Patient currently admitted. Patient Case Presentation: A complicated case of cellulitis. History. History. Patient KV. History

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Sheryl Ellen Hensley
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1 Patient Case Presentation: A complicated case of cellulitis Patient currently admitted Ryan LeBlanc PharmD/MBA Candidate 2008 Patient KV KV is a 38 yo wf 5 3 tall, 355lb (161kg) CC: painful recurrent right leg ulcer that has not healed completely for years and has become infected Admitted diagnosis: cellulitis of the right leg History HPI Chronic venous insufficiency Morbid obesity Lymphedema Stroke right right side hemiparesis Recurrent ulcer on right shin (4 years) Multiple surgical debridements staring in March 2006 Frequent infection with various organisms and IV and PO antibiotic treatments HTN 190/110, 170/100 Refuses enoxaparin History PMH 11 years ago rupture of intracerebral aneurysm Pregnancy-induced hypertension Intracranial surgery to clip the aneurysm Residual right hemiplegia Sustained minor leg would 4 years ago Will not fully heal Persistent ulcer with frequent infection requiring hospitalization on Right wrist surgery Right lobectomy of lung Hypertension Chronis sinusitis and allergic rhinitis History FH HTN, cancer, hypercholesterolemia, stroke SH Denies smoking, alcohol or drug abuse NKDA Allergic to catgut 1

2 Home Medications Ciprofloxacin 750mg po bid Toprol XL 50mg po qpm For blood pressure Claritin 5mg po qam For allergic rhinitis Tylenol 325mg 3 tabs po prn pain Darvocet 2 tabs po prn pain Current Hospital Medications Claritin 10mg po qd Allergic Rhinitis Hydralazine 10mg po q6h prn HTN Lovenox 40mg SQ qd DVT prophylaxis Morphine sulfate 4mg IV q4h prn Pain Prinivil 20mg po bid HTN Toprol XL 50mg po q7pm HTN Tylenol 325mg po q6h prn Pain Vicodin 5/500 po q4h prn Pain Tygacil 50mg IV q12h Infection Aquacel Ag Apply for up to 14d Antimicrobial dressing All WNL WBC 5.7 Scr 0.76 BUN 16 GLU 74 Afebrile Labs Current Assessment On 9/10/2007, KV was hospitalized for the 5 th time in the past year and a half with a recurrent right leg ulcer with cellulitis. The status of the problem is partial improvement. DRP KV has been prescribed tigecycline (Tygacil ) ) without meeting JRMC s usage criteria. The current problem is severe, yet the priority for pharmacy intervention is low and not urgent. The broader problem of appropriate use of Tygacil is severe, of high priority and in urgent need of pharmacy intervention. Plan for Care on Admission Treatment goal: : eradication of the infection and prevention of further complications. Surgical debridement under general anesthesia Empiric treatment with IV antibiotics pending wound and blood culture results Use culture results to guide antibiotic prescribing Manage HTN Cellulitis Acute infection of the deeper layers of skin Characterization: redness, swelling, warmth, pain, nonelevated, poorly defined margins Usually a history of minor trauma, abrasion, ulcer, or surgery May lead to bacteremia (30%) Originates from normal flora of skin 2

3 Treatment of Cellulitis Uncomplicated Goal is to cure and prevent recurrence Directed PO antimicrobial therapy Complicated Goal is to cure and prevent recurrence Directed IV antimicrobial therapy Incision and drainage Surgical debridement Failure Indicates underlying local or systemic problem Obesity Lymphedema Venous insufficiency Tygacil Approved by the FDA: June 15, 2005 First in class Tetracycline analogue glycylcycline glycylcycline Broad spectrum Gram-positive, gram-negative, anaerobic bugs Indications Pts 18yo and older Complicated skin and skin structure infections Complicated intraabdominal infections Tygacil Dosage: 100 mg IV, followed by 50 mg every 12 hours administered over 30 to 60 min Treatment duration: 5 to 14 days Hepatic function impairment: Dose adjustment for severe hepatic impairment 100 mg, followed by 25 mg every 12 hours Renal function impairment: No dosage adjustment for renal impairment or hemodialysis patients Adverse effects Minor GI Pregnancy category D Usage Criteria for Tygacil Was Tygacil used according to JRMC usage criteria? Recommended usage criteria 1. ID consult 2. Treatment of susceptible infections in patients with either: a. an allergy to vancomycin OR b. documented resistance to two or more antibiotics (other than tigecycline) 3

4 Most Recent ID Consult Report Performed the day after debridement Assessed for appropriate antibiotic management At admission, started piperacillin/tazobactam (Zosyn ) ) based on micro history: Enterobacter cloacae MSSA Pseudomonas aeruginosa Continued Zosyn and added levofloxacin (Levaquin ) pending wound and blood culture results Micro Reports Tissue culture Results suggestive of superficial contamination No virulent bugs found Blood culture Not ordered Levaquin and Zosyn discontinued Tygacil started KV s Current Cellulitis Treatment Current stay at JRMC admitted 9/10 9/10 Zosyn 100mls iv q6h 9/11 debridement 9/11-9/13 9/13 Levaquin 750 mg ivpb qd until culture results back 9/13-present Tygacil 50mg iv q12h (for 3 weeks) Why Tygacil? Is there something in her history to warrant its use? KV s Cellulitis Treatment History 3/2/2006 to 3/6/2006 3/2 to 3/6 ampicillin 500 mg iv pb q6 3/2 to 3/6 gentamicin ~150 mg IV q12 Discharged on oral ampicillin Escherichia coli Enterococcus fecalis KV s Cellulitis Treatment History 6/5/2006 to 6/9/2006 6/5 Zosyn 2.25g iv q8h 6/5 to 6/7 clindamycin 600mg iv q6h and rifampin 300mg po bid 6/7 to 6/8 imipenem/cilastatin (Primaxin)) 500mg iv q8h 6/8 to 6/9 ciprofloxacin (Cipro) 500 mg po bid based on culture and sensitivity discharged on ciprofloxacin Pseudomonas aeruginosa 4

5 KV s Cellulitis Treatment History 8/21/2006 to 8/25/2006 8/21 to 8/22 Levaquin 500 mg iv pb qd 8/23 to 8/25 Cipro IV 200mls q12h Discharged on oral ciprofloxacin No virulent bugs growth of mixed skin flora KV s Cellulitis Treatment History 3/5/2007 to 3/9/2007 3/5 to 3/5 Levaquin 100mls q24h for post-op op antibiotic prophylaxis 3/5 to 3/9 Zosyn 3.375g iv pb q6h Discharged on Zosyn Enterobacter cloacae Staphylococcus aureus sensitive to oxacillin MIC < 0.25 KV s Current Cellulitis Treatment Current stay at JRMC admitted 9/10 9/10 Zosyn 100mls iv q6h 9/11 debridement 9/11-9/13 9/13 Levaquin 750 mg ivpb qd until culture results back 9/13-present Tygacil 50mg iv q12h (for 3 weeks) Did the history help? Usage criteria ID consult Allergic to vancomycin OR Shown resistance to at least 2 antibiotics Rational for Tygacil use in KV What I think the physician was thinking? Since pt keeps coming back with infection, decided to pull out the big guns Tigecycline is indicated for complicated skin infections Wanted to target Enterobacter Based on my conversation with ID MD What to do now? Continue Tygacil for now Second attempt to identify the bug(s) If find virulent bug resistant to the regulars continue If find bug sensitive to the regulars switch switch to the appropriate regular Find out additional parts of KV s history Would clinic PCP Psych consult Depression 5

6 What to do later? Improve communication with physicians about appropriate antimicrobial use of Tygacil and other antibiotics Pay closer attention to pt history when entering orders for antibiotics to aid in evaluating the appropriateness of their use Conclusions Physician is using Tygacil unnecessarily No documentation of resistance to antibiotics Wound not healing venous insufficiency to lower extremities secondary to obesity poor right-side mobility post stroke lymphedema Likely to see this patient again Take Home Points Good communication is essential physicians, nurses, patient Pharmacists must get more involved with helping physicians pick appropriate meds time, motivation, communication 6

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