Objectives

• Able to identify signs and symptoms of parasitic infections
• Able to differentiate specific pathogens and parasitic diseases
• Able to provide appropriate pharmacotherapy management for patients with parasitic infections

 Parasites Drug Information

Patient comes to your local pharmacy where you are the pharmacist. She states she has to pick up medicine for pinworms after her kids were seen by the pediatrician. Provide the dose only for the MOM.

Dad (age 47, weight 170 lbs):

Mom (age 45, weight 150 lbs):

Daughter (age 14, weight 100 lbs):

Son (age 18 months, weight 40 lbs):

Counseling instructions for the family:

2. You receive a prescription for Malarone for one patient and Doxycycline for another patient – both patients are friends and traveling to Ghana. Please provide the instructions for the chemoprophylaxis for each patient and counseling that is needed. Please be specific in your instructions.

Objectives

• Able to assess and evaluate UTI-related pharmacotherapy

Instructions

With the case information provided, please give a clear pharmacotherapy recommendation.

UTI Simple Case 

A patient present with complaints of urinary frequency and burning on urination. The leukocyte esterase is positive as is the nitrate test. The culture is provided below. The patient has no allergies and G6PD is WNL. Provide a recommendation.  See culture results below.

Recommendation:

Objectives

• Able to identify signs and symptoms of Lyme disease
• Able to describe pathogen and carrier for Lyme disease
• Able to interpret laboratory result from Lyme disease to aid the treatment
• Able to provide appropriate pharmacotherapy management for patients with Lyme disease

Instructions

With the case information provided, please answer the following questions.

Scenario: You are working at CVS Pharmacy. Johnny, who is a 7-year-old boy, presents to you with his parents with a complaint of painful rash. His parents ask you for a topical cream product to relieve itchiness. Johnny’s rash is pictured below.

Erythematous annular plaque measuring 6 × 5 cm in size with a central blister on the back of the left leg.

Additional information: This is a 7-year-old boy from a Rhode Island presented to you with a 3-4 day history of sudden appearance of a painful brownish raised lesion over the back of his left leg, associated with surrounding redness which was increasing progressively. The child did not have fever or any other systemic complaints. He gave a history of visit to the nearby forest a few days before the appearance of the lesion. On examination, there was an erythematous annular plaque on the back of the left lower leg approximately 6 × 5 cm in size, with a central brownish fluid filled blister. Induration and tenderness were present over the lesion, and local popliteal lymphadenopathy was seen. In addition, there was a lymphangitic streak on the inner aspect of the thigh. Other systemic examination was unremarkable.

Question 1: With the information provided, what OTC topical product would you recommend to the parents?

Question 2: If you do not believe this is treatable at CVS, let’s assume that your CVS has capacity to run all lab test in the world, what laboratory investigations you would like to obtain?

Question 3: You ordered the lab and the results were as follows:

• Serology for Borrelia burgdorferi (23 KDa) antigen was done with enzyme-immunoassay technique.
  • IgM was raised at 4.4 U/ml (normal <0.90)
  • IgG was found to be normal [0.3 U/ml (normal <0.90)
• What is IgM? Why is only IgM elevated but not IgG?

Question 4: What insect/bug carries the spirochete Borrelia burgdorferi? Please pick from the pictures below

Tick 1:

Tick 2:

Tick 3:

Tick 4:

Question 5: Should Johnny receive antibiotic prophylaxis for Lyme disease? Also list out subjective and objective data you need to obtain to determine the need to antibiotic prophylaxis

Question 6: Now you want to treat Johnny’s Lyme disease. What is your pharmacotherapy recommendation?

Question 7: What is the appropriate treatment duration for Johnny’s Lyme disease?

Question 8: After a few days after john’s started his therapy based on question 7, Johnny’s parents are asking you whether amoxicillin is better. What do you think about this?

Hint: you should perform literature search on this question.

Objectives

• Able to understand the general structure and infrastructure needed to implement a stewardship program
• Able to work through examples of antimicrobial stewardship techniques  

Instructions

By taking on the role of the antimicrobial stewardship pharmacist, please complete the listed alerts below and their associated questions.

IV to PO Alert

“10/3/2022: Patient is on an IV antimicrobial with other medications ordered PO.

This alert does not link to diet or PRN PO medication orders.”

Patient Information:

30-year-old Male admitted 9/30/22 with Status Asthmaticus

Date	9/30/16	10/1/16	10/2/16	10/3/16
Diet	NPO	Start NGT feeding	NGT feeding titrating to goal	NGT feeding at Goal
BP	96/49	120/60	135/70	130/65

PMH:  Asthma

PSH: none

NKDA

Admitted to the MICU for ventilator management.

VS: 36.6 C BP: 96/49 HR: 129 RR: 20

9/30: NPO. Received cefepime x 1.

10/1: Tube Feeds started. Placed on ceftriaxone IV 2 G q24h.

10/3: currently at goal. No residuals.

Pt is sedated with propofol.

Pt is on prednisone and other medication via NGT.

Ceftriaxone still active.

Patient sputum culture from 9/30: H. Influenza, Beta-lactamase: negative

What pharmacotherapy change would you make for this patient’s antimicrobial regimen?

De-escalation

ALERT: “Antibiotic therapy should be re-evaluated”.

Patient Information:

56-year-old man who presented to the hospital emergency department with status epilepticus. He was intubated, had a central line placed in the internal jugular vein, and was admitted to the intensive care unit (ICU). The seizure was successfully broken by aggressive treatment.  Empiric antibiotic therapy was initiated with vancomycin and piperacillin/tazobactam on day 5, after spiking a fever of 103.4°F.  While in the ICU with a central line in place, 2 sets of blood cultures were drawn. The patient is hemodynamically stable, with no other abnormal findings on physical examination. 

Patient has no drug allergies.

Microbiology
Blood culture hospital day 5	2 out of 2 bottles positive for Gram positive cocci in clusters
	Final Results: Staphylococcus aureus
	Oxacillin	S
	Vancomycin	S

What change would you make for the patient’s antimicrobial therapy? For what duration?