The Fifth Patient

Elham Barkhordari, Pharm D Candidate 2012

t was not a typical Friday morning; I was sitting in the nursing station making every attempt to hide my grief after losing a 35 year-old lung cancer patient. She was laughing when we saw her during rounds only the day before. I was wiping away my tears when I was asked to join the oncology team for daily rounds. I truly didnt wish to encounter more cancer patients and felt more like going home and watching sitcoms all day. One case, however, did attract my attention that morning. It was the fifth patient we rounded on that day. Hers was a case of hospital-acquired pneumonia (HAP) in a Stage III breast cancer patient. As the resident started presenting the patients case, my attention was caught when the resident mentioned that no improvement had been observed in the patients pneumonia status within the last three days. After the case presentation on that patient ended, the Oncology Attending started inquiring more about the patients cancer status. My attention, however, stayed with the comment about a case of HAP being treated for three days with no sign of improvement. My knowledge of antibiotic treatment told me that there should have been some clinical improvement seen within 24 hours on appropriate medication.

Unfortunately, I didnt have the patients information printed, so I quietly asked the resident, What antibiotic is the patient on? He informed me that he initiated the patient on doxycycline and levofloxacin three days prior. As soon as he made this statement, something about the regimen did not seem to look right to me. Immediately, I knew that something was missing from the regimen, and yet I doubted my own memory, believing that there was little chance that an inappropriate regimen would be ordered by the sharpest residents and approved by distinguished oncologists for three full days in one of the nations top hospitals. Yet there I was: a fourth year pharmacy student who wasnt particularly proud of her Infectious Disease knowledge, questioning the patients antibiotic regimen. I began to go over her case methodically in my head as the rounds continued. I read the patients chart more thoroughly along with the Infectious Disease Society of Americas (IDSA) guidelines for HAP. In doing so, I confirmed my first instinct that problem with the patients regimen was the absence vancomycin. The guidelines state for empiric coverage for methicillin resistant staphylococcus vancomycin at adequate dosing and in combination with other classes of antimicrobials is recommended, even though in recent years resistance to this agent has been observed. Use of the alternative agent linezolid is also acceptable in the absence of contraindications.

After gathering the information, I asked the resident privately about a regimen without vancomycin. He replied, Doxycycline covers for MRSA and has fewer side effects, so I didnt think vancomycin was necessary. My measured response to him reflected my understanding that, as a future PharmD, I am part of a health-care team and do not wish to cause strife in pointing out a potential fault with another health-care providers treatment plan. I always thought that for MRSA coverage in HAP the use of the use of either vancomycin or linezolid is recommended. This patient does not look like she has any contraindications to these meds, but perhaps there is something about her case that I am missing. I tried to frame my words carefully. The resident then looked at me and replied, But I read in my Sanford guide that doxy also covers for MRSA.

I then asked him, Perhaps what you read was under soft Skin and Soft Tissue infections? He appeared thoughtful and then left rounds to check on my question. He came back a couple minutes later and quietly spoke with the Attending. Shortly after, he came up to me and thanked me for noticing the conflict. He then discontinued the order for doxycycline and put the order in for Vancomycin. He was in the process of ordering Cefepime for coverage with a beta-lactam, when the other resident pointed out that the patient had an allergy to penicillins. When given penicillin in the past, the patient had broken out in hives, a sign of a true allergy. Since cefepime is a cephalosporin which belongs to the family of beta-lactams there is a chance that cefepime might also cause an allergic reaction in a patient who had previously demonstrated an allergy to another beta-lactam. However, a much lower chance of reactivity is observed (less than 1%) and the phenomenon is being managed differently depending on the types of allergic reactions.

Once again, I respectfully added my thoughts to the decision-making process. From what I recall, we can still give her the Cefepime and monitor her closely for allergic reactions.

I dont think we can do that, she replied and walked away. Knowing that it is important to be able to cite evidence for treatment decisions, I discussed the case with a clinical pharmacist who could guide me in my search of literature which would lend credence to my statement about cross-reactivity of beta-lactams. The PharmD agreed with my recommendation and gave me a recent review article on beta-lactam cross-reactivity. I read it carefully and understood why the cross-reactivity had been such a concern in the past. I then understood the residents concern. I shared the review article with the resident. She approached me later and said, That was a great article, I think you should present a topic on beta-lactam cross- reactivity next week to the medical students. We dont get a lot of information on this topic. I told her that I would be honored to do so and would welcome the opportunity to learn more about the subject myself.

I learned from this experience that pharmacists enjoy an exciting position in health care. With a knowledge base of disease pathophysiology and pharmacotherapy, we are equipped to become integral parts of health care teams as drug therapies become more prolific and complex. No longer simply dispensers of drugs, we can act as teammates ensuring optimal pharmaceutical care for patients.

Driving home that evening, I thought, What a day! First, I witnessed a patient die because of what we couldnt do for her. But on the other hand, I got to be part of a team that possibly saved a patients life today because of what we could do for her.

References

1. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. American Journal of Respiratory and Critical Care Medicine. 2005;171(4):388-416.

2. Lesher BA. Allergic Cross-reactivity Among Beta-lactam Antibiotics. Pharmacists Letter/Prescribers Letter. 2005; 21.