Albert Zichichi, PharmD Candidate, and Craig I. Coleman, PharmD
Case 1: Staphylococcus aureus
is the most common agent causing purulent cellulitis. Consequently, when a diagnosis of purulent cellulitis is made, it is important to consider a patient’s risk factors for methicillin-resistant S aureus (MRSA), including nasal colonization, prior MRSA infection, recent hospitaliza- tion, and/or antibiotic use. Because JM has purulent cellulitis and has had re- cent exposure to an antibiotic (levofloxacin for her UTI), empiric therapy should include an antibiotic with MRSA coverage (ie, trimethoprim-sulfamethoxazole, doxycycline or minocycline, linezolid or clindamycin). As the pharmacist, you might recommend doxycycline 100 mg taken orally twice daily.
The pharmacist should explain to the resident that it would be best to collect more information before increasing TO’s insulin dose because there are multiple reasons why she could have morning hyperglycemia. Specifically, TO could be experiencing a “Dawn phenomenon” or a “Somogyi effect.” The Dawn phenomenon occurs due to insufficient basal insulin administration overnight, and the Somogyi effect occurs because of too much basal insulin overnight, causing hypoglycemia and rebound hyperglycemia. You explain fur- ther that the way to distinguish between the 2 would be to have your patient take early-morning (2 AM to 3AM) fasting blood glucose readings via finger stick. If these blood glucose values are consistently high, the patient is likely experiencing the Dawn phenomenon. If these blood glucose readings are low, the patient is probably experiencing the Somogyi effect.
Albert Zichichi is a PharmD candidate at the University of Connecticut School of Pharmacy, Storrs, Connecticut. Dr. Coleman is professor of pharmacy practice at the University of Connecticut School of Pharmacy.