karebear12892 Posted March 7, 2016 Share Posted March 7, 2016 Hi everyone, I'm not a PA yet, but I'm participating in a clinical rotation at a rural ER. The attending physician and I just saw a patient with questionable pneumonia (radiology interpretation = "scattered bilateral airspace disease"). Stable vital signs, very non-septic appearing, and agreeable to outpatient follow-up with PCP later this week. Given IM Rocephin in the ED. However, we had difficulty finding an antibiotic she could take as an outpatient that would not interact with her Coumadin. We ended up just sticking with IM Rocephin and emphasizing the need to see her doctor this week, given that the risks of starting an antibiotic at this point outweighed the benefits. I'm curious - would you all have done the same thing, or started her on an antibiotic? If so, which one? Thanks for your input! Link to comment Share on other sites More sharing options...
Timon Posted March 7, 2016 Share Posted March 7, 2016 Cefdinir (Omnicef) covers CPNA, is available PO, and doesn't interact with Coumadin. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 7, 2016 Moderator Share Posted March 7, 2016 good thought on omnicef. . I just try to avoid the really bad ones(cipro, septra) and stick to ones like cephalosporins as above with minimal interactions. I always tell them to go to the anticoag clinic 2-3 days after starting a new abx for an inr and possible dose adjustment on their coumadin. it's important to tx the underlying infection. coumadin doses can always be adjusted up or down to accommodate the abx. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted March 7, 2016 Share Posted March 7, 2016 Over the years I have felt safe cutting the coumadin dose in half and having their INR checked within 72 hours as they start antibiotic. Older females with resistant UTIs can be complex and you have to use a quinolone sometimes. Cutting the coumadin dose in half hasn't caused any problems to date and the INR providers haven't lynched me. I try to look at the nature of their anticoag - how brittle is this person? What are the risks of a higher INR for 48-72 hours? How compliant is the patient? How insightful is the patient? Same thing with prednisone and coumadin - how bad do we need the prednisone? If a true bacterial issue is at hand - treating it is as important as the anticoag issue. My very old 2 cents...... Link to comment Share on other sites More sharing options...
RuralER/Ortho Posted March 8, 2016 Share Posted March 8, 2016 I think that it is prudent to recheck INR on any Coumadin patient 72 hours after starting abx. Much of the increase in INR is not due to drug interactions, but alteration of the gut flora (killing vitamin k producing bacteria). Essentially any abx can do this and its unpredictable in patients. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3712345/#__ffn_sectitle Just another reason to make sure what you are treating is actually bacterial! Just my thoughts.... Probably not even worth 2 cents.... Link to comment Share on other sites More sharing options...
Reality Check 2 Posted March 8, 2016 Share Posted March 8, 2016 Don't discount yourself. All of our 2 cents together is a WEALTH of knowledge and experience! Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted March 9, 2016 Moderator Share Posted March 9, 2016 How necessary was the antibiotic? Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 10, 2016 Moderator Share Posted March 10, 2016 Okay to run a little low in most cases of needing anticoag BUT careful with the mechanical valve patients In general - I use pcv/augmentin/cephalosporins if possible, but honestly now just tell them to skip one day of anticoag one day after starting ABX then check them at day 3-4 and seemingly working okay..... In general I think a little to high INR in a high risk thrombosis patient is better then to low, and the converse in someone with a low thrombosis risk - - - ie the person with DVT X 5 and PE X 3 on plavix and Coumadin and Asa - well heck, those I am just checking an INR 2 days after starting (and skip a dose of Coumadin day 2) But for the simple a-fib'r their is little risk to running in the high 1's for a few days, but risk of bleed if they get supra therapeutic...... If in doubt - get and INR Link to comment Share on other sites More sharing options...
DogLovingPA Posted March 13, 2016 Share Posted March 13, 2016 Doxycycline is also a good choice for Coumadin patients - does not interact. If I have to use an antibiotic that interacts (which is most) I just advise them to keep a close eye on their INR and make sure they have recently checked it (to ensure they aren't currently supra-therapeutic). Link to comment Share on other sites More sharing options...
sk732 Posted March 13, 2016 Share Posted March 13, 2016 Doxycycline is also a good choice for Coumadin patients - does not interact. If I have to use an antibiotic that interacts (which is most) I just advise them to keep a close eye on their INR and make sure they have recently checked it (to ensure they aren't currently supra-therapeutic). I'm a big doxy fan...also PO cefuroxime. Since pretty much everything interacts with warfarin, pick the lesser of the evils and check the INR in a few days if you're really worried...the crap, oops, meds they're taking, the more likely I'll check and more frequently. SK Link to comment Share on other sites More sharing options...
UGoLong Posted March 14, 2016 Share Posted March 14, 2016 Depending on their indication for warfarin, I'd cut their dose in half and have them check with their clinic in 3 days. The only exception I would make would be for an artificial heart valve. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted March 14, 2016 Share Posted March 14, 2016 In most cases, not referencing the original scenario, I think the bigger question is does the pt. REALLY need the abx.? Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted March 14, 2016 Share Posted March 14, 2016 Is the cost of doxycycine going to be prohibitive? Might make omnicef a better choice. Disclosure: many of my ED patients have either medicaid or no insurance. Link to comment Share on other sites More sharing options...
sk732 Posted March 14, 2016 Share Posted March 14, 2016 Not sure what it's like in the US, but doxy is pretty cheap...cefuroxime isn't terribly, but is coming down now that Ceftin isn't the only brand on the market. SK Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 14, 2016 Moderator Share Posted March 14, 2016 doxy is spendy down here. the generic makers realized they were the only ones making it and jacked the price a few years ago because they could... Link to comment Share on other sites More sharing options...
sk732 Posted March 14, 2016 Share Posted March 14, 2016 Shame...it's one of my favorite go to Abx. SK Link to comment Share on other sites More sharing options...
winterallsummer Posted March 17, 2016 Share Posted March 17, 2016 I recommend using whatever antibiotic is best regardless and having them follow up sooner for an INR check. I wouldn't lose a ton of sleep over picking the abx that will interfere least with their Coumadin. Pick the right abx for the bug you are treating. Also doxy can interact with Coumadin. That being said quick teaching point: if the CXR was read as bilateral patchy infiltrate and you felt they had pneumonia (cough, fever, white count etc) then this was more likely an atypical pneumonia such as mycoplasma which rocephin DOESNT cover for and you should've instead gone with doxy, zithro, levaquin (if pt has comorbidities) etc. also you have them a dose of rocephin so that covers them 24 hours - then what? If they really do have PNA and get sick and don't have a PCP or can't be seen the next day (pretty dang hard to get next day appointment) they're going to come back and then what's the plan? Assuming this wasn't an atypical (in which case the CXR wouldve likely had a more classic lobar opacity) are you gonna have them return daily for a shot? Totally impractical. So you have to get comfortable giving an abx that will alter their INR and its on them to follow up on this. I would not personally advise telling them to skip any Coumadin doses (unless you decided to check INR on that visit and it was high - but NO need to do this). Totally respect UGoLong opinion but he is a cardiologist PA and I personally would not feel comfortable altering their Coumadin dose from an ER perspective. If they have a stroke (unlikely but possible) and you cut their dose that could lie on you from a medicolegal perspective. Giving the right abx and having them follow up for an INR in 3D - certainly within standard of care. All that being said UGOLong certainly knows more about Coumadin than me but that's just my opinion. May be safe to have them half the dose or something but I personally would not mess with this, and if I were, I'd want an INR to see if they're even in range beforehand. Everything in medicine is a risk benefit. Risk of them having ICH is not as high from dying of a true PNA (unless this wasn't a true PNA in which case why even give abx?). So you HAVE to get comfortable with assuming risk. The best way in this case to manage that risk would be write for the right abx (in this case something with atypical coverage) and have then have their INR checked in 72h. If you want to have them half their dose until then (which I wouldn't) you probably should check an INR there. As far as giving an antibiotic or not... If you think they have PNA they need abx. Most PNA pts don't look septic. If they have a fever a white count a cough, especially if elderly and with comorbidities, probably needs treatment. If they came in for a cough for a day, no fever, pristine vitals, no white count - probably viral and PCP recheck with good ER return precautions is the right way to go. If the ONLY sign of PNA is the CXR read and clinically you don't think it's PNA - probably fine to not give abx. Final option is check a CRP (cheap) or pro calcitonin (better but more expensive) and use this to guide therapy. Link to comment Share on other sites More sharing options...
medic25 Posted March 23, 2016 Share Posted March 23, 2016 If I'm starting something with potential to interact with coumadin, I'll frequently have a discussion with the PCP/cardiologist who prescribes it and come up with a plan. You can get a sense of how tightly they need to be controlled (mechanical valve vs. atrial fib), and the PCP can help ensure repeat testing and potential dosage adjustments. Link to comment Share on other sites More sharing options...
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