Pharmacy Care Note
Assessment of current medical condition(s)
1. C. difficile infection (CDI):
Uncontrolled; DTP: Adverse Drug Reaction and Needs Additional Therapy; JL , a 57-year-old Hispanic
female, is on day 5 of her hospital admission today. She was admitted for a purulent skin infection,
however after 4 days of antibiotic therapy (linezolid 600 mg by mouth twice daily and levofloxacin 500 mg
by mouth daily), the patient has begun to have watery diarrhea (approximately 8 times a day) along with
abdominal cramping and fevers. In addition, patient is on Omeprazole 20 mg daily, HCTZ 25 mg daily, and
Acetaminophen 500 mg as needed for pain. Patient also states that she is thirsty and has had loss of her
appetite due to the persistent diarrhea. A PCR test for C.diff Toxin came back positive. In addition, her
WBC is very elevated at 21x103/mm3. Patient complains that the diarrhea is persistent and “nasty.” After
interviewing the patient, it was discovered that JL has had a C.diff infection previously, approximately 2
months ago, and was treated with Metronidazole for 10 days and took the full course of the therapy. The
patient declines traveling recently. After interviewing the patient, this watery, persistent diarrhea is likely a
recurrent C.diff infection, and this is JL’s chief concern. JL’s recent antibiotic exposure (especially to
Fluroquinolones – levofloxacin) as well as her Proton Pump Inhibitor (omeprazole) are the likely causes of
her C.diff infection. The goal of JL’s therapy is to shorter her duration of symptoms, shorten duration of
fecal shedding, and resolve her infection without recurrence. It is recommended to discontinue any
antimicrobials or streamline them in order to achieve our goal of resolving JL’s CDI.
2. Purulent Skin infection (MRSA):
Current Status is Controlled; Unnecessary Drug Therapy; JL was admitted to the hospital 5 days ago for a
purulent skin infection. According to the wound exudate culture, it was confirmed to be Methicillin –
resistant S. aureus (MRSA). Patient was then started on Linezolid (600mg by mouth twice daily) and
Levofloxacin (500mg by mouth daily) following incision and drainage. Both JL and her physicians agree
that this infection is improving. According to the 2014 Infectious Disease Society of America guidelines,
treatment for this infectious requires therapy that lasts 5 – 10 days, and therefore her therapy can be
discontinued upon discharge from the hospital today. The goal of resolving her MRSA skin infection has
been accomplished.
3. GERD:
Current status is Controlled: Unnecessary Drug Therapy; Upon interview with JL today on day 5 of her
admission to the hospital for a purulent skin infection (confirmed to be MRSA), she states that she is
symptom free of her previous GERD, which she had “a long time ago.” She states that she had symptoms
of GERD a couple times in the past, so her doctor prescribed Omeprazole 20 mg daily. Patient has been
adherent to her Omeprazole medication, but since she is not experiencing GERD symptoms any longer, she
does not want to continue taking this medication if it is unnecessary. Due to the adverse effects associated
with PPIs (proton pump inhibitors) such as Omeprazole, for example her current C.difficile infection, it is
recommended to discontinue this medication and if patient still desires a medication recommendation for as
needed use, switch her to an H2RA (such as Ranitidine) to be used only when needed. The goal to resolve
this patients heartburn/GERD has been achieved. Another goal for this patient would be to prevent any
recurrent GERD; this can be accomplished by giving the patient a recommendation for an as needed H2RA.
Plan
1. C. difficile infection:
Start: Vancomycin 125mg PO q6h for 10 days.
Because patient was taking Metronidazole previously for her initial CDI, it is recommended to
give this Vancomycin dose. Recommendation per the 2017 IDSA guidelines.
Additionally, recommend patient education on how this infection can spread and the importance of hand
hygiene and sanitation as well as the importance of taking the antibiotic as prescribed.
Monitor: WBC; Educate patient on signs/symptoms for them to monitor and report to Primary Care
Provider such as fever, reduced BP (ensure patient is not in shock, especially because this patient is
hypertensive normally), hydration (ensure not drinking overly sweet drinks as that can worsen diarrhea),
appetite (ensure patient’s appetite has come back), no allergic reaction (such as a rash)
Follow Up: with primary care provider in 10 days to ensure C.diff infection has completely been resolved.
2. Purulent Skin infection (MRSA):
Continue: linezolid 600 mg by mouth twice daily
This infection came back as MRSA when cultured, so the Linezolid is effective at treating this and
should be continued for another 5 days to the full therapy length (10 days total) according to 2014
IDSA guidelines.
Stop: levofloxacin 500 mg by mouth daily
According to the 2014 Infectious Disease Society of America guidelines, treatment for this
infectious requires therapy that lasts 5 – 10 days for Levofloxacin
Since this Fluorquinolone is a likely cause of the patients CDI, we should discontinue this
medication
Monitor: appearance of infection to ensure it has been fully resolved
Follow up: with primary care provider (PCP) if patient sees and reappearance of skin infection OR if
patient does not see improvement over the next 5 days.
3. GERD:
Stop: Omeprazole 20 mg
Optional Start: Zantac 75mg by mouth as needed for GERD symptoms if patient desires a
recommendation for as needed symptoms
Instruct patient on how to take this medication as it is as needed, unlike her previous PPI which was a daily
medication. Educate patient on taking this medication with a glass of water 30-60 min before or after a
meal.
Educate patient on any trigger foods as well as non-pharmacological ways to reduce likelihood of GERD
symptoms, for example elevating the head of the bed
Monitor: Symptoms of GERD and ensure that they don’t resurface
Follow up: with regular pharmacist to report symptoms if they return as they can direct patient to whether
they can self-treat or if they require a prescription and to be seen by PCP. F/u if any symptoms resurface in
14 days. Although if patient experiences symptoms sooner, they should tell their PCP
