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Lauren S. Schlesselman, PharmD
Published Online: Sunday, January 1, 2006   [ Request Print ]

CASEONE:

GY, a 55-year-old man, presents to the emergency department of the local hospital with a 4-day history of diarrhea associated with abdominal cramping. He complains that he has experienced at least 6 bowel movements daily during that time. Until today, the stools have been watery, but now he is passing mucus and blood-tinged stools. He admits to experiencing fatigue and chills, but no weight loss or change in appetite.

Upon further questioning, GY admits that he recently finished a course of antibiotics. Although he is unable to remember which antibiotic he took, the emergency department pharmacist is able to contact the pharmacy that filled GY's antibiotic prescription. According to the retail pharmacist, GY received a 10-day supply of cefuroxime.

The physician decides to admit GY for further workup. Among the tests ordered is a culture of GY's stool. The culture is positive for Clostridium difficile. The culture is negative for Salmonella, Shigella, and Campylobacter.

The physician wants to initiate antimicrobial therapy to treat GY's C difficile-associated diarrhea. Since the patient is hospitalized, the physician wants to prescribe intravenous (IV) antibiotics. He orders IV vancomycin.

When the pharmacy receives the order, should the pharmacist make any recommendations on GY's antibiotic therapy?

CASE TWO:

On a busy day at Tablet and Capsule Pharmacy, a consultation with the pharmacist is requested. When the pharmacist approaches the consultation area, she is greeted by a woman who is well-known to the pharmacist because she routinely picks up medications for her parents.

The woman is holding a home pregnancy test in her hand. She franticly explains to the pharmacist that the pregnancy test was positive. The pregnancy was not planned.The woman is a college student who will graduate in June. She is concerned that she will not be able to finish her degree before the baby is born. Although she has an appointment with her doctor next week, she wants to know now when the baby is due.

The pharmacist asks the woman when her last menstrual period began. If the woman's last menstrual period began on January 1, what is the woman's estimated date of confinement (ie, her "due date")?

CASE THREE:

 While working at Little White Pill Pharmacy, the pharmacy technician asks to speak privately with the pharmacist. She shows the pharmacist a written prescription for metronidazole 2 g. She does not want anyone else to know that she has vaginal trichomoniasis, so she is hoping the pharmacist will be able to discreetly fill the prescription without the other employees seeing it.

After the pharmacist fills the prescription, the grateful technician asks if she has to take all of the tablets at once or if she can take them as separate doses. She explains that she often experiences "stomach problems" when she takes medications.

How should the pharmacist advise her to take the metronidazole?

Dr. Schlesselman is an assistant clinical professor at the University of Connecticut School of Pharmacy.

Click Here For The Answer -----------> [-]

CASE ONE: Metronidazole remains the treatment of choice for Clostridium difficile. GY does not have any contraindications to oral medication, so oral metronidazole should be considered. Although oral vancomycin is effective, the risk of vancomycin-resistant enterococci makes it a less desirable option. As for intravenous (IV) therapy, IV vancomycin is considered less effective than IV metronidazole. IV vancomycin does not achieve sufficient drug concentrations in the intestinal lumen.

CASE TWO: Since the exact date of ovulation is not known, the estimated date of confinement is based on the first day of the last menstrual period. Using Nagele's rule, the estimated date of confinement is the first day of the last menstrual period plus 7 days minus 3 months. In this woman's case, the estimated date of confinement is January 1 plus 7 days (equals January 8) minus 3 months, so her date is October 8.

CASE THREE: The pharmacist should advise the technician to take the entire 2 g of metronidazole at once. Taking the entire dose at once allows for high peak serum concentrations, therefore improving delivery of the medication to the site of action.

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