Cotrimoxazole - optimal dosing in the critically ill.

The optimum dosage regimen for cotrimoxazole in the treatment of life threatening infections due to susceptible organisms encountered in critically ill patients is unclear despite decades of the drug's use. Therapeutic drug monitoring to determine the appropriate dosing for successful infection eradication is not widely available. The clinician must utilize published pharmacokinetic, pharmacodynamic, and effective inhibitory concentration information to determine potential dosing regimens for individual patients when treating specific pathogens. Using minimum inhibitory concentrations known to successfully block growth for target pathogens, the pharmacokinetics of both trimethoprim and sulfamethoxazole can be utilized to establish empiric dosing regimens for critically ill patients while considering organ of clearance impairment. The author's recommendations for appropriate dosing regimens are forwarded based on these parameters.

Comparison of physician- and pharmacist-managed warfarin sodium treatment in open heart surgery patients.

OBJECTIVES: To compare the effectiveness of pharmacists and physicians in obtaining therapeutic anticoagulation on initiation of warfarin sodium therapy immediately following prosthetic cardiac valve insertion. Secondary objectives were the percentage of days with an international normalized ratio (INR) greater than four, the percentage of days with an INR less than two, the time to stabilize the INR within the therapeutic range, and the percentage of patients experiencing at least one major bleed. METHODS: This study was a before and after comparison using a retrospective chart review of patients who received warfarin sodium following cardiac valve surgery. Physicians dosed independently and pharmacists used a warfarin sodium nomogram to manage patients. RESULTS: A total of 227 patients (physician group, n=130; pharmacist group, n=97) satisfied the inclusion criteria. No differences were found between the two groups in the percentage of days in the therapeutic range (P=0.27), the percentage of days with INR less than two (P=0.06), the percentage of patients discharged before their INR stabilized (P=0.91) or the percentage of patients with a major bleed (P=0.72). The pharmacist group had 5.9% fewer days (P<0.001) with an INR greater than four than the physician group. CONCLUSIONS: Appropriately trained pharmacists appear equally safe and effective as physicians when managing warfarin sodium therapy in patients who have undergone cardiac valve replacement.

Pretreatment with ibuprofen to prevent electroconvulsive therapy-induced headache.

BACKGROUND: Although electroconvulsive therapy (ECT) has been widely recognized as an effective treatment for severe depression and various other psychiatric illnesses, adverse effects have been frequently reported, especially a high incidence of headache. Analgesics, such as acetaminophen, narcotics, or nonsteroidal anti-inflammatory drugs (NSAIDs), are commonly used to treat ECT-induced headache. The objective of this study was to determine whether pretreatment with ibuprofen would prevent the onset or decrease the severity of headache that occurs after ECT. METHOD: All inpatients on the psychiatric units who required ECT treatment were asked to participate in the study. Thirty-four patients were randomly assigned to receive either ibuprofen, 600 mg, or placebo orally 90 minutes prior to the initial ECT session, with the alternate treatment given for the second ECT treatment. Patients were asked to complete a questionnaire prior to and after the first 2 ECT treatments regarding the pattern, severity, and onset of headache. Severity of the headache was measured on a visual analogue scale (VAS). RESULTS: Ten patients experienced headache in neither treatment arm, while 7 patients experienced headache in both treatment arms. Eleven patients experienced headache with placebo but not with ibuprofen, while 2 patients experienced headache with ibuprofen but not with placebo. Ibuprofen was significantly more effective than placebo in preventing the onset of headache post-ECT (p =.022). The mean +/- SD VAS headache scores were 1.49 +/- 1.54 and 0.54 +/- 0.91 in the placebo and ibuprofen arms, respectively. Ibuprofen was significantly more effective than placebo in reducing the severity of ECT-induced headache (p =.007). CONCLUSION: Ibuprofen premedication reduced the frequency and severity of headache post-ECT and should be considered for appropriate patients who suffer from ECT-induced headache.