- - This is an EM Impulse miniseries Push Dose pearls with your hosts, Sarah Maderis and Julia Magana. - Welcome back to EM Impulse. This is an episode of Push Dose Pearls. That's our ongoing series of brief podcasts that address the questions we all have regarding medications in the emergency department. And we are here with Chris Adams, our ED Clinical Pharmacist at uc, Davis, and our own EM Pulse pharmacist. I'm just gonna claim you Chris here, .
I love it, . And - Today we're gonna be talking about antibiotics in the ed. See if there are any new updates that we need to be aware of. So, Chris, what is your favorite new antibiotic in the ED setting and why? - I think that the one that comes to mind that is a little bit more challenging, honestly, is Doba Vanson. - Yes, I knew you were gonna say that. . - It's a really fun idea. Um, but unfortunately it has a lot of pitfalls associated with it.
And so we've been trying to find ways to utilize it safely and effectively, uh, where we're not breaking the bank, but also ensuring that we're giving it to the appropriate patients. - So walk us through that. What is the right way to use this really new cool medication? And remind us like how long it lasts. What are the indications, kind of how do we use this med? - So this is an extremely long acting medication.
So you've got a half-life that provides a single dose regimen, meaning it lasts so long that generally speaking, only one dose is necessary for treating skin and soft tissue infection, simple skin and soft tissue infections. That's - So huge, Chris. Yeah, I mean like, just like, let's just pause here for a second. and recognize, let's do a moment of silence and, uh, recognition of how cool this is . - It really is a, a very huge potential for benefits here.
And I think that with most emergency medicine, uh, interventions just a single dose in most cases, and that fixes the problem. That's lovely, right? That, that, who doesn't love that? However, the cost associated with this medication, though, it shouldn't dictate what therapy options we're using.
It is a problem and that's probably why a lot of audience members haven't really heard of this before, or at least not used it before the right way or at least the, the way that we've found that works for the use of dovan or double vanson is by utilizing a three 40 B program. So that's a program that allows, um, uh, specific populations to receive or, and institutions that see those populations to receive a significantly lower drug cost for the specific medication.
So the requirements for the population though is outpatient, meaning that patients that get admitted or are going to get admitted if you use this medication in them, then the, that lower cost no longer applies. So it kind of negates that the potential for a possible benefit here. So ensuring that we're utilizing this just in the emergency department and then discharging patients, that's perfect.
But if they're, if there's a possibility, this patient's gonna get admitted and that becomes a problem. Okay. So first step, ensuring that they are, uh, a candidate to be immediately discharged or discharged apps after observation. - So we do have other treatments, oral treatments, cheaper treatments for cellulitis or other soft tissue infections. So when is the right time to be choosing dalvance in this patient or dalbavancin in this patient that you might be discharging?
- It's situations in which you can't or won't be able to utilize PO options or where a patient has potentially failed Those other options, those situations may include, uh, where a patient was, has tried multiple different therapy options and they're just not working or they saw some benefit and, um, have had a relapse of their symptoms.
Another common situation is when you have some type of barrier to therapy, whether that be an inability to seek therapy or a situation where patients are not able to be adherent to the therapy that was prescribed to them. In this situation, you can use a single dose of this medication and there is no need for adherence and there is relatively no need for follow up. And so in those really, really challenging, um, social situations or disposition situations, dalvance may be an appropriate option.
- I love the idea of a single dose. Um, that's obviously really cool. Can I use this in kids? - It's looking like, yes. So there's new information and it looks like there's a new FDA approval for the use of dovan in a pediatric patient population for these simple skin soft tissue infections from a very early age. Uh, I'm quoting here the from birth, uh, and beyond. So it sounds like with pediatric patients, we're gonna be potentially utilizing dovan in appropriate situations going forward.
- Alright, so let's talk about some other updates. What about for community acquired pneumonia? What is our go-to treatment these days? - So community acquired pneumonia was, uh, the guideline associated with that was relatively recently updated. And so the, the Go-to new option, and this is not gonna come to a surprise for any pediatric provider out there, but amoxicillin has made a comeback here.
It has really dethroned the, uh, macrolides, uh, and uh, doxycycline as your initial therapy option. And now in both uncomplicated or or simple patients as well as uh, patients with significant comorbidities, amoxicillin is considered one of the first-line options for therapy. - So are the macrolides and doxycycline still considered first line as well? - They're considered alternative therapies. You certainly can turn to them in a situation where you have a beta-lactam allergy.
Um, and in your patients that have significant comorbidities that are a little bit more complex, you will add a, uh, macrolide or um, uh, doxycycline onto them. Uh, however it is is no longer thought of as being the first line option for cap therapy in the community. - So what about Levofloxacin?
- Great question. Monotherapy is still an acceptable option, but that's generally gonna be reserved for your, your patients with significant comorbidities such as chronic heart failure, lung, liver, renal disease, diabetes, alcoholism. In those situations, you, you can to turn to a monotherapy of a respiratory fluoroquinolone such as, uh, levo flux moxifloxacin or gemifloxacin. - And are we still super worried about all the side effects of quinolones - Y?
Yeah, that was obviously an in vogue, uh, discussion and decision point. Um, but I really feel like the use of fluoroquinolones is still a very real option, especially in an appropriate patient population. I think that, that the majority of worry should be at least considered, but I don't think that they should be, um, causing you to change therapy if these are the appropriate options. - Okay. So I know how to dose amoxicillin for pneumonia in peds, but how are we dosing it for adults?
- Amoxicillin in an adult patient population that does not have major comorbidities is just gonna be one gram three times daily in a patient population that has significant comorbidities. Again, chronic heart failure, lung, liver or renal disease. In those situations, you flip over into Augmentin and you dose that the the 500 TID or the 8 75 BID. - And how many days are we talking about - In general? That would be somewhere in the range of five to seven.
And in those patients with significant comorbidities, you can bump it up to 10. - Okay. Let's talk about kids in a community acquired pneumonia. What is your first line treatment in your preschool patient - In in those situations? I don't feel like it changes too much, especially given that amoxicillin has always been our standby option in that patient population. Yep. And so I think that, uh, initiating therapy
with amoxicillin is totally reasonable. Yeah, - I think that interesting thing in the preschool world is that that is so often a virus that there's definitely a little bit of pushback to be like, don't treat. I think that makes a lot of us nervous, especially if there's a low bar pneumonia that's there. If there's like little schmutzy viral schmutzy around Perry Hyler, um, I, I feel completely comfortable not treating that if the child's well appearing and stuff like that.
But if there's a low bar pneumonia, even if it's virus, I still personally skew towards amoxicillin. But what about TID versus BID dosing for amoxicillin in kids? - It's looking like BID might be an option. Unfortunately, I don't think the primary literature is they're just yet to say that we should be flipping directly over to BID dosing. The benefit here would be it's just easier to administer these medications if you're doing it twice daily as opposed to three times daily.
However, I still think that we should stick with the TID dosing regimen given that we're just not quite there yet. - Yeah, I'm, I'm ready for that swap for my kids for sure. Well what about the school age kids? Still primary amoxicillin - Pretty much now in, in those situations? Um, depending on what their comorbidities or are or how sick they're presenting, I think you can start considering other options, uh, as far as uh, adding on a macrolide or potentially using a fluoroquinolone.
However, again, your standby in most, uh, situations for kids presenting with, uh, pneumonia like symptoms and that are likely gonna be discharged to outpatient, starting with amoxicillin is likely gonna be a good choice. - Yeah. And I just have that discussion of like, we're gonna start here. I think this is gonna work, especially if it's low bar, which honestly is most of the pneumonias that I'm treating with antibiotics. And then keep in touch with your pediatrician. Absolutely.
We'll see if we need to change things. Yeah. - Talk to me about STIs or sexually transmitted infections because I know there have been some changes. - Yeah, this is an area that, uh, I work a lot in. Um, in uh, 2021, the CDC updated their treatment guidelines and so there are some pretty significant changes that we do need to talk about and that we're still seeing the old practices trickle in. So certainly an important area to discuss.
So first for OC infections, the old standby of ceftriaxone two 50 IM is a thing of the past. We have now, uh, been seeing significant rates of resistance with that dosing pattern. And so the new recommendation is to provide patients with a dose of ceftriaxone 500 milligrams for those that are left less than 150 kilos if greater than that, in those obese patients, it is recommended to give a full gram of ceftriaxone. - Are you still giving that? I am - So yes.
And, and, and the volume isn't too much, but uh, I am can be utilized. However, if you have a line, use it. So that old uh, um, uh, myth of the depot effect associated with I am ceftriaxone has been, uh, disproven and realistically, um, we can use either IV or Im depending on what with whatever is available, but if you don't have a line, you don't need it. - And at our shop we also give that with lidocaine, if we're giving it Im, 'cause it can be pretty uncomfortable.
- It can be certainly. And and lidocaine is certainly a nice touch. It, it certainly can help. Um, but it's still gonna be painful. - Oh yeah, it is , lemme tell you, it is . - Uh, next up is chlamydia for those infections we have now switched gears. Um, the old option was azithromycin one gram orally just one time and that's it. Uh, and then quinolones were also a kind of a thing of the past these days. We are now, uh, recommending doxycycline 100 milligrams twice daily for seven days.
So that's a major shift here. And as you can see, if as you look at all these different options, these one single dose options are becoming a thing of the past and, and or the dosing is having to be increased because of resistance patterns. So the chlamydia infections are another, uh, situation where we're having to switch to a seven day course.
- Now I feel like a lot of the patients that I see in the emergency department, I don't know the name of the STI, I just know that they have Citis or UR arthritis or PID and I'm like, okay, I'm just, you know, I I'm worried about this particular STI possibility here. What do you recommend for treating patients presumptively versus testing and waiting to find out what the name of the bug is?
- So I, I think that in most situations, especially if they're symptomatic or potentially if they describe a really high risk lifestyle, treating empirically is, is a very useful option for several reasons. First of all, you are decreasing the risk that the patient's gonna be a loss to follow up. Uh, if you don't treat the patient and have a, a really extensive, uh, callback program where we're gonna call the patient and ensure that they receive appropriate therapy in those situations.
We have somewhere in the range of 50 to 75% of patients who are completely lost to follow up. Meaning we can't get ahold of them, they don't have an appropriate phone number on file. They don't have an address on file. And so the potential to the community for further spread from that individual is significant.
In addition, um, if you are treating empirically, you're providing therapy earlier obviously, and so you're reducing the amount of time that, that, that individual can potentially spread that infection throughout the community. So I do think that it is a appropriate use of resources to provide empiric therapy in situations. But in your patient that is, um, is not symptomatic and doesn't have a, a significant high risk behavior, realistically we could potentially await in those patients.
- What about metronidazole? - So metronidazole or FLAG is, uh, another situation that can be utilized certainly in a situation where you have a concern for tri ssis or PID or pelvic inflammatory disease In those situations, uh, we're again no longer doing the single oral therapy option in young women in the, in that situation we're doing Metronidazole 500 milligrams orally twice daily for seven days.
Now in men that are presenting, uh, with symptoms that are concerning for tricho isis, in those situations, the two gram dose of metronidazole is an appropriate option. That single dose, uh, however, again, because of resistance patterns and failures of therapy, that seven day course of flagal is now an appropriate option in PID. We're adding on Flagal or Metronidazole for now 14 days in those situations.
Uh, and again it's because we're just, we're seeing some failures of therapy - Now for some of my patients, especially with the, the cervicitis. Um, or for a male, um, UR arthritis related to an STI, they may have a really difficult time adhering to that seven day course of antibiotics. Is there still a role for that one-time dose in select patients? - Yes, there is. So the, the one-time dose specifically of azithromycin you're referring to is an option.
Um, however, due to treatment failures and resistance patterns, that's why the switch took place. However, because we do see patients where adherence to therapy options is likely gonna be a challenge, azithromycin still does have a place in therapy. Now we are seeing actually some providers using both options where they're giving azithromycin and giving a prescription for doxycycline 'cause it's the preferred option. And that way they're ensuring that some kind of therapy is being provided.
Seems like a little bit of overkill, but at the same time, it's probably in the patient's best interest if there truly is gonna be a major, uh, barrier to adherence to a medication therapy. That's - Really interesting. I've not heard that, but I have had significant concerns about patients completing this doxy course. I mean, it, I get it. I read the data, I understand why this is important. It just feels like this is a population that we're gonna see.
I I'm just interested to see what's gonna happen in the future because I think there's gonna be a massive amount of non-compliance. - Absolutely. I think that as time goes on, we're gonna continuously have to increase doses and extend therapies. - And I just wanna throw out there too that the new CDC guidelines no longer require you to get a cervical sample to send. Yes. So we don't need to be doing pelvic exams.
In fact, patients can even do a self swab to send, which makes it a lot easier and less invasive if a patient doesn't want a pelvic exam. Now Chris, I had another question too. We are seeing a resurgence of syphilis. Do you think we're gonna get to a point where we're treating empirically for syphilis as well? - We're seeing that intermittently. Um, and you're absolutely right.
Within our own shop, we do see a huge amount of syphilis cases and it's really shocking because we generally, you consider syphilis kind of a thing of the past, but that's really not the case. Realistically, it is prevalent in many communities and empiric therapy in some situations certainly could be an appropriate, you know, uh, option.
So I think that, uh, it kind of goes back to what the pres the patient is, is, um, what information they're providing us if they have that high risk lifestyle or if they have symptoms that are specifically concerning for syphilis, absolutely treating empirically syphilis is appropriate and it's, I wouldn't say it's benign 'cause it's very painful. Um, but that, that shot of penicillin is not fun.
However, realistically giving a dose of penicillin, I mean the, the collateral damage associated with that simple antibiotic is, is very minimal. So I think that giving that in in certain situations is totally reasonable. And again, it, it will prevent us from having these lost to follow up patients, um, and prolonging the duration of time that this patient may potentially be spreading it within the community. - And can that be given iv?
- So IV is a completely separate type of penicillin and it's a much longer duration. Yeah. And so ensuring that you're getting the right agent the right route to is certainly important. So it can be given iv, but it's generally in like a neurosyphilis situation. - Okay. Let's jump over to uncomplicated UTIs, urinary tract infections. Anything new we need to know? - So there's a few things. So with uncomplicated UTIs, the standard therapy options still apply.
You have your beta-lactams, you have macro bit or nitro toin. You could potentially use phosphomycin. You have Bactrim or Trimeth, uh, sulfamethoxazole. And then finally, um, you have your fluoroquinolones. All of those are still options. Uh, but the one that, there's two things that I wanna touch on. First of all, the old dogma associated with Nitro ferone cannot be used in male patients.
That's not true. So there's new, new evidence that's emerging that is suggesting that the use of Macrobid or Nitro ferone is totally legitimate in a uncomplicated male patient population. It, it, it provides just as good a coverage. And so realistically that's an option that we really should be utilizing because of, again, that collateral damage. There's very little associated with it and it's a very effective, well tolerated medication.
- So I was always taught that AUTI in a male is by definition complicated, but we're talking about a patient with maybe only cystitis symptoms in an otherwise pretty healthy patient. - Absolutely, that's correct cystitis. And there's no concern for poly nephritis and there's no anatomical challenges associated with their urinary system. - What about kids with uncomplicated UTIs? How do you approach treatment with them?
- Generally speaking, I think that initiating therapy with aid beta-lactam is, is, is an appropriate first-line option for these patients or macrobid from that matter, depending on what their age is. But I do think that those two options are, are fairly safe and effective in that patient population and usually we'll cover the etiology, the bacteria that we're most commonly concerned about. So those two are, are generally my go-to options.
- And by beta-lactam you're talking about like an amoxicillin, - Amoxicillin or a, uh, Keflex or, or um, a uh, septinine. Those type of beta-lactams are usually very effective. Yeah, - Yeah. My go-to is Keflex in the uncomplicated UTI in a child. It is kind of sucky because of the frequency of dosing of course, but the resistance patterns works well for our site in particular, amoxicillin has kind of gone out of favor because of the resistance, uh,
that e coli has shown towards amoxicillin. I - Agree. We most commonly utilize Keflex. Uh, absolutely. Generally the only time we're turning to amoxicillin is if you actually have culture data that really supports its use. - Yes, absolutely. Now the complicated UTI, the febrile UTI, the patient that has kidney involvement in a child, how do you approach that? - Depending on age, oftentimes the option for adult patients also holds true pediatrics.
We frequently turn to fluoroquinolones or levofloxacin in, in our case, frequently in these situations as it is the first line or guideline recommended agent for a pyelonephritis or a significantly complicated UTI. - Yeah, I tend to go more towards the cine ears in our kids. Um, and I like the one-day dosing that you can get, um, with that. Um, so that's my usual go-to in the more complicated pediatric patient. I did Bactrim for years on them and I felt like that was good.
But the resistance pattern is starting to show increased resistance to Bactrim. So I've been switching over and again, the once day dosing is kind of brilliant . - I don't think that there's any problem with that. I think the use of beta-lactams like ceftin are totally legitimate in these pyelonephritis patients.
The only reason why, uh, levofloxacin or fluoroquinolone was recommended by guidelines for pyelonephritis was there was a slight increase in the, the number of relapses or recurrent UTIs or pyelonephritis in an adult patient population. So that's the only reason. But that data is really old now. And the reality is resistance patterns have likely changed with fluoroquinolones. And I think that utilizing a beta-lactam like ceftin ear, even in a pediatric population is totally legitimate.
- Yeah, cine is affix amine. Those are kind of nice go-to dosing and have shown pretty good in kids with complicated UTIs for discharge. Like that's where a lot of our data is - Now in the adult patient with that complicated UTI or pilo, um, we know Macrobid doesn't concentrate well on the kidneys. So that's out. And you've mentioned these other ones, the, um, quinolones, uh, trimeth sulfamethoxazole or Bactrim and our, um, cephalosporins, those tend to be the three that we think about.
I know that the quinolones are sort of ideal from a bacteriology standpoint, if that's the right word, but we also know that a lot of our adult patients we have concern for prolonged QT or other complications. What do you recommend for in terms of these three - If you're looking to avoid a fluoroquinolone? Uh, I think that the use of a beta-lactam or cephalosporin in these situations is, is a great place to start now. Um, pyelonephritis should be treated effectively by this agent.
Um, and uh, theoretically you should be able to use Bactrim as another perfectly acceptable alternative. Um, but technically speaking, the the guidelines do recommend that fluoro clone first line, but I do think that the, as resistance patterns change, I do think that cephalosporins are a perfectly acceptable option to initiate therapy for these pyelonephritis patients. - This might change based on local resistance patterns too, right?
- Absolutely, yeah. If you have identified within your own shop that there is significant resistance to say Bactrim for, uh, a common UTI pathogen, I think that in those cases you certainly should be avoiding it or at least, uh, prioritizing the use of another alternative therapy - And significant resistance to you is what, greater than 15% Generally, - It, it lies within like a 10 to 15%, uh, of bacteria that we identify as having resistance.
So if, if you're above 10, that's, that's kind of where we draw the - Line. Yeah, absolutely. I actually pull up our antibiogram not infrequently. I think my last two shifts, I've pulled it up because it really helps me understand and remember where I need to be. So I like that. - Now talk to me about phosphomycin. - Phosphomycin once upon a time was my favorite drug .
Um, it, it, uh, has in some situations saved admissions, uh, for me in patients because it's just like this really special drug in that it's just a onetime dose and you're good to go, right? And unfortunately it's becoming a situation where we are seeing increasing resistance patterns with fos mycin and failures of therapy.
And so there's newer information that is making it clear that Foss Mycin should probably be not our, you know, fifth option or fifth class of medication for UTIs, that we should use it as an alternative therapy when all else fails. And it may again save us an admission. And that that certainly is a great option. However, it is a challenge. So with Phosphomycin, there is no susceptibility testing nothing that you can really, you know, hang your hat on.
And so you're not really gonna be able to know that you've treated the patient successfully unless you follow symptoms or if they're able to tell you they have symptoms. So in those patients where, uh, you know, it's critical that you know you've had cure in those situations, the only thing that is really going to guide you is symptoms. And so it's, it's a challenge because you don't have laboratory results that are gonna be helpful.
- And if we're gonna use it, when can we use that one-time dose and when does it need to be? Re-dos? - The traditional thought is that Foss Mycin can be utilized as a single dose in the simple cystitis and then re-dosing. Commonly what's done is every other day for three doses, uh, is often reserved and recommended for these complicated or plon nephritis type patients. - Well, I think this is a good spot to wrap up our push dose Pearls episode on antibiotics. Thanks so much, Chris, for coming.
- My pleasure. Thanks for having me.