emperic therapy (was: surgeons nose)

Robert Morrell Jr. bmorrell at ISNET.IS.WFU.EDU
Mon Aug 7 13:25:55 EST 1995


On Mon, 7 Aug 1995 Steven_Projan at internetmail.pr.cyanamid.com wrote:
> You must be kidding.
> First off empiric therapy with vanco is just plan stupid as it only affords gram 
> positive coverage (so it wouldn't touch such common nosocomial pathogens as E. 
> coli, Klebsiella and Pseudomonas).

Obviously I was only speaking of the gram positive coverage of an empiric 
therapy combination. 

> Secondly such a use of vancomycin will only hasten the day when MRSA acquire 
> vancomycin resistance.  Vancomycin should be reserved for cases where it is 
> needed.

So, in a hospital where 50-60% of all Staph aureus is ox resistant, you
would tell a physician to treat a probable staph infection with oxacillin
=until= (and if) the organism was recovered and tested against oxacillin
and then and only then treat with vanc, assuming the patient is still
alive.... 

> The right drug for the right bug.

certainly, but when? This whole issue of emperic therapy changes is one 
that will come up more and more often as new resistance patterns emerge. 
For instance our pediatrics recently added vanc as emperic therapy when 
considering probable Strep pneumo infections, because our percentage of 
resistance crossed over 20% for pen and over 5% for the cephs. For them 
this meant that between 1 and 4 patients in twenty would fail therapy, 
and given the nature of that infection, the docs would not get a second 
chance, so vanc up front.

As a lab person I empathize with those want the susceptibity reports to be
used more carefully (switching back to ox once the mic report is in would
be great, but many docs are reluctant to change therapy if the patient is
getting better.) and I certainly worry about increasing resistance through
over usage (though as an aside we have been a chronic and long term
overuser of vanc and as of yet have seen only a few VRE's)

However, I also understand the physicians desire to hit the pathogen =now=
not later when the cultures come back (if they ever do). We in the labs 
too seldom look at this from the docs POV. 

*                     Bob Morrell                       *
*              bmorrell at isnet.is.wfu.edu                *
* The operation was a success, as the autopsy will show *





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