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Obtaining Cultures Before Antibiotic Treatment Volume 20, Number 10 November/December 2006 Drugs & Therapy B � U � L � L � E � T � I � N PRESCRIBING FORMULARY UPDATE The Pharmacy and Therapeutics Collect before you treat: Committee met October 17, 2006. 2 drugs were added in the Formulary, obtaining cultures before and 1 was deleted. 2 drugs were designated nonformulary and not antibiotic treatment available. There was 1 criteria-for- use change and 3 interchanges hen treating infections, health- ate that antimicrobial therapy should approved. Wcare providers realize the impor- be reassessed once these organisms tance of initiating antibiotic therapy as have been identified in order to more soon as possible. It is also recognized accurately direct therapy.1 ◆ ADDED that tailoring pharmacologic therapy Obtaining cultures after antimicro- to the organism(s) responsible for the bial therapy has been started can cause Methoxsalen infection is equally important. When inconclusive results because organisms ® (UVADEX by Therakos) initiating therapy, standard of care calls that would otherwise be detected may not necessarily grow after exposure to Varenicline (Chantix® by Pfizer) for the use of broad-spectrum antibiot- ics to cover the organisms usually asso- an antibiotic agent. The administration ◆ DELETED ciated with the infection being treated. of antimicrobials before the collection Therapy is streamlined after cultures of samples may decrease blood culture Mivacurium and sensitivities are available. Delaying yields. (Mivacron® by Abbott)* therapy when infectious processes are The American Heart Association encourages acquiring blood cultures *Nonformulary and not available suspected is not an option, but similar- ly, obtaining adequate cultures before promptly when diagnosing infective 2 ◆ CRITERIA-FOR-USE CHANGES administering antibiotics is equally endocarditis. In fact, a positive blood important. In these situations, timing culture is a major diagnostic criterion Clonidine Injection (Duraclon® is key. Obtaining appropriate cultures for infective endocarditis. Most patients by Xanodyne Pharmaceuticals) before initiating antimicrobial therapy with infective endocarditis will yield a plays an important role in patient care. positive culture. However, low-grade ◆ INTERCHANGES Why is this so important? The bacteremia (less than 50 colony-form- prompt identification of offending ing units per milliliter of blood) is a ® Bupropion SR for Wellbutrin XL organisms will influence diagnosis, common occurrence.2 In these cases Guaifenesin Liquid for Mucinex®* therapy, and prognosis. This will not of low-grade bacteremia, the adminis- only benefit the patient by providing tration of antibiotics before obtaining ® *Mucinex designated nonformulary more appropriate and definitive treat- blood cultures may affect bacterial and not available ment, but will also help control the growth in the sample and hinder the Paroxetine IR for Paxil® CR† emergence of antibiotic resistance by ability to appropriately tailor therapy minimizing the use of broad-spectrum to the offending pathogen. † 1 mg = 1.25 mg (eg, 20 mg = 25 mg) agents, when possible. Appropriate antibiotic therapy plays Obtaining cultures before antibiotic an important role in the prevention of use improves the chances of identifying antibiotic resistance. The Centers for Methoxsalen is a naturally oc- the offending microorganism, which Disease Control and Prevention (CDC) curring photoactive agent. It is in a improves patient care. Inappropriate outlines that in order to help control class of compounds known as pso- antibiotic use can result in prolonged antibiotic resistance and effectively ralens. Psoralens react upon activa- hospital stays and increased costs, but diagnose and treat infections, it is very tion to ultraviolet (UV) light in the it can also have adverse consequences important to obtain cultures in order to 315-400 nm wavelengths (ie, UVA). on the patient’s prognosis. target antimicrobial therapy to suscep- Although their exact mechanism The Surviving Sepsis Campaign (continued on page 3) of action is unknown, psoralens Guidelines state that antibiotic therapy covalently bond to DNA and inhibit should be initiated within 1 hour of ◆ cellular replication. recognition of severe sepsis.1 These INSIDE THIS ISSUE In extracorporeal photopheresis guidelines state that appropriate (ECP), white blood cells (WBCs) are cultures should be obtained in order ◆ Annual index separated from the patient’s whole to identify causative organisms before ◆ Pharmacokinetic consults (continued on next page) starting therapy. The guidelines reiter- Formulary update, from page 1 Hospitalized patients are particu- mivacurium for marketing reasons blood. The WBCs are placed in the larly good targets for smoking cessa- and has no plans to resume market- photoactivation bag along with normal tion efforts, since continued smoking ing of mivacurium. There are no saline and plasma, and methoxsalen is could inhibit their recoveries. First-line other manufacturers of mivacurium. added to the bag before being exposed agents for smoking cessation have Therefore, mivacurium was deleted to UVA irradiation. ECP is performed been nicotine replacement therapies from the Formulary and designated using either the UVAR® Photopheresis (NRTs) or bupropion in combination nonformulary and not available. System, or the UVAR® XTS™ System. with behavioral modification therapy. The neuromuscular blocking agent The manufacturer outlines the dosage Although quit rates with these treat- with the most similar onset of action as 200 mcg if the UVAR® Photophere- ments have been modest, any reduc- and clinical duration of effect listed sis System is used, or a prescribed tion in cigarette smoking is important in the Formulary is vecuronium (ie, dosage specific to treatment volume because of the health consequences of onset 2.5-3 minutes and duration 25- with the UVAR® XTS™ System. The continued smoking. 30 minutes). photoactivated WBCs are then re- Evidence from published randomized Clonidine is a centrally acting al- administered to the patient. The net controlled trials suggests that vareni- pha2 agonist that inhibits sympathet- effect is a modulation of the patient’s cline has equal or better efficacy than ic outflow and decreases systemic cellular immune system. bupropion. It has a different adverse vascular resistance. It was originally The current labeled indication for effect profile than bupropion (ie, more marketed with a labeled indication ECP using UVADEX® sterile solution nausea versus less insomnia) and may for hypertension, but the inhibition is for the palliative treatment of cuta- be associated with more weight gain (ie, of sympathetic outflow led to various neous T-cell lymphoma. At Shands at 2-3 pounds). Varenicline has not been di- off-labeled uses (eg, hot flushes, UF, the primary use will be off-label rectly compared with NRT or bupropion alcohol withdrawal). It is available as for the treatment of graft-versus-host in combination with NRT. an oral tablet and transdermal patch disease (GVHD). Nausea is a common dose-dependent for these uses. Several publications report the adverse effect, which may be reduced The only parenteral form of benefits of ECP in patients with by gradually increasing the daily dos- clonidine has a labeled indication treatment-refractory acute and age (eg, taking 0.5 mg once daily for for epidural administration for the chronic GVHD. Some of the benefits the first 3 days, 0.5 mg twice daily for treatment of pain. Clonidine’s alpha2 described in these reports include the next 4 days, and then 1 mg twice agonist effects at the spinal level are complete and partial resolution of daily). In addition, patients should be thought to prevent transmission of cutaneous and visceral manifesta- advised to take varenicline after eat- pain signals to the brain. tions of GVHD. In addition they also ing and with a full glass of water to Low doses (eg, 1 mcg/Kg) of in- demonstrate improved survival rates decrease the risk of developing nausea. travenous clonidine have been used in patients who respond to ECP, Abnormal dreams, constipation, vomit- for several off-labeled indications compared to non-responders. An ing, flatulence, and xerostomia are also including the treatment of post-op- additional advantage of ECP is that associated with varenicline use. Dos- erative shivering and with regional when clinical response is obtained, age reductions can be considered for anesthesia to decrease general anes- other immunosuppressive therapies patients unable to tolerate the adverse thesia requirements. There is a risk, can be reduced or even discontinued, reactions. Using varenicline with NRT however, for hemodynamic instability thereby reducing their potential for may increase adverse effects. Also, as when intravenous clonidine is used toxicity with chronic use. In addition, with any new drug, whether there are for off-labeled uses; therefore, its use ECP is reported as being well toler- any rare, but serious, adverse effects will be restricted to the OR, PACU, ated by patients. will be determined only with wide- Florida Surgical Center, and to ad- These reports, however, have spread use. ministration by an anesthesiologist. limitations. Randomized controlled The typical dosage for varenicline is When patients are receiving oral or clinical trials would help to define 1 mg twice a day. Lower dosages are transdermal clonidine for hyperten- ECP’s place in the treatment of treat- used in severe renal dysfunction (CLcr sion or other uses and patients
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