case STUDIES

Pharmacy Times, Volume 0, 0

CASEONE:

GY, a 55-year-old man, presentsto the emergencydepartment of the local hospitalwith a 4-day history of diarrheaassociated with abdominalcramping. He complainsthat he has experienced atleast 6 bowel movementsdaily during that time. Until today, the stools have beenwatery, but now he is passing mucus and blood-tinged stools.He admits to experiencing fatigue and chills, but no weightloss or change in appetite.

Upon further questioning, GY admits that he recently finisheda course of antibiotics. Although he is unable to rememberwhich antibiotic he took, the emergency departmentpharmacist is able to contact the pharmacy that filled GY'santibiotic prescription. According to the retail pharmacist, GYreceived 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 cultureis positive for Clostridium difficile. The culture is negative forSalmonella, Shigella, and Campylobacter.

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

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

CASE TWO:

On a busy day at Tablet andCapsule Pharmacy, a consultationwith the pharmacist isrequested. When the pharmacistapproaches the consultationarea, she is greeted by awoman who is well-known tothe pharmacist because sheroutinely 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 pregnancytest was positive. The pregnancy was not planned.The womanis a college student who will graduate in June. She is concernedthat she will not be able to finish her degree before thebaby is born. Although she has an appointment with her doctornext week, she wants to know now when the baby is due.

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

CASE THREE:

 While working at Little WhitePill Pharmacy, the pharmacytechnician asks to speak privatelywith the pharmacist.She shows the pharmacist awritten prescription for metronidazole2 g. She does notwant anyone else to knowthat she has vaginal trichomoniasis, so she is hoping the pharmacistwill be able to discreetly fill the prescription withoutthe other employees seeing it.

After the pharmacist fills the prescription, the grateful technicianasks if she has to take all of the tablets at once or if shecan take them as separate doses. She explains that she oftenexperiences "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.

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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 desirableoption. As for intravenous (IV) therapy, IV vancomycin is considered less effective than IV metronidazole. IV vancomycin does not achieve sufficientdrug 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. UsingNagele'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 estimateddate 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 highpeak serum concentrations, therefore improving delivery of the medication to the site of action.

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