --> 00:08:08,995 that that is so often a virus 190 00:08:09,105 --> 00:08:11,715 that there's definitely a little bit of pushback 191 00:08:11,715 --> 00:08:12,955 to be like, don't treat. 192 00:08:13,315 --> 00:08:15,235 I think that makes a lot of us nervous, 193 00:08:15,285 --> 00:08:18,035 especially if there's a low bar pneumonia that's there. 194 00:08:18,255 --> 00:08:20,715 If there's like little schmutzy viral schmutzy 195 00:08:20,715 --> 00:08:22,995 around Perry Hyler, um, I, 196 00:08:23,155 --> 00:08:25,235 I feel completely comfortable not treating 197 00:08:25,235 --> 00:08:27,555 that if the child's well appearing and stuff like that. 198 00:08:27,655 --> 00:08:30,515 But if there's a low bar pneumonia, even if it's virus, 199 00:08:30,875 --> 00:08:34,355 I still personally skew towards amoxicillin. 200 00:08:34,615 --> 00:08:37,275 But what about TID versus BID dosing 201 00:08:37,535 --> 00:08:38,875 for amoxicillin in kids? 202 00:08:39,505 --> 00:08:42,075 - It's looking like BID might be an option. 203 00:08:42,075 --> 00:08:44,995 Unfortunately, I don't think the primary literature is 204 00:08:44,995 --> 00:08:47,235 they're just yet to say that we should be flipping 205 00:08:47,795 --> 00:08:49,315 directly over to BID dosing. 206 00:08:49,695 --> 00:08:51,395 The benefit here would be it's just easier 207 00:08:51,535 --> 00:08:54,115 to administer these medications if you're doing it twice 208 00:08:54,115 --> 00:08:55,925 daily as opposed to three times daily. 209 00:08:56,115 --> 00:08:58,085 However, I still think that we should stick 210 00:08:58,085 --> 00:08:59,965 with the TID dosing regimen given 211 00:08:59,965 --> 00:09:01,525 that we're just not quite there yet. 212 00:09:01,715 --> 00:09:04,085 - Yeah, I'm, I'm ready for that swap 213 00:09:05,865 --> 00:09:06,965 for my kids for sure. 214 00:09:07,715 --> 00:09:09,205 Well what about the school age kids? 215 00:09:09,205 --> 00:09:10,725 Still primary amoxicillin 216 00:09:11,105 --> 00:09:13,125 - Pretty much now in, in those situations? 217 00:09:13,585 --> 00:09:17,285 Um, depending on what their comorbidities or are 218 00:09:17,385 --> 00:09:19,245 or how sick they're presenting, 219 00:09:19,605 --> 00:09:22,725 I think you can start considering other options, uh, as far 220 00:09:22,725 --> 00:09:24,645 as uh, adding on a macrolide 221 00:09:24,705 --> 00:09:26,645 or potentially using a fluoroquinolone. 222 00:09:26,675 --> 00:09:30,805 However, again, your standby in most, uh, situations 223 00:09:30,805 --> 00:09:33,845 for kids presenting with, uh, pneumonia like symptoms 224 00:09:33,865 --> 00:09:36,445 and that are likely gonna be discharged to outpatient, 225 00:09:37,125 --> 00:09:39,445 starting with amoxicillin is likely gonna be a good choice. 226 00:09:39,715 --> 00:09:41,245 - Yeah. And I just have that discussion 227 00:09:41,245 --> 00:09:42,645 of like, we're gonna start here. 228 00:09:43,045 --> 00:09:45,445 I think this is gonna work, especially if it's low bar, 229 00:09:45,445 --> 00:09:47,245 which honestly is most of the pneumonias 230 00:09:47,245 --> 00:09:48,645 that I'm treating with antibiotics. 231 00:09:49,105 --> 00:09:52,005 And then keep in touch with your pediatrician. Absolutely. 232 00:09:52,005 --> 00:09:53,285 We'll see if we need to change things. Yeah. 233 00:09:54,475 --> 00:09:57,725 - Talk to me about STIs or sexually transmitted infections 234 00:09:57,725 --> 00:09:59,325 because I know there have been some changes. 235 00:09:59,835 --> 00:10:02,405 - Yeah, this is an area that, uh, I work a lot in. 236 00:10:02,585 --> 00:10:07,325 Um, in uh, 2021, the CDC updated their treatment guidelines 237 00:10:07,345 --> 00:10:09,605 and so there are some pretty significant changes 238 00:10:09,835 --> 00:10:11,205 that we do need to talk about 239 00:10:11,545 --> 00:10:14,445 and that we're still seeing the old practices trickle in. 240 00:10:14,465 --> 00:10:17,085 So certainly an important area to discuss. 241 00:10:17,625 --> 00:10:20,805 So first for OC infections, the old standby 242 00:10:21,065 --> 00:10:25,045 of ceftriaxone two 50 IM is a thing of the past. 243 00:10:25,745 --> 00:10:29,605 We have now, uh, been seeing significant rates of resistance 244 00:10:29,875 --> 00:10:31,285 with that dosing pattern. 245 00:10:31,465 --> 00:10:34,525 And so the new recommendation is to provide patients 246 00:10:34,525 --> 00:10:38,085 with a dose of ceftriaxone 500 milligrams for those 247 00:10:38,085 --> 00:10:41,845 that are left less than 150 kilos if greater than that, 248 00:10:41,845 --> 00:10:43,685 in those obese patients, it is recommended 249 00:10:43,685 --> 00:10:46,245 to give a full gram of ceftriaxone. 250 00:10:47,015 --> 00:10:48,275 - Are you still giving that? I am 251 00:10:48,815 --> 00:10:49,815 - So yes. 252 00:10:49,815 --> 00:10:51,555 And, and, and the volume isn't too much, 253 00:10:51,615 --> 00:10:53,755 but uh, I am can be utilized. 254 00:10:53,755 --> 00:10:55,955 However, if you have a line, use it. 255 00:10:56,295 --> 00:11:00,755 So that old uh, um, uh, myth of the depot effect associated 256 00:11:00,755 --> 00:11:03,595 with I am ceftriaxone has been, uh, disproven 257 00:11:03,975 --> 00:11:07,555 and realistically, um, we can use either IV 258 00:11:07,615 --> 00:11:10,555 or Im depending on what with whatever is available, 259 00:11:10,695 --> 00:11:12,475 but if you don't have a line, you don't need it. 260 00:11:13,095 --> 00:11:15,555 - And at our shop we also give that with lidocaine, 261 00:11:15,555 --> 00:11:16,795 if we're giving it Im, 'cause 262 00:11:16,795 --> 00:11:17,875 it can be pretty uncomfortable. 263 00:11:18,175 --> 00:11:19,235 - It can be certainly. And 264 00:11:19,235 --> 00:11:20,995 and lidocaine is certainly a nice touch. 265 00:11:21,055 --> 00:11:22,315 It, it certainly can help. 266 00:11:22,735 --> 00:11:24,115 Um, but it's still gonna be painful. 267 00:11:24,335 --> 00:11:27,315 - Oh yeah, it is , lemme tell you, it is . 268 00:11:28,175 --> 00:11:30,275 - Uh, next up is chlamydia 269 00:11:30,535 --> 00:11:33,555 for those infections we have now switched gears. 270 00:11:33,815 --> 00:11:37,915 Um, the old option was azithromycin one gram orally 271 00:11:37,915 --> 00:11:38,955 just one time and that's it. 272 00:11:39,495 --> 00:11:42,515 Uh, and then quinolones were also a kind of a thing 273 00:11:42,515 --> 00:11:44,075 of the past these days. 274 00:11:44,175 --> 00:11:47,275 We are now, uh, recommending doxycycline 100 milligrams 275 00:11:47,275 --> 00:11:48,595 twice daily for seven days. 276 00:11:48,615 --> 00:11:49,915 So that's a major shift here. 277 00:11:50,375 --> 00:11:52,115 And as you can see, if 278 00:11:52,215 --> 00:11:53,965 as you look at all these different options, 279 00:11:54,335 --> 00:11:58,245 these one single dose options are becoming a thing 280 00:11:58,245 --> 00:12:01,805 of the past and, and or the dosing is having to be increased 281 00:12:01,805 --> 00:12:03,165 because of resistance patterns. 282 00:12:03,465 --> 00:12:07,045 So the chlamydia infections are another, uh, situation 283 00:12:07,095 --> 00:12:09,645 where we're having to switch to a seven day course. 284 00:12:10,705 --> 00:12:12,845 - Now I feel like a lot of the patients 285 00:12:12,845 --> 00:12:14,765 that I see in the emergency department, 286 00:12:15,045 --> 00:12:18,925 I don't know the name of the STI, I just know that they have 287 00:12:19,455 --> 00:12:22,445 Citis or UR arthritis or PID 288 00:12:22,585 --> 00:12:24,885 and I'm like, okay, I'm just, you know, 289 00:12:25,045 --> 00:12:29,205 I I'm worried about this particular STI possibility here. 290 00:12:29,675 --> 00:12:31,645 What do you recommend for 291 00:12:32,205 --> 00:12:34,525 treating patients presumptively versus testing 292 00:12:34,745 --> 00:12:38,005 and waiting to find out what the name of the bug is? 293 00:12:39,095 --> 00:12:41,795 - So I, I think that in most situations, 294 00:12:41,965 --> 00:12:43,675 especially if they're symptomatic 295 00:12:43,935 --> 00:12:46,795 or potentially if they describe a really high risk 296 00:12:46,985 --> 00:12:49,755 lifestyle, treating empirically is, 297 00:12:49,935 --> 00:12:53,115 is a very useful option for several reasons. 298 00:12:53,445 --> 00:12:56,275 First of all, you are decreasing the risk 299 00:12:56,275 --> 00:12:58,235 that the patient's gonna be a loss to follow up. 300 00:12:58,495 --> 00:12:59,875 Uh, if you don't treat the patient 301 00:12:59,935 --> 00:13:03,195 and have a, a really extensive, uh, callback program 302 00:13:03,195 --> 00:13:04,555 where we're gonna call the patient 303 00:13:04,815 --> 00:13:06,715 and ensure that they receive appropriate 304 00:13:06,715 --> 00:13:08,755 therapy in those situations. 305 00:13:08,895 --> 00:13:11,915 We have somewhere in the range of 50 to 75% of patients 306 00:13:12,295 --> 00:13:13,875 who are completely lost to follow up. 307 00:13:13,875 --> 00:13:15,075 Meaning we can't get ahold of them, 308 00:13:15,075 --> 00:13:16,875 they don't have an appropriate phone number on file. 309 00:13:16,875 --> 00:13:18,075 They don't have an address on file. 310 00:13:18,455 --> 00:13:21,075 And so the potential to the community 311 00:13:21,135 --> 00:13:24,315 for further spread from that individual is significant. 312 00:13:24,975 --> 00:13:27,675 In addition, um, if you are treating empirically, 313 00:13:27,675 --> 00:13:30,235 you're providing therapy earlier obviously, 314 00:13:30,575 --> 00:13:33,035 and so you're reducing the amount of time that, that, 315 00:13:33,145 --> 00:13:35,355 that individual can potentially spread 316 00:13:35,355 --> 00:13:37,115 that infection throughout the community. 317 00:13:37,495 --> 00:13:41,475 So I do think that it is a appropriate use of resources 318 00:13:41,475 --> 00:13:43,915 to provide empiric therapy in situations. 319 00:13:44,215 --> 00:13:48,195 But in your patient that is, um, is not symptomatic 320 00:13:48,735 --> 00:13:52,075 and doesn't have a, a significant high risk behavior, 321 00:13:52,505 --> 00:13:55,315 realistically we could potentially await in those patients. 322 00:13:55,785 --> 00:13:57,155 - What about metronidazole? 323 00:13:57,895 --> 00:14:02,715 - So metronidazole or FLAG is, uh, another situation that 324 00:14:03,295 --> 00:14:05,435 can be utilized certainly in a situation 325 00:14:05,435 --> 00:14:09,675 where you have a concern for tri ssis or PID 326 00:14:09,675 --> 00:14:13,115 or pelvic inflammatory disease In those situations, uh, 327 00:14:13,205 --> 00:14:17,395 we're again no longer doing the single oral therapy option 328 00:14:17,615 --> 00:14:19,435 in young women in the, in 329 00:14:19,435 --> 00:14:22,595 that situation we're doing Metronidazole 500 milligrams 330 00:14:22,595 --> 00:14:24,675 orally twice daily for seven days. 331 00:14:25,375 --> 00:14:28,715 Now in men that are presenting, uh, with symptoms that are 332 00:14:28,715 --> 00:14:31,355 concerning for tricho isis, in those situations, 333 00:14:31,375 --> 00:14:35,395 the two gram dose of metronidazole is an appropriate option. 334 00:14:35,395 --> 00:14:37,955 That single dose, uh, however, again, 335 00:14:37,955 --> 00:14:39,275 because of resistance patterns 336 00:14:39,275 --> 00:14:41,955 and failures of therapy, that seven day course 337 00:14:41,975 --> 00:14:45,435 of flagal is now an appropriate option in PID. 338 00:14:45,565 --> 00:14:46,995 We're adding on Flagal 339 00:14:46,995 --> 00:14:50,955 or Metronidazole for now 14 days in those situations. 340 00:14:51,265 --> 00:14:52,645 Uh, and again it's 341 00:14:52,645 --> 00:14:54,925 because we're just, we're seeing some failures of therapy 342 00:14:56,035 --> 00:14:57,815 - Now for some of my patients, especially 343 00:14:57,815 --> 00:14:59,255 with the, the cervicitis. 344 00:14:59,515 --> 00:15:03,255 Um, or for a male, um, UR arthritis related to an STI, 345 00:15:04,005 --> 00:15:06,695 they may have a really difficult time adhering to 346 00:15:06,695 --> 00:15:08,375 that seven day course of antibiotics. 347 00:15:08,795 --> 00:15:10,815 Is there still a role for 348 00:15:10,815 --> 00:15:13,055 that one-time dose in select patients? 349 00:15:13,555 --> 00:15:16,815 - Yes, there is. So the, the one-time dose specifically 350 00:15:16,835 --> 00:15:20,135 of azithromycin you're referring to is an option. 351 00:15:20,395 --> 00:15:22,615 Um, however, due to treatment failures 352 00:15:22,615 --> 00:15:24,535 and resistance patterns, that's why the switch took place. 353 00:15:24,845 --> 00:15:28,975 However, because we do see patients where adherence 354 00:15:29,155 --> 00:15:32,015 to therapy options is likely gonna be a challenge, 355 00:15:32,615 --> 00:15:35,455 azithromycin still does have a place in therapy. 356 00:15:36,155 --> 00:15:39,455 Now we are seeing actually some providers using both options 357 00:15:39,585 --> 00:15:41,735 where they're giving azithromycin 358 00:15:42,035 --> 00:15:44,575 and giving a prescription for doxycycline 359 00:15:44,655 --> 00:15:45,815 'cause it's the preferred option. 360 00:15:46,395 --> 00:15:48,415 And that way they're ensuring that some kind 361 00:15:48,415 --> 00:15:49,655 of therapy is being provided. 362 00:15:50,185 --> 00:15:51,655 Seems like a little bit of overkill, 363 00:15:51,655 --> 00:15:54,095 but at the same time, it's probably in the patient's best 364 00:15:54,335 --> 00:15:57,255 interest if there truly is gonna be a major, uh, barrier 365 00:15:57,395 --> 00:15:59,535 to adherence to a medication therapy. That's 366 00:15:59,535 --> 00:16:00,535 - Really interesting. 367 00:16:00,535 --> 00:16:03,535 I've not heard that, but I have had significant concerns 368 00:16:03,545 --> 00:16:06,135 about patients completing this doxy course. 369 00:16:06,655 --> 00:16:07,695 I mean, it, I get it. 370 00:16:07,855 --> 00:16:10,455 I read the data, I understand why this is important. 371 00:16:10,835 --> 00:16:13,335 It just feels like this is a population 372 00:16:13,335 --> 00:16:14,495 that we're gonna see. 373 00:16:14,855 --> 00:16:16,935 I I'm just interested to see what's gonna happen in the 374 00:16:16,935 --> 00:16:19,415 future because I think there's gonna be a massive 375 00:16:19,435 --> 00:16:20,695 amount of non-compliance. 376 00:16:21,335 --> 00:16:23,095 - Absolutely. I think that as time goes on, 377 00:16:23,105 --> 00:16:25,535 we're gonna continuously have to increase doses 378 00:16:25,535 --> 00:16:26,615 and extend therapies. 379 00:16:27,315 --> 00:16:28,655 - And I just wanna throw out there too 380 00:16:28,655 --> 00:16:31,295 that the new CDC guidelines no longer require you 381 00:16:31,295 --> 00:16:33,535 to get a cervical sample to send. 382 00:16:33,635 --> 00:16:35,855 Yes. So we don't need to be doing pelvic exams. 383 00:16:35,995 --> 00:16:39,095 In fact, patients can even do a self swab to send, 384 00:16:39,185 --> 00:16:40,335 which makes it a lot easier 385 00:16:40,635 --> 00:16:44,135 and less invasive if a patient doesn't want a pelvic exam. 386 00:16:44,875 --> 00:16:46,535 Now Chris, I had another question too. 387 00:16:47,195 --> 00:16:49,055 We are seeing a resurgence of syphilis. 388 00:16:49,235 --> 00:16:50,415 Do you think we're gonna get to a point 389 00:16:50,415 --> 00:16:52,535 where we're treating empirically for syphilis as well? 390 00:16:52,825 --> 00:16:54,895 - We're seeing that intermittently. 391 00:16:55,075 --> 00:16:56,495 Um, and you're absolutely right. 392 00:16:56,495 --> 00:16:59,575 Within our own shop, we do see a huge amount 393 00:16:59,635 --> 00:17:01,935 of syphilis cases and it's really shocking 394 00:17:01,935 --> 00:17:04,895 because we generally, you consider syphilis kind of a thing 395 00:17:04,895 --> 00:17:06,535 of the past, but that's really not the case. 396 00:17:07,005 --> 00:17:10,375 Realistically, it is prevalent in many communities 397 00:17:10,555 --> 00:17:11,935 and empiric therapy 398 00:17:12,755 --> 00:17:16,135 in some situations certainly could be an appropriate, 399 00:17:16,315 --> 00:17:17,495 you know, uh, option. 400 00:17:17,795 --> 00:17:20,575 So I think that, uh, it kind of goes back to 401 00:17:20,885 --> 00:17:23,895 what the pres the patient is, is, um, 402 00:17:24,045 --> 00:17:26,095 what information they're providing us if they have 403 00:17:26,095 --> 00:17:27,135 that high risk lifestyle 404 00:17:27,595 --> 00:17:30,175 or if they have symptoms that are specifically concerning 405 00:17:30,175 --> 00:17:32,615 for syphilis, absolutely treating empirically 406 00:17:33,255 --> 00:17:37,215 syphilis is appropriate and it's, I wouldn't say it's benign 407 00:17:37,375 --> 00:17:38,535 'cause it's very painful. 408 00:17:39,075 --> 00:17:41,375 Um, but that, that shot of penicillin is not fun. 409 00:17:41,445 --> 00:17:44,935 However, realistically giving a dose of penicillin, 410 00:17:45,375 --> 00:17:48,335 I mean the, the collateral damage associated with 411 00:17:48,335 --> 00:17:50,885 that simple antibiotic is, is very minimal. 412 00:17:51,465 --> 00:17:52,645 So I think that giving 413 00:17:52,715 --> 00:17:55,885 that in in certain situations is totally reasonable. 414 00:17:56,305 --> 00:17:59,725 And again, it, it will prevent us from having these lost 415 00:17:59,725 --> 00:18:01,365 to follow up patients, um, 416 00:18:01,545 --> 00:18:03,685 and prolonging the duration of time 417 00:18:03,795 --> 00:18:06,165 that this patient may potentially be spreading 418 00:18:06,165 --> 00:18:07,245 it within the community. 419 00:18:08,065 --> 00:18:09,525 - And can that be given iv? 420 00:18:09,985 --> 00:18:13,205 - So IV is a completely separate type of penicillin 421 00:18:13,505 --> 00:18:15,685 and it's a much longer duration. 422 00:18:15,755 --> 00:18:16,845 Yeah. And so ensuring 423 00:18:16,845 --> 00:18:19,165 that you're getting the right agent the right route 424 00:18:19,185 --> 00:18:20,805 to is certainly important. 425 00:18:21,025 --> 00:18:22,245 So it can be given iv, 426 00:18:22,265 --> 00:18:25,085 but it's generally in like a neurosyphilis situation. 427 00:18:25,755 --> 00:18:26,965 - Okay. Let's jump over 428 00:18:26,985 --> 00:18:28,765 to uncomplicated UTIs, 429 00:18:29,365 --> 00:18:31,605 urinary tract infections. Anything new we need to know? 430 00:18:32,225 --> 00:18:36,365 - So there's a few things. So with uncomplicated UTIs, 431 00:18:36,545 --> 00:18:38,805 the standard therapy options still apply. 432 00:18:38,865 --> 00:18:41,485 You have your beta-lactams, you have macro bit 433 00:18:41,485 --> 00:18:42,765 or nitro toin. 434 00:18:42,865 --> 00:18:45,125 You could potentially use phosphomycin. 435 00:18:45,225 --> 00:18:48,965 You have Bactrim or Trimeth, uh, sulfamethoxazole. 436 00:18:49,425 --> 00:18:52,605 And then finally, um, you have your fluoroquinolones. 437 00:18:52,665 --> 00:18:54,245 All of those are still options. 438 00:18:55,065 --> 00:18:56,245 Uh, but the one that, 439 00:18:56,245 --> 00:18:57,485 there's two things that I wanna touch on. 440 00:18:57,485 --> 00:18:59,685 First of all, the old dogma associated 441 00:18:59,685 --> 00:19:02,725 with Nitro ferone cannot be used in male patients. 442 00:19:03,065 --> 00:19:06,165 That's not true. So there's new, new evidence 443 00:19:06,165 --> 00:19:09,525 that's emerging that is suggesting that the use of Macrobid 444 00:19:09,525 --> 00:19:14,245 or Nitro ferone is totally legitimate in a uncomplicated 445 00:19:14,435 --> 00:19:15,645 male patient population. 446 00:19:15,945 --> 00:19:18,005 It, it, it provides just as good a coverage. 447 00:19:18,005 --> 00:19:19,925 And so realistically that's an option 448 00:19:19,925 --> 00:19:21,365 that we really should be utilizing 449 00:19:21,365 --> 00:19:23,765 because of, again, that collateral damage. 450 00:19:23,765 --> 00:19:25,325 There's very little associated with it 451 00:19:25,625 --> 00:19:28,325 and it's a very effective, well tolerated medication. 452 00:19:28,665 --> 00:19:31,245 - So I was always taught that AUTI in a male is 453 00:19:31,345 --> 00:19:33,205 by definition complicated, 454 00:19:33,385 --> 00:19:34,605 but we're talking about a patient 455 00:19:34,635 --> 00:19:37,005 with maybe only cystitis symptoms in an 456 00:19:37,005 --> 00:19:38,245 otherwise pretty healthy patient. 457 00:19:38,965 --> 00:19:40,165 - Absolutely, that's correct cystitis. 458 00:19:40,505 --> 00:19:43,005 And there's no concern for poly nephritis 459 00:19:43,345 --> 00:19:46,205 and there's no anatomical challenges associated 460 00:19:46,235 --> 00:19:47,685 with their urinary system. 461 00:19:48,845 --> 00:19:52,455 - What about kids with uncomplicated UTIs? 462 00:19:52,675 --> 00:19:53,855 How do you approach treatment with them? 463 00:19:54,325 --> 00:19:56,855 - Generally speaking, I think that initiating therapy 464 00:19:57,125 --> 00:19:59,455 with aid beta-lactam is, is, 465 00:19:59,635 --> 00:20:02,495 is an appropriate first-line option for these patients 466 00:20:02,755 --> 00:20:04,015 or macrobid from that matter, 467 00:20:04,015 --> 00:20:05,375 depending on what their age is. 468 00:20:05,675 --> 00:20:08,855 But I do think that those two options are, are fairly safe 469 00:20:09,035 --> 00:20:11,175 and effective in that patient population 470 00:20:11,175 --> 00:20:13,855 and usually we'll cover the etiology, the bacteria 471 00:20:13,855 --> 00:20:16,135 that we're most commonly concerned about. 472 00:20:16,915 --> 00:20:19,335 So those two are, are generally my go-to options. 473 00:20:19,715 --> 00:20:21,175 - And by beta-lactam you're talking about 474 00:20:21,175 --> 00:20:22,215 like an amoxicillin, 475 00:20:23,245 --> 00:20:25,895 - Amoxicillin or a, uh, Keflex or, 476 00:20:26,075 --> 00:20:28,855 or um, a uh, septinine. 477 00:20:29,065 --> 00:20:31,815 Those type of beta-lactams are usually very effective. Yeah, 478 00:20:32,045 --> 00:20:33,045 - Yeah. 479 00:20:33,045 --> 00:20:36,655 My go-to is Keflex in the uncomplicated UTI in a child. 480 00:20:37,155 --> 00:20:38,575 It is kind of sucky 481 00:20:38,575 --> 00:20:40,615 because of the frequency of dosing of course, 482 00:20:41,315 --> 00:20:44,055 but the resistance patterns works well 483 00:20:44,075 --> 00:20:47,380 for our site in particular, amoxicillin has kind of gone out 484 00:20:47,380 --> 00:20:49,445 of favor because of the resistance, uh, 485 00:20:49,445 --> 00:20:52,005 that e coli has shown towards amoxicillin. I 486 00:20:52,005 --> 00:20:53,005 - Agree. 487 00:20:53,005 --> 00:20:55,445 We most commonly utilize Keflex. Uh, absolutely. 488 00:20:55,515 --> 00:20:56,885 Generally the only time we're turning 489 00:20:56,885 --> 00:20:59,325 to amoxicillin is if you actually have culture data 490 00:20:59,325 --> 00:21:00,605 that really supports its use. 491 00:21:00,865 --> 00:21:05,845 - Yes, absolutely. Now the complicated UTI, the febrile UTI, 492 00:21:05,985 --> 00:21:08,845 the patient that has kidney involvement in a 493 00:21:08,845 --> 00:21:10,085 child, how do you approach that? 494 00:21:10,555 --> 00:21:13,765 - Depending on age, oftentimes the option 495 00:21:13,785 --> 00:21:16,125 for adult patients also holds true pediatrics. 496 00:21:16,265 --> 00:21:18,285 We frequently turn to fluoroquinolones 497 00:21:18,285 --> 00:21:19,845 or levofloxacin in, in our case, 498 00:21:20,565 --> 00:21:23,285 frequently in these situations as it is the first line 499 00:21:23,305 --> 00:21:26,045 or guideline recommended agent for a pyelonephritis 500 00:21:26,065 --> 00:21:28,365 or a significantly complicated UTI. 501 00:21:29,365 --> 00:21:34,295 - Yeah, I tend to go more towards the cine ears in our kids. 502 00:21:34,435 --> 00:21:36,535 Um, and I like the one-day dosing 503 00:21:36,845 --> 00:21:38,895 that you can get, um, with that. 504 00:21:39,275 --> 00:21:42,335 Um, so that's my usual go-to in the more 505 00:21:42,335 --> 00:21:44,215 complicated pediatric patient. 506 00:21:44,855 --> 00:21:47,215 I did Bactrim for years on them 507 00:21:47,715 --> 00:21:49,015 and I felt like that was good. 508 00:21:49,015 --> 00:21:50,615 But the resistance pattern is starting 509 00:21:50,615 --> 00:21:52,495 to show increased resistance to Bactrim. 510 00:21:52,515 --> 00:21:53,975 So I've been switching over 511 00:21:53,995 --> 00:21:56,895 and again, the once day dosing is kind of brilliant . 512 00:21:57,685 --> 00:21:59,125 - I don't think that there's any problem with that. 513 00:21:59,205 --> 00:22:02,405 I think the use of beta-lactams like ceftin are totally 514 00:22:02,415 --> 00:22:04,885 legitimate in these pyelonephritis patients. 515 00:22:05,345 --> 00:22:08,205 The only reason why, uh, levofloxacin 516 00:22:08,205 --> 00:22:11,605 or fluoroquinolone was recommended by guidelines 517 00:22:11,605 --> 00:22:15,445 for pyelonephritis was there was a slight increase in the, 518 00:22:15,705 --> 00:22:18,965 the number of relapses or recurrent UTIs 519 00:22:18,965 --> 00:22:21,725 or pyelonephritis in an adult patient population. 520 00:22:21,725 --> 00:22:24,445 So that's the only reason. But that data is really old now. 521 00:22:24,585 --> 00:22:27,125 And the reality is resistance patterns have likely changed 522 00:22:27,125 --> 00:22:28,125 with fluoroquinolones. 523 00:22:28,185 --> 00:22:31,285 And I think that utilizing a beta-lactam like ceftin ear, 524 00:22:31,395 --> 00:22:33,725 even in a pediatric population is totally legitimate. 525 00:22:33,875 --> 00:22:35,565 - Yeah, cine is affix amine. 526 00:22:35,775 --> 00:22:38,805 Those are kind of nice go-to dosing 527 00:22:39,065 --> 00:22:41,205 and have shown pretty good in kids 528 00:22:41,205 --> 00:22:43,245 with complicated UTIs for discharge. 529 00:22:43,245 --> 00:22:44,805 Like that's where a lot of our data is 530 00:22:45,545 --> 00:22:48,125 - Now in the adult patient with that complicated UTI 531 00:22:48,145 --> 00:22:49,365 or pilo, um, 532 00:22:49,425 --> 00:22:51,605 we know Macrobid doesn't concentrate well on the kidneys. 533 00:22:51,605 --> 00:22:54,045 So that's out. And you've mentioned these other ones, the, 534 00:22:54,185 --> 00:22:58,245 um, quinolones, uh, trimeth sulfamethoxazole or Bactrim 535 00:22:58,545 --> 00:23:00,965 and our, um, cephalosporins, those tend 536 00:23:00,965 --> 00:23:02,205 to be the three that we think about. 537 00:23:03,525 --> 00:23:06,245 I know that the quinolones are sort 538 00:23:06,245 --> 00:23:09,245 of ideal from a bacteriology standpoint, if 539 00:23:09,245 --> 00:23:11,245 that's the right word, but we also know that a lot 540 00:23:11,245 --> 00:23:14,045 of our adult patients we have concern for prolonged QT 541 00:23:14,145 --> 00:23:15,365 or other complications. 542 00:23:15,875 --> 00:23:18,445 What do you recommend for in terms of these three 543 00:23:18,785 --> 00:23:21,205 - If you're looking to avoid a fluoroquinolone? 544 00:23:21,545 --> 00:23:24,485 Uh, I think that the use of a beta-lactam 545 00:23:24,485 --> 00:23:27,765 or cephalosporin in these situations is, is a great place 546 00:23:27,765 --> 00:23:28,965 to start now. 547 00:23:29,185 --> 00:23:32,285 Um, pyelonephritis should be treated 548 00:23:32,285 --> 00:23:34,245 effectively by this agent. 549 00:23:34,345 --> 00:23:37,805 Um, and uh, theoretically you should be able to use Bactrim 550 00:23:38,025 --> 00:23:40,925 as another perfectly acceptable alternative. 551 00:23:41,345 --> 00:23:43,165 Um, but technically speaking, 552 00:23:43,265 --> 00:23:44,605 the the guidelines do recommend 553 00:23:44,605 --> 00:23:46,005 that fluoro clone first line, 554 00:23:46,185 --> 00:23:50,405 but I do think that the, as resistance patterns change, 555 00:23:50,605 --> 00:23:54,165 I do think that cephalosporins are a perfectly acceptable 556 00:23:54,165 --> 00:23:55,405 option to initiate therapy 557 00:23:55,545 --> 00:23:56,885 for these pyelonephritis patients. 558 00:23:57,355 --> 00:23:58,485 - This might change based on 559 00:23:58,485 --> 00:23:59,965 local resistance patterns too, right? 560 00:24:00,605 --> 00:24:02,485 - Absolutely, yeah. If you have identified within your own 561 00:24:02,555 --> 00:24:06,885 shop that there is significant resistance to say Bactrim 562 00:24:06,905 --> 00:24:10,325 for, uh, a common UTI pathogen, I think 563 00:24:10,325 --> 00:24:13,045 that in those cases you certainly should be avoiding it 564 00:24:13,045 --> 00:24:15,165 or at least, uh, prioritizing the use 565 00:24:15,165 --> 00:24:16,525 of another alternative therapy 566 00:24:17,065 --> 00:24:19,005 - And significant resistance to you is what, 567 00:24:19,005 --> 00:24:20,965 greater than 15% Generally, 568 00:24:20,965 --> 00:24:24,725 - It, it lies within like a 10 to 15%, uh, of bacteria 569 00:24:24,875 --> 00:24:26,965 that we identify as having resistance. 570 00:24:26,965 --> 00:24:28,965 So if, if you're above 10, that's, 571 00:24:28,965 --> 00:24:30,245 that's kind of where we draw the 572 00:24:30,245 --> 00:24:31,245 - Line. 573 00:24:31,245 --> 00:24:31,685 Yeah, absolutely. 574 00:24:32,125 --> 00:24:35,125 I actually pull up our antibiogram not infrequently. 575 00:24:35,285 --> 00:24:37,005 I think my last two shifts, I've pulled it up 576 00:24:37,005 --> 00:24:39,085 because it really helps me understand 577 00:24:39,465 --> 00:24:42,565 and remember where I need to be. So I like that. 578 00:24:43,445 --> 00:24:44,945 - Now talk to me about phosphomycin. 579 00:24:45,865 --> 00:24:48,345 - Phosphomycin once upon a time was 580 00:24:48,345 --> 00:24:49,545 my favorite drug . 581 00:24:50,205 --> 00:24:54,145 Um, it, it, uh, has in some situations saved admissions, uh, 582 00:24:54,165 --> 00:24:55,265 for me in patients 583 00:24:55,495 --> 00:24:58,425 because it's just like this really special drug in 584 00:24:58,425 --> 00:25:00,825 that it's just a onetime dose and you're good to go, right? 585 00:25:01,885 --> 00:25:05,185 And unfortunately it's becoming a situation 586 00:25:05,235 --> 00:25:08,145 where we are seeing increasing resistance patterns 587 00:25:08,145 --> 00:25:10,345 with fos mycin and failures of therapy. 588 00:25:11,165 --> 00:25:14,425 And so there's newer information that is making it clear 589 00:25:14,425 --> 00:25:18,025 that Foss Mycin should probably be not our, you know, 590 00:25:18,025 --> 00:25:21,065 fifth option or fifth class of medication for UTIs, 591 00:25:21,415 --> 00:25:22,465 that we should use it 592 00:25:22,465 --> 00:25:25,025 as an alternative therapy when all else fails. 593 00:25:25,045 --> 00:25:27,305 And it may again save us an admission. 594 00:25:27,305 --> 00:25:29,425 And that that certainly is a great option. 595 00:25:29,815 --> 00:25:31,945 However, it is a challenge. 596 00:25:32,325 --> 00:25:33,345 So with Phosphomycin, 597 00:25:33,345 --> 00:25:35,945 there is no susceptibility testing nothing 598 00:25:35,945 --> 00:25:38,305 that you can really, you know, hang your hat on. 599 00:25:38,645 --> 00:25:41,225 And so you're not really gonna be able to know 600 00:25:41,225 --> 00:25:42,945 that you've treated the patient successfully 601 00:25:43,005 --> 00:25:44,505 unless you follow symptoms 602 00:25:44,505 --> 00:25:46,585 or if they're able to tell you they have symptoms. 603 00:25:47,205 --> 00:25:49,585 So in those patients where, uh, you know, it's critical 604 00:25:49,585 --> 00:25:52,585 that you know you've had cure in those situations, 605 00:25:52,885 --> 00:25:54,105 the only thing that is really going 606 00:25:54,105 --> 00:25:55,985 to guide you is symptoms. 607 00:25:56,285 --> 00:25:58,025 And so it's, it's a challenge 608 00:25:58,025 --> 00:26:00,305 because you don't have laboratory 609 00:26:00,305 --> 00:26:01,345 results that are gonna be helpful. 610 00:26:02,005 --> 00:26:03,825 - And if we're gonna use it, when can we use 611 00:26:03,825 --> 00:26:05,625 that one-time dose and when does it need to be? 612 00:26:05,865 --> 00:26:06,865 Re-dos? 613 00:26:07,255 --> 00:26:10,835 - The traditional thought is that Foss Mycin can be utilized 614 00:26:10,895 --> 00:26:15,395 as a single dose in the simple cystitis and then re-dosing. 615 00:26:15,915 --> 00:26:19,155 Commonly what's done is every other day for three doses, uh, 616 00:26:19,375 --> 00:26:22,835 is often reserved and recommended for these complicated 617 00:26:22,855 --> 00:26:24,555 or plon nephritis type patients. 618 00:26:25,105 --> 00:26:26,515 - Well, I think this is a good spot 619 00:26:26,515 --> 00:26:29,275 to wrap up our push dose Pearls episode on antibiotics. 620 00:26:29,275 --> 00:26:30,675 Thanks so much, Chris, for coming. 621 00:26:31,215 --> 00:26:32,435 - My pleasure. Thanks for having me.