Saturday, October 27, 2012

Rotation #4: Pediatrics Infectious Disease

Posted by Kristen Gardner at Saturday, October 27, 2012

  • This rotation was an inpatient clinical rotation specializing in pediatrics infectious disease
  • I was on this rotation with another student- always helpful!
  • The medical team is smaller than others with an attending, 3rd year fellow ( --> PGY-6), 1st year medical resident, 4th year medical student from Wayne State, me and my classmate, and Dr. Klein the clinical pharmacist
    • I appreciated the smaller team and focusing on 1-3 patients/day for my first clinical rotation then following them through their stay

What did I see?
  • Septic arthritis
  • Complicated pneumonia cases with abscess development in the lungs
  • Tracheitis
  • UTIs (especially with patients who had neurogenic bladder)
  • Culture negative sepsis
  • Meningitis
  • Fungemia and bacteremia
  • Mold peritonitis

What did I do?
  • Worked up patients
    • patient load/week ~8 patients but this varied depending on how many consults we had for the week
  • Had patient discussion with my preceptor every day for 1-2 hours
  • Rounding with the pediatrics/infectious disease consult team
  • Attended the Pediatrics Infectious Disease weekly case conference every Thursday
  • Attend journal club for the above group
  • Presented an overview of antifungal agents to the above group
  • Delivered 4 topic discussions on shunt infections, community acquired pneumonia in infants and children, infective endocarditis, antibiotic lock therapy
  • Normally students attend daily microrounds in the pathology department where they learn about a new  test everyday. We did not attend.

Common drugs
  • Zosyn, Unasyn, ceftriaxone, Bactrim, clindamycin, 
  • Amphotericin B and Ambisome (lipid version of ampho B), voriconazole, micafungin
  • PCP prophylaxis drugs such as bactrim, dapsone, atovaquone, pentamidine
    • Know differences between these such as efficacy (e.g. incidence of recurrence, resolution of infection), fluid requirement, dose adjustments, side effect profile)

    • Describe their fever curve (how many fevers, how long were they febrile, is it getting better/worse)
    • Have their vent setting changed or need for nasal cannula (if relevant such as with tracheitis, pneumonia, etc)
    • For pharmacokinetics know when doses were given (date and time), time of last dose, when and where level was drawn from, what is their goal peak and trough. Consider many factors when interpreting levels!
    • Know all info about cultures obtained (where, when, preliminary/final result, how (e.g. wound swab, blood draw, heel stick; this may signify if positive culture with Staphlococcus epidermidis or coagulase negative microorganism is a contaminate) especially in relation to antibiotics administered to patient. For example, if culture is negative, is there really no bug or no bug because antibiotics were being given
  • Be proactive; anticipate questions and follow your patients closely! Know what to keep an eye out for!
  • Consider colonization vs. infection (sometimes this is difficult!)
  • LISTEN to the team even for your other classmates
  • ASK your classmates for help! If someone had a PICU rotation, ask about dialysis dosing! If someone has had a psychiatry rotation- ask them for information first! This saves you time and builds skills you will use as a pharmacist. You cannot be at the top of your game for every specialty and disease state. It is impossible.
  • HAVE FUN! Sing kids happy birthday, play with them in their room, and learn to French braid hair if that is all they keep asking for
  • Check the medical administration record (MAR) to see if the kids are throwing up from antibiotics (If so, there will be comments. You may use this information to recommend adjusting the frequency or dose an antibiotic such as clindamycin)
  • Take INITIATIVE and follow-up with your preceptor on questions posed to which you did not know the answer. They may not hold you accountable for this by asking you later but it demonstrates motivation and prompt follow-through.
  • Be familiar with common labs values of neonates, infants, children
  • Be familiar with our restricted antibiotics and protocols and hold the medical team accountable for these

Common Interventions
  • Reminding the medical teams of some of out institutions/unit specific antibiotic resistance patterns (hint: use the UMHS antibiogram)
  • Adjusting antibiotic dosages- either increase or decrease dose
  • Pharmacokinetic monitoring/adjustments with vancomycin and aminoglycosides
  • Antibiotic regimens for IV -> po switches
  • Antibiotics regimens IV inpatient à IV outpatient (for when a patient is on a q6hr regimen inpatient as this is difficult to adhere to as an outpatient)
  • Recommending labs: basic metabolic panel, renal labs (SCr/BUN), LFTs, voriconazole trough level
  • Providing pharmacokinetic knowledge to the medical team (oral bioavailability, protein binding, renal excretion, antibiotic coverage). 
    • Medical students have limited knowledge about antibiotics. I consider ID an ESSENTIAL niche for pharmacists. 
    • You will very likely use this information on every rotation.

Fun Facts
  • For antifungals we monitor voriconazole, posaconazole, itraconazole, and flucytosine levels at UMHS
    • Sign of voriconazole toxicity (level > 5) is when patient is having visual disturbances or hallucinations
  • There are many different formulations of amphotericin B (non-lipid and lipid with 3 different lipid formulations)
  • Voriconazole and echinocandins (e.g. micafungin) do not appreciably accumulate in the urine and cannot use to strictly treat candiduria
  • fluconazole has NO mold coverage, only yeast; all candida spp. may not be sensitive to fluconazole
  • when adjusting vancomycin and aminoglycoside levels- try to cap modifications at 30% dose change or frequency change. Do not do both at once.
  • Do not forget about fosfomycin and its coverage spectrum! This treatment can be VERY useful!
  • Ciprofloxacin has a narrower spectrum vs. levofloxacin
  • For community acquired pneumonia (CAP) in children < 5yo, you do not need to empirically cover for atypical pathogens UNLESS they are strongly suspected based on the clinical presentation
  • Always embrace antibiotic stewardship and use the antibiotic with the most narrow spectrum, even when choosing on empiric therapy
  • Ambisome does not share the nephrotoxicity risk of amphotericin B
  • voriconazole IV formulation has a vehicle (a cyclodextrin) that is eliminated slower then the drug --> we try to minimize use to 2 weeks or else the vehicle can cause nephrotoxicity
  • triazoles can cause a transient transaminitis that usually manifests after 7-10 days of treatment--> baseline LFTs needed and follow-up in 1 week to assess. D/C if 5x upper normal limit

What was difficult?
  • It was my first clinical rotation, and I am way too curious of a student. Therefore, it was hard for me to make myself prioritize (even though I knew what I had to do, I would get side tracked). But, exhaustion is a great motivator.
  • We are a consult team; therefore, we may get PICU patients who have been in the hospital since birth! Initially, I felt overwhelmed in these cases because there was so much data in the medical chart. Hint: graphing results in Carelink is your best friend to visualize trends and figure out their baseline values. Read the ADMIN note, prog note/reason for consult, and go from there.

Do I recommend this rotation? YES! It is a great way to get a dose of two worlds: infectious disease and pediatrics. The little kiddies are challenging! Dr. Klein is extremely respected by the medical team and is very knowledgeable. She is always available for questions and responds to pages quickly. She holds a final jeopardy at the end of the rotation. I was somewhat anxious about this but it was really fun! If you paid attention on rotation it is a breeze!

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