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Ashley & Brooke Barlow PharmD Profile picture
@theABofPharmaC
May 18, 2020 • 5 tweets • 3 min read • Read on X
#OLILT #IDtwitter
ESBL vs AmpC🦠what is the difference in resistance & tx?

Resistance
ESBLs ➡️ encoded by plasmid genes
AmpC ➡️encoded by plasmid genes OR "inducible resistance" via derepression of chromosomal🧬genes
⚠️can👀susceptible but resistance develops ON therapy!
Treatment➡️Carbapenems➡️𝟏st line💊of choice

However➡️rate of carbapenem resistance is📈➡️today I was asked about cefepime tx

AmpC➡️typically resistant to some/ALL cephalosporins BUT cefepime is STABLE against AmpC! (unless other mechanisms of resistance are present)
ESBL➡️typically can hydrolyze cefepime, data for ⤴️innoculum infections or if MIC >1 shows ⤴️ failure, some data shows ⤴️mortality if using cefepime REGARDLESS of MIC😳
aac.asm.org/content/59/12/…
For more readings check these resources out
cmr.asm.org/content/31/2/e…

idstewardship.com/gram-negative-… @IDstewardship

ncbi.nlm.nih.gov/pmc/articles/P…

Feel free to comment with your own pearls!
Also excellent review by @emilylheil tandfonline.com/doi/full/10.15…

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More from @theABofPharmaC

Ashley & Brooke Barlow PharmD Profile picture
Jan 7, 2022
Time ⏰ for Part #2 of the Tweetorial 🧵 on the DDI btwn PHT & VPA with a focus on drug metabolism 💊🔄

If you haven’t seen it yet - check out Part 1 by @JimmySuhMD on the albumin interaction btwn PHT & VPA
 
However, that’s only half of the story!⚠️
 
1/n First, let’s discuss basics on phases of drug metabolism 🔄
 
Phase I: Oxidation (ex. CYP450 enzymes)
 
Phase II: Conjugation (ex. Glucuronidation)
 
🎯 Goal 👉🏻 covert drug to an active (pro-drug) or inactive metabolite and ⤴️ solubility ➕ ⤴️drug elimination via urine/bile
2/n What are the key 🔑 metabolic pathways for VPA?

There’s 3️⃣ big ones
 
Phase1️⃣ (~10%)
➢ Substrate of CYP2A6, CYP2B6, CYP2C9
➢ *4-ene metabolite▶️ hepatotoxic ⚠️
 
Phase2️⃣ (~30 – 50%)
➢ Conjugation via glucuronosyltransferase
 
Other▶️Mitochondrial β-oxidation (~40%)
Read 12 tweets
Ashley & Brooke Barlow PharmD Profile picture
Nov 30, 2021
A #MedTwitter🧵on the frequently obtained, but ever mysterious🕵️‍♀️ Procalcitonin (PCT) 🦠

💡 What is it?
💡 Where does it come from?
💡 What factors/comorbid conditions may impact PCT?

#IDTwitter #TwitteRx
1/n First, let’s discuss the normal, physiologic role of PCT 🧬

✨116 chain amino acid
✨Neuroendocrine hormone
✨Produced by thyroid C-cells
✨Enzymatically cleaved to calcitonin
✨ Regulate Ca+2 & PO4- homeostasis

DOI 10.1093/ajhp/zxaa089

@AJHPOfficial @SESmithPharmD Image
2/n Why/How does PCT ⤴️ in bacterial infections?

✨Nonendocrine tissues (adipocytes, spleen, pancreas, etc) produce PCT but LACK 🛑 enzymes to cleave to calcitonin

✨Stimulus for non-thyroid PCT production include
1️⃣LPS/bacterial toxins ⚠️
2️⃣Cytokines (IL6, TNFa, ILb) Image
Read 9 tweets
Ashley & Brooke Barlow PharmD Profile picture
Sep 21, 2021
Let’s talk CSF 🧠 💦

☝️ What is it & why is it important?
✌️ Key considerations in CSF sampling 🧪 & analysis 🧐 for suspected infection 🦠

A #NeuroTwitter 🧵 inspired by bedside rounds with attending @BuslKatharina & NCC team👏🏻
So to start, what is CSF? 🤔

CSF▶️clear, sterile fluid secreted by choroid plexus 💦 in the ventricles ➡️circulates throughout the subarachnoid space🧠 & spinal canal🦴

⭐️Function▶️ protective barrier 🛡 provides nutrients 🍎& facilitates removal toxins/metabolic byproducts⚠️
Now, let’s discuss🖐key pearls when analyzing CSF🧐for poss infection🦠

1️⃣Consider the source!

Obtained from a…
▶️“Closed”system, ie LP💉?
▶️“Open”system, ie EVD🧠?

⚠️Interpret CSF💦from “open”sys w/caution▶️blood🩸& inflammation🔥from underlying condition are often present
Read 8 tweets
Ashley & Brooke Barlow PharmD Profile picture
Aug 20, 2021
Now that the salty🧂debate on the TYPE of fluid to use in the ICU has largely been solved, how about the RATE of IVF? 🤔

Back to the BaSICS💦

✅The Balanced Solutions in Intensive Care Study📖 (BaSICS) ▶️compared 333mL/hr vs 999 mL/h

Does IVF rate impact 90-day mortality? 🤔
💡 10, 520 ICU pts randomized 🏥

Fluid volume:

1162 mL in the SLOW infusion group 💦
vs. 1252 mL in the FASTer group

🛑NO difference in☝️ outcome: 90-day mortality (HR 1.03, CI, 0.96-1.11)

🛑No difference in✌️outcomes: RRT, AKI, ventilator free days, ICU/hospital LOS
Notably, when reviewing this study, the baseline characteristics are a key 🔑 consideration

< 5% of the cohort in both groups had sepsis (⬇️ the generalizability in this population) 🦠

Patients with AKI or ESRD were excluded from the trial 💡
Read 5 tweets
Ashley & Brooke Barlow PharmD Profile picture
May 27, 2021
Alert 🎙Pharmacy Grand Rounds Thread Ahead! 🚨

Last week I had one of my final presentations of the year! With a catchy title😉

Urine for an Update! Updates in the management of metastatic urothelial cancer

Hold your bladders, this is an extensive update! 😂
#oncopharm Image
Bladder cancer can be divided into two ✌️subtypes:
1) Non-muscle invasive: encompasses in-situ and localized disease➡️5-yr OS >70%

2) Muscle invasive: encompasses regional or metastatic disease➡️5-yr OS dismal especially for metastatic disease 😔 Image
Cisplatin=SOC
50% of pts w are ineligible due to older age👵🏻, poor PS, ⬇️ renal function, ⬇️hearing, neuropathy, heart failure 🫀& other comorbities that ⬆️ risk of ⚠️

Carboplatin yields inferior responses➡️NOT 🙅🏻‍♀️ an equal alternative due to ⬇️ OS😢➡️pt left w/minimal tx options Image
Read 12 tweets
Ashley & Brooke Barlow PharmD Profile picture
Apr 26, 2021
What medications 💊 are should be avoided 🛑 or used with caution ⚠️ in patients with Myasthenia Gravis? 🤔

See 👀 the thread 🧵below⤵️ that summarizes an amazing grand rounds presentation by @UKPharmRes PGY1 @AliW_PharmD on key 🔑 medication considerations in MG
1️⃣Antibiotics to avoid or use w/caution🦠 💊

🛑FQs = FDA BBW for ⤴️ risk of MG crisis ➡️ avoid use if possible
⚠️ Macrolides ⤴️ rate of MG crisis (case reports)
⚠️ AG linked to ⤴️ ICU acquired weakness & exacerbate ‼️ MG crisis
📝Risk⬆️ w/neomycin vs. tobramycin & amikacin
Antibiotics considered to be SAFE alternatives to the above include

✅Beta-lactams
✅Tetracyclines
✅Linezolid
✅Bactrim

Ex. In an MG patient who presents 🏥 w/CAP 🫁 ➡️ choose ceftriaxone + doxycycline✅ OVER ceftriaxone + azithromycin🛑
Read 7 tweets

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