Liver abscess

There is this Indian uncle who had admitted to my ward complaining of fever for 3 days and worsening abdominal pain for 1 week. Patient is an alcoholic. Initially he was suspected to have acute calculus cholecystitis and meliodosis. However, CT scan showed that he actually had liver abscess. (a pus filled cavity in the liver).

His blood culture and sensitivity taken on admission showed present of Enterobacter Sakazakii. As there is multiple loculi, and the size of each of the loculus was small, there is no indication for surgical drainage of the abscess. Therefore the surgeons plan to start on conservative management, which is starting antbiotics treatment. So, for how long should we give the antibiotics???

There are 3 types of liver abscess, namely pyogenic, amebic and also fungal liver abscess. In this article, lets discuss pyogenic and amebic liver abscess. Pyogenic abscess is usually present as multiple loculi on the CT scan and commonly cause by gram negative enteric organism such as Klebsiella pneumonia, Enterobacteriacae, enterococcus, anaerobics. On the other hand, amebic liver abscess is usually present as single loculus caused by parasite Entamoeba histolytica. The antibiotics required for this 2 types are different.

Patient in this case received antibiotics (IV cefoperazone 1g BD and IV metronidazole) for 5 days and later discharge with Tab cefuroxime 250mg BD and Tab metronidazole 400mg TDS for 6 weeks. The careless houseman in charge only prescribed 1 week antibiotics for him. Luckily the error was later amended after being informed by us. (this HO did not even show a slight appreciation!!!!! OMG, seriously beh tahan with her "DO I CARE" face. Can't she just say THANK YOU???)

Come back to the case, the national antibiotics guidline in Malaysia back in 2008 is not clear... The guideline only mentioned that patient should be treated until clinical improvement achieved. In pyogenic liver abscess, the choice of IV antibiotics include:
IV Ampicilin + IV Metronidazole + IV Gentamicin, x 2 weeks (Effective but resistant toward ampicilin increased and Gentamicin may cause nephrotoxicitiy)
or
IV Ampicillin/sulbactam alone x 2 weeks. (metronidazole may be added if cant rule out amebic)

Then, the alternative agents include:
IV 3rd gen cephalosporin + IV Metronidazole x 2 weeks or
IV ciprofloxacin + IV Metronidazole x 2 weeks.

For amoebic liver abscess, IV metronidzole 500mg TDS may be started for 10 days and Tab Tinidzole 2g OD for 3-5 days.

Then from Sanford guideline, pyogenic liver abscess may be treated with:
IV metronidazole + (IV ceftriazone or IV ciprofloxacin or IV Pip/Tazo or IV Amp/Sulbactam)
and amebic liver abscess with metronidazole, however the duration was not mentioned.

A search on the total duration of antibiotics patient should received is unclear and inconclusive. The suggested duration include IV antibiotics for 2 to 3 weeks followed by oral anitbiotics for 3 to 12 weeks. The common practice in Hospital Selayang as informed by one of the doctor is IV antibiotics for 2 weeks followed by 6 weeks oral antibiotics.

In the Malaysia ICU antibiotic guideline, pyogenic liver abscess required 6 weeks of oral antibiotics while amebic liver abscess only require 7 to 10 days of therapy followed by a luminal agent for gut colonisation. Suggested regimen for those who is hemodynamically unstable are:
IV Pip/Tazo + IV metronidazole  ---- prefered
IV Cefepime + IV metronidazole ---- prefered
IV Meropenem + IV metronidazole ---- alternative
IV Imipenem/Cilastatin + IV metronidazole ---- alternative

Then for those who is hemodynamically stable are:
IV Ceftriaxone + IV metronidazole
IV Pip/Tazo + IV metronidazole

The SD number for patient is SD330816 for future reference.

Onychomycosis (Nail infection)

My doctor asked me regarding the choice of drug in onychomycosis (nail fungal infection) today. She informed that patient's condition was severe and topical antifungal did not help and oral antifungal may be needed in this patient.

Itraconazole can be use in this kind of patient. The dose and duration for this infection is very unique and it worth to be keep in mind.

1. For onychomycosis which involve fingernail only:
200mg BD x 1 week, then off for 3 weeks, followed by 200mg BD for another week.

2. For onychomycosis which involve toenail (Trichophyton rubrum or T. mentagrophytes):
200mg BD x 12 consecutive weeks

3. For onycomycosis (toenails with or without fingernail involvement):
200mg OD x 12 weeks OR 200mg BD x 1 week, repeat 1 week course twice with 3 week off time between each course.

Myasthenia gravis

Today we had pharmacist round in the medical ward. We had reviewed 2 patients in the medical ward. The first patient is a 78 years old Malay female who was admited for myasthenia gravis (MG) and later progress to myasthenia crisis. Patient was presented with dysphagia, ptosis, diplopia and fatigue. She was also diagnosed with new onset of atrial fibrillation, with existing hypertension and hyperlipidemia.

 

Patient was treated with tab pyridostigmine 30mg TDS for MG. and later the dose was increased to 60mg TDS. At the same time she was also given IVIG infusion 20g OD for 5 days. (0.4g/kg/day). Patient responded to the treatment. However, she still has dysphagia upon review. After IVIG infusion was completed, Tab prednisolone 50mg OD (1mg/kg) was later started for MG and there is plan to initiate immunosuppressant such as Azathioprine or cyclosporine in this patient. These medications are usually required for lifelong unless the culprit organ of secreting antibody has been removed. In the ward, patient's hypertension was also treated with tab amlodipine 10mg OD and her lipid profile showed that total cholesterol was 6 and the LDL was 5.01, as a result, tab simvastatin 20mg was later increased to 40mg ON.

 

Important point of myasthenia gravis include this is an autoimmune disease. Usually affecting voluntary muscle and may cause severe fatigue and respiratory distress. The common cause influde hyperactive thymus. Thymus is an organ that we used during childhood to produce T-lymphocytes, but the organ became dormant in adulthood. However in MG, the thymus gland is hyperactive and this required removal of thymus if the condition was severe.

 

Questions raised during the round included why treatment was not initiated for atrial fibrillation. Suggestions was made to score the patient according to CHA2DS2-VASc score and assess the bleeding risk according to HAS-BLED. I score the patient myself. Total CHA2DS2-VASc score: 4, patient is a candidate for anticoagulation and should be counselled on starting warfarin.

 

C-Chronic heart failure history - 0/1

H-Hypertension history - 1/1

A-Age>75 - 2/2

D-Diabetes mellitus - 0/1

S-Stroke history - 0/2

V-Vascular disease history - 0/1

A-Age 65 to 74 - 0/1

Sex-Female - 1

 

H-Hypertension history

A-Age>65, alcohol usage history

S-Stroke history

B-Prior major bleeding history

L-Labile INR

E-Medication usage predispose to bleeding.

D-Renal / liver disease

 

HAS-BLED score was 2: hypertension and age. The risk is low. If AF is confirmed, suggestion should be made to start warfarin.

 

Questions raised also include should the simvastatin be discontinued as simvastatin may cause muscle weakness and further worsen patient's condition. I suggested that simvastatin may be continued for short period of time and to monitor her condition and only discontinued when patient showed symptoms of muscle weakness again.

 

A list of drugs which should be used cautiously in patient with MG as these medications may worsen patient's symptoms upon using was also mentioned. This include phenytoin, beta blocker, loperamide, aminoglycoside, tetracycline, sulfonamide, fluoroquinolone, colistin, Quinidine, CCB. Further list can refer to

 

http://www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&ved=0CCoQFjAA&url=http%3A%2F%2Fwww.myasthenia.org%2FLinkClick.aspx%3Ffileticket%3DJuFvZPPq2vg%253D&ei=ErWxUs-NC8eHrQfolIDwDA&usg=AFQjCNF---Bkimg54LK4kCXHNP9yf40qRg&sig2=MtfZTA5OkgTD4AEn_aNGEQ

 

 

 

We then proceed to the next patient in the ward next door. 

 

 

 

Gold Coast Itinerary

Gold Coast in 5 Days – Itinerary

1/11/13 Friday: Malaysia to Gold Coast (940pm flight)

2/11/13 Saturday:

750 am: Touch down at Coolangatta airport
Rent a car and drove from airport to Surfer paradise
Reach Capricorn One: 198 Ferny Avenue, Surfers Paradise
Gold Coast Theme Park---- Sea world
(book ticket online $75 for 3 theme parks unlimited entry till 2014)

Australian Outback Spectacular Show (730pm) --- dinner provided

3/11/13 Sunday:
Tamborine Wine Tasting (930am to 430pm) $125/pax
Lunch in DeliVino cafe
Dinner at Cavill Avenue (la piatto pizza)

 

4/11/13 Monday :

Gold Coast Theme Park :
Morning: Warner Bros Movie world 
After lunch: Wet n Wild Water World
Australia fair shopping center
Dinner: Red rooster

 

5/11/13 Tuesday :
Brisbane Day trip (drove from surfers paradise to Brisbane)
Miramar River Cruise to Lone Pine Koala Sanctuary ($68 round trip)
Gallery of modern art
Gathering with friends

 

6/11/13 Wednesday:
Walk and photo session at the beach of surfers paradise
Breakfast at ocean avenue
Movie world AGAIN
Harbour town factory outlet
Surfer paradise beach front night market
Gold Coast to Malaysia (945pm flight)

 

7/11/13 Thursday:

Arrive at Malaysia (405am)  

Translation: Who had ruined the pharmacy profession?
Author: Xiao huang
Source: Sin Chew daily 20.7.2012

Please refer to the original article if you have any queries. This translation is only based on my personal understanding from the article.

I just hand in my resignation letter before I wrote this article, telling the government hospital that I had worked for a few years: Let’s not meet again. I still remembered how I had struggled to enter the University for Pharmacy Degree 8 years ago. 8 years had passed, now I can only sigh and wonder why am I so determined to get into the profession way back then.

The public thinks that Pharmacist is a good profession; however, this is not the truth.  In the government hospital, our status is worse than doctors and nurses, and always become the “punching bag” of specialists, nurses and patients. It is the pharmacists’ fault not able to give full supply of 3 to 6 months medications for patients with chronic diseases. It is also our fault to provide generic medications rather than branded medications. Besides that, we often sneer by the senior doctors or even junior doctors when we try to provide recommendation on patients’ management and patients rolled their eyes on our suggestions.

Talking about the wages and welfare, pharmacists in the government hospitals are just like an illegitimate child. We do not have overtime allowance for the 24hours and weekend extended services. It is very common that the manpower in the government hospital is always insufficient and we have to do multitasking & “one man show”. Amidst all this, we still try to do our best. However, the officers in the health ministry are always eyeing on our RM700 critical allowance, using cost cutting as an excuse to try to abolish this allowance. On the other hand, when all other government servants are allowed to take up part time job as long as they get approval from their supervisor and their part time job does not affect the daily job; pharmacists in the government hospitals are not allowed to have a part time job.  Dear fellow officers, do you intend to force the pharmacists in government sector to quit?  5 years ago, when there were not enough pharmacists in the government sectors, the government enforce 4 years compulsory service. As a result, we chose to stay back to service in the government.  After 5 years, the government informed us that the private sectors need more pharmacists, so they have shortened the compulsory service. The government cannot afford our salary?  Or there is really a better offer in the private sector? We feel that the government is taking advantage on us.

In the private hospital, the status of the pharmacists is worse than the medical assistants. Private hospitals only employed pharmacists to fulfil the requirement set by the ministry of health. Only 4 pharmacists are employed in a medium sized private hospital. Is that sufficient? Low wages and welfare, long working hours, the effort that they put in is incompatible with the salary that they get. Who will understand the actual situation facing by pharmacists in the private sectors despite their glamorous status? Besides that, the pharmaceutical companies and factories employed the pharmacists just for their licence. In academic and research field, the role of pharmacists are still very important. However, how long can they survive when they are marginalized by the government?

The community pharmacy which is more related to our daily life and better known by the public has also come to a miserable situation. With the mushrooming of chain pharmacies, independent pharmacies are struggling on whilst at death’s door. Even the multilevel marketing companies want to have a share in the business. Pharmacies are supposed to sell medications and supplements. However, the pharmacies now are similar to the grocery shops where the toiletries, cosmetics and even junk food filled up most of the space in the shops, especially in those pharmacy shops own by the multilevel marketing company. This type of business operation is insulting the pharmacists’ profession. In order to survive, each pharmacy used various methods to attract customers, from the basic customer service to the discounting price war and misuse of certain medications. Is this healthy? Or are we massacring each other?

Next, is the medical revolution proposed under 1 care national healthcare system benefitting our nation or it is just another white elephant project? First of all, the retired government servants can seek treatment in the government hospitals and get their prescriptions filled in the pharmacies appointed by the government, and payment will be given to these pharmacy shops via the appointed contractors. Why the patients can only get their prescriptions filled in certain pharmacies? Why there is a need to pay these pharmacies via certain appointed contractors? Why can’t the government hospitals purchase these medications to supply to the retired government servant? Why do we need such a big project? Since the government sectors are notorious for “fishing culture” we all understand what is happening here. On the other hand, 1 care system proposed dispensing separation, to return the dispensing right to pharmacists and at the same time privatised the government pharmacies. However, there are rules that medications can only be supplied by certain companies. This proposal is only using dispensing separation to support the clique. The assistance provided by the government had made certain bumi companies to monopolize the market. Do we need more of these companies? This policy is definitely going to bring the pharmacy profession to a dead end.

To sum it up, who created the current situation of the pharmacy profession? Who had ruined the registered pharmacists’ professional status? The answers are as follow. Firstly, there is not much restriction in approving more private colleges to set up pharmacy courses, which causes the overload of pharmacist graduates. It is difficult to control the quality of the curriculum of each college and therefore the qualities of the graduates are also uneven.  When there are too many pharmacy graduates enter the job market, the government sectors cannot absorb all of them and the supply of pharmacy graduates are also way more than the demand in private sectors. As a result, the bubbling of the pharmacy profession begins. Unemployment, low income, selling medications in black market, giving discounts in order to survive all begins. Where this profession with hundreds and thousands of years stands?

Secondly, allowing doctors to dispense medications.  The pharmacists are not needed when this policy remains. Dispensing separation would allow the maximization of professional knowledge of pharmacists in improving patient’s management. The pharmacists then have a role to monitor doctor’s management. Also, the dispensing right must be built on the zero benefits of doctors, pharmacists and pharmaceutical companies and it is important that doctors and pharmacists have their own role. The dispensing separation is the right way to go in the future and the dispensing right must be slowly return to pharmacists.

Thirdly, the prices of medications are not controlled. If the 1care system is enforced, the government should set the maximum price or strictly control the price of medications in the market. This is easier for the enforcement sectors to monitor the market and it can also avoid the misuse of medications and the selling of adulterated medications to the public due to vicious competitions. When these problems arise, the patients and consumers are going to suffer in the end. The pharmacy profession needs a healthier environment to survive.

Number four will be the professional qualifications. This problem hit the retail pharmacies the most. All of the retail pharmacies must be owned by pharmacists rather than businessmen without professional background. At the same time, the multilevel marketing companies should be restricted to setup more pharmacies which sell other more of other non medictations. Government should also provide monetary assistance to those pharmacists who wish to open their own shops.

Each healthcare professional have their own roles in building a healthy healthcare system. There is not a single profession can be replaced. In order for the pharmacists’ profession to have a brighter future, we must control the setup of the pharmacy degree, implementing the dispensing separation system and strictly control the pricing of medications and recognized the professional qualifications. Please return a healthier surviving environment and the pride to the profession.