ILLUSTRATION BY KIRSTIE BELLE DIONGZON

Case 1
KE is a 52-year-old woman who was admitted to the hospital after she was found to have splinter hemorrhages in her nailbed accompanied by generalized malaise for 2 weeks. She presented with a temperature of 102.10F, a white blood cell count of 14.1 x 103 cells/mL, and a heart rate of 114 beats/min. Blood cultures were ordered and grew Enterococcus faecalis susceptible to gentamicin. A transesophageal echocardiogram revealed vegetation on the mitral valve, and KE was given a diagnosis of native valve endocarditis. The pharmacist receives an order for gentamicin 3 mg/kg IV once daily and ampicillin 2 g IV every 4 hours. KE’s creatinine clearance is 106 mL/min and she has no known drug allergies.

Do you believe this is an appropriate antibiotic regimen for KE’s infective endocarditis caused by enterococci?


Case 2
KS is a 28-year-old woman who presents to your community pharmacy with a prescription for podofilox 0.5% gel applied twice a day for 3 days, followed by 4 days of no therapy. KS was told by her doctor to repeat that regimen for up to 1 month or until clearance of her external anogenital warts. KS tells you she has used podofilox gel to treat her genital warts with limited success in the past. She attributes some of the past lack of effectiveness to unintentional nonadherence due to the complexity of the regimen.

As the pharmacist, what suggestions might you have for KS?


Answers 
Case 1: According to the recently released (2015) American Heart Association guidelines for infective endocarditis in adults, KE should receive ampicillin sodium 2 g IV every 4 hours plus gentamicin sulfate 3 mg/kg (based on ideal body weight) IV in 2 to 3 equally divided doses. It is important to note that the dosing of gentamicin has changed from previous recommendations, which allowed the antibiotic to be administered as a single daily dose. Therefore, KE’s gentamicin dosing should be modified accordingly. Since KE has native valve endocarditis with symptoms starting less than 3 months ago, she should be treated for 4 weeks.

Case 2: In the 2015 update of the Centers for Disease Control and Prevention’s Sexually Transmitted Diseases Treatment Guidelines, imiquimod 3.75% cream is listed as a first-line patient-applied therapy for external anogenital warts. Two strengths of imiquimod cream are available—3.75% and 5%—but their regimens differ in frequency and duration. Imiquimod 5% cream is applied 3 times per week at bedtime for up to 16 weeks or until clearance of warts. Imiquimod 3.75% cream is applied once daily at bedtime for up to 8 weeks or until clearance of warts. To increase KS’s adherence to therapy and likelihood for treatment success, the pharmacist might recommend KS discuss changing her prescription to imiquimod 3.75% cream applied once daily at bedtime for up to 8 weeks.
 
Mr. Tsoi is a PharmD candidate at the University of Connecticut School of Pharmacy, Storrs, Connecticut. Dr. Weeda is an Outcomes Research fellow at the University of Connecticut School of Pharmacy, Storrs, CT. Dr. Coleman is professor of pharmacy practice at the University of Connecticut School of Pharmacy.