Title: Academic physician quarterly
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Title: Academic physician quarterly
Physical Description: Serial
Language: English
Creator: College of Medicine, University of Florida
Publisher: College of Medicine
Place of Publication: Jacksonville, Fla.
Publication Date: July 2010
Copyright Date: 2010
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Bibliographic ID: UF00088871
Volume ID: VID00014
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.

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CLINICAL CASE



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RX UPDATES


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NEWS AND NOTES
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CHAIRMAN'S MESSAGE

Dear colleagues:
July 1st ushers a new academic and fiscal year. As usual, a
new crop of trainees are joining the Department. The aca-
demic credentials of this group are impeccable. This new res-
idents have a mean Step 1 score on USMLE of 92. These
extraordinary high scores have been common place for our
trainees in the last two years. These exceptional young physi- \
cians are also engaged in innovative research.
On this year's Research Day, one third of platform and poster
presentations of fellows and residents were made by the members of the Depart-
ment. Of the platform presentations Dr. Senan Sultan was the fourth place prize
winner and Dr. Thomas Walsh received the fifth place prize. In addition among
the poster presentations Dr. Aasita Patel received the second place prize and Dr.
Abdul-Razzak Alamir received the 5th place prize. I am very happy to see that the
research productivity of the house staff is excellent. The challenge for all of us is
to maintain this excellence.
The exceptional performance of our residents would not have been possible with-
out the dedication and commitment of our faculty members. Indeed year after
year our faculty members continue to receive the highest honors for teaching. This
year fourteen faculty members of the Department were recognized for their ex-
ceptional contributions to the teaching mission of the University of Florida.
In parallel to the stellar performance of our residents and faculty members, the De-
partment had an exceptionally good financial year despite the economic chal-
lenges. This unprecedented outcome was the result of the sacrifices and the hard
work of many outstanding faculty members and their support personnel.
The past year has certainly been a very productive academic year and we are look-
ing forward for another year full of academic accomplishments.
Arshag D. Mooradian, M.D.
Professor of Medicine
Chairman, Department of Medicine







I FOCUS


Robert Kim, M.D.

Assistant Professor of Medicine


Division of Cardiology






Atrial Fibrillation: Current Update

Atrial fibrillation (AF) is an electrical disorder affecting pri-
marily the left atrium (LA) of the heart. The atria fail to con-
duct the electrical impulses properly and beat very rapidly in
a totally irregular and chaotic manner, resulting in atrial con-
tractile dysfunction. It is a progressive disease which, if left
untreated, will lead to tissue fibrosis, cellular electrical per-
turbation and adverse structural remodeling of the heart
chamber.
AF poses a major public health problem in the United
States and Europe. Prevalence increases from 0.1% among
adults younger than 55 years to 9.0% in persons aged 80
years or older.1 Currently, more than 2.3 million US adults
are afflicted. With the growing older population, these num-
bers are only expected to increase. The common risk factors
for developing AF include age, high blood pressure, coro-
nary artery disease, congestive heart failure and hyperactive
thyroid. Other less well recognized risk factors such as pos-
itive family history will become better characterized in the
future through genetic studies.
There are many treatment options for AF. They can be di-
vided into two general categories. The so-called "rhythm-
control approach" strives to keep the patient out of AF by
the maintenance of sinus rhythm (the normal rhythm of a
healthy heart). The so-called "rate-control approach" lets the
patient remain in AF while only the heart rate is kept under
control. The former approach is used for patients who ex-
perience adverse symptoms when they are in AF. The latter
approach is generally reserved for older patients with heart
disease who are not necessarily symptomatic while in AF.
Rhythm control can be achieved by anti-arrhythmic drugs
(AADs), electrical cardioversion, catheter ablation (CA) or a
combination thereof. Rate control is primarily achieved with
heart rate-controlling medications. Each of these modalities
has its own advantages and disadvantages.
One of the popular controversies is whether one of the two
approaches is superior to the other. Several large random-
ized trials performed in the past 10 years have demonstrated


the comparable clinical outcomes (cardiovascular morbidity
and mortality) of two strategies. Clinicians often point to the
toxicities of AADs used to maintain sinus rhythm as a po-
tential reason for the observed lack of superiority of rhythm-
control in these trials. As a result, the rhythm-control
strategy has been accepted with less enthusiasm than it prob-
ably deserves to be. There are two important limitations of
such trials. First, the relatively young and healthy patients
with symptomatic AF for which the rhythm-control ap-
proach would have been ideal are underrespresented in
these studies. Second, the rhythm-control strategy taken as
a whole is not capable yet of keeping all patients in sinus
rhythm all the time, making the comparison of the outcomes
of two strategies somewhat unfair. Physicians have been
concentrating their effort in recent years to develop a better
way of maintaining sinus rhythm in patients with AF.
A very important treatment aspect of AF is systemic anti-
coagulation. The risk of ischemic stroke in patients with AF
who are not adequately anticoagulated is approximately 5%
per year. This value is incrementally higher for patients with
cardiovascular risk factors. Thus, for patients with one or
more cardiovascular risk factors, systemic anticoagulation
with warfarin is strongly recommended. Other options for
anticoagulation (e.g. plavix), although not firmly established,
exist for those who cannot tolerate warfarin.
Catheter ablation is a special means of achieving a cure
(rhythm control) of AF in a select group of patients who are
experiencing frequent symptomatic episodes of AF. This is
a highly complex procedure lasting approximately 5-6 hours
during which the four pulmonary veins are electrically iso-
lated from the LA. This is performed by the use of a thin
catheter that delivers radiofrequency (a form of heat) energy
at its tip. It has been demonstrated in a landmark study 10
years ago that a vast majority of the electrical triggers initi-
ating AF episode reside within the muscular cuffs of pul-
monary veins, a vascular structure that drains oxygenated
blood from the lungs into LA. This procedure aims to elim-
inate such triggers by pinpoint tissue destruction. Patients
undergoing this procedure can expect up to 70% cure rate at
one year follow-up. Appropriate patient selection is critical
to success and patients with AF are encouraged to contact
our Section of Cardiac Electrophysiology to see whether they
would be an appropriate candidate to undergo this proce-
dure.

REFERENCES:
1. Go AS, Hylek EM, Phillips KA, Chang YC,Henault LE, Selby JV and Singer
DE. Prevalence of Diagnosed Atrial Fibrillation in Adults. JAMA 2001;285:2370-
5.


Continued on Page 3





Focus continued from Page 2


J. Davis Cury, M.D.

Associate Professor of Medicine


Chief, Division of Pulmonary,
Critical Care & Sleep Medicine





Bronchoscopy: An Important
Diagnostic and Therapeutic Tool

Almost all bronchoscopic procedures are performed with
the flexible fiberoptic bronchoscope (the rigid bronchoscope
was used in the past). Flexible fiberoptic bronchoscopy al-
lows detailed inspection of the first several divisions of the
tracheobronchial tree. Numerous instruments can be passed
through the working channel of the scope for a variety of di-
agnostic and therapeutic indications.

Common Indications for Bronchoscopy
Hemoptysis
Suspicion of Lung Cancer
Staging of Lung Cancer
Atelectasis
Pulmonary Infections
Refractory Wheezing
Esophageal Cancer
Foreign Body
Interstitial Lung Disease
Lung mass
Bronchial Strictures, Stenosis


Almost always these procedures are done after the appli-
cation of topical lidocaine for anesthesia and then after the
administration of Fentanyl and Versed to achieve conscious
sedation. This results in a very low risk to the patient of ei-
ther harm or significant discomfort which allows these pro-
cedures to generally be outpatient procedures. The
procedure itself takes 10-15 minutes and most patients have
no memory of the procedure.
Biopsy of visible
airway lesions is di-
agnostic 95% of the
time with less than a
5% complication
rate. Transbronchial
lung biopsies cou-
pled with bron-
choalveolar lavage
yield diagnoses of 50% 90% in diffuse parenchymal lung
disease depending on the etiology of the process, usually
with the same low likelihood of complication
More specialized bronchoscopic procedures using a flexi-
ble ultrasound bronchoscope coupled with transtracheal
needle aspiration can give a specific tissue diagnosis of me-
diastinal disease processes such as malignant or infectious
adenopathy. These procedures can prevent the need for
more invasive surgical procedures such as mediastinoscopy.
This diagnostic modality has become a mainstay in the stag-
ing of lung cancer.
Bronchoscopy is performed daily on an elective basis after
a patient has been evaluated by one of our four pulmonary
physicians.


GME CORNER


Jeffrey House, D.O.

Assistant Professor of Medicine,
General Internal Medicine


Program Director, Internal
Medicine Residency



Each academic year is full of new beginnings and new
faces. Before long a new cohort of interns will be learning
their way around the hospital, their pockets filled with notes,
handbooks, and journal articles. However, these are not the
only new faces we will be seeing on the wards, at morning
report, and noon conferences.


First, I am pleased to introduce Dr.
Christina Bailey who will be taking
on the role as Associate Program Di-
rector. Dr. Bailey hails from the Uni-
versity of Texas Medical School at
Houston. Following medical school
she completed both her internal
medicine residency and her fellow-
ship in infectious disease here at the
University of Florida, Jacksonville.
Dr. Bailey has been on faculty since 2003 and therefore is in-
timately familiar with this institution. She also has experience
in graduate medical education, serving as Assistant Fellow-
ship Director of Infectious Disease. Although the learning
curve for this position will be steep, Dr. Bailey is up to the
Continued on Page 4





GME Corner continued from Page 3


task and will bring a new dynamic to the resident learning
environment.
The Chief Medical Residents are chosen 18 months in ad-
vance, and represent our strongest resident leaders. The po-
sition is an honor and for many, leads to fellowship training
in subsequent years. Today we introduce our CMR for July
2010, Dr.'s JP Pham and Naveen Seecheran.

Dr. JP Pham trained at Marshall
University for medical school. He is
a quiet, determined leader and is rec-
ognized for his mentoring and teach-
ing skills, both crucial qualities for
an effective chief. He was recently
awarded a scholarship for the 19th
Annual Mayo Internal Medicine Re-
iview Course. JP plans to pursue a
fellowship in cardiology.

Both Dr.'s Pham and Seecheran have the medical knowl-
edge, communication skills, and professionalism to continue
in the long line of outstanding chief residents we have had


over the years. They have already begun taking on many of
the chief resident duties andrecently returned from the An-
nual Association of Program Directors in Internal Medicine
Chief Resident Meeting.

Dr. Naveen Seecheran is a graduate
of the University of the West Indies.
He is well recognized as being one of
the brightest residents we have had
at this program and is well versed in
the historical perspective of medi-
cine. Naveen may be best known for
-, ,. his outstanding performance as part
U/ of the Medical Jeopardy Team at the
Florida ACP, both in 2008 and 2009
which came in 1st and 2nd place respectively. Naveen is also
planning to pursue a fellowship in cardiology following his
chief resident year.

Please join me in welcoming the new GME leadership.
Under their direction, the Internal Medicine Residency Pro-
gram will be in good hands for the upcoming 2010-2011 year.


SA CLINICAL CASE ]


Robert Zaiden, MD, Assistant Professor, Oncology
Taren Ohman, MD, Internal Medicine Resident
Jeffery House, DO, Assistant Professor, GIM
Bruce Villas, MD, Associate Professor, Pathology
Fauzia Rana, MD, Assistant Professor, Oncology


Angioimmunoblastic T-cell lymphoma

presenting as extensive psoriasis: a case re-

port and discussion


CASE PRESENTATION
A 38-year-old woman was admitted with bilateral inguinal lym-
phadenopathy and suspected right hip abscess. She had experi-
enced a full body, dry scaly rash a month earlier, and a skin biopsy
by a dermatologist at an outside facility was suggestive of psoria-
sis. A CT scan of the right lower extremity obtained after admission
was negative for abscess but revealed marked superficial lym-
phadenopathy. Blood and urine cultures were positive for methi-
cillin-resistant Staphylococcus aureus (MRSA).
The patient was treated with IV and oral antibiotics, and dis-
charged home to continue antibiotic therapy. She remained febrile
despite having completed her IV antibiotic regimen, and noted in-
creasing pain and swelling bilaterally in her axillary and inguinal
regions. The extensive pruritic, scaly rash noted on previous ad-


mission persisted, and the patient was readmitted for further
workup.
Physical examination showed dry and tight-appearing skin with
nodular, hyperkeratotic lesions that were actively pruritic. Excori-
ations and open lesions with minimal weeping involved the entire
body. Examination of the extremities revealed multiple tender right
inguinal lymph nodes measuring 1-2 cm and a tender rubbery left
inguinal lymph node measuring 5-6 cm. A right cervical lymph
node measuring 2-3 cm was also noted.
Laboratory data revealed a white-cell count of 27,000 and a he-
moglobin concentration of 8.8 mg/dL. Peripheral smear showed a
few smudge cells, with 46% lymphocytes and 32% granulocytes.
Tests for HIV, HBV, and HCV were negative. Serum protein elec-
trophoresis showed a diffuse hypergammaglobulinemia. A PET
scan revealed bilateral axillary and inguinal areas of increased
metabolic activity. Histologic examination of an excised hyperme-
tabolic left inguinal lymph node showed partial effacement of its
architecture, with polymorphous lymphocytes, eosinophils, plasma
cells, histiocytes, vascular proliferation, and clusters of atypical
large lymphoid cells with pale "clear" cytoplasm (Figure 1) Im-
munostains revealed the atypical large lymphoid cells to be CD3+
(Figure 2), CD20-, CD15-, CD30-, and ALK-1-, consistent with T-
cell immunoblasts. Flow cytometric analysis of the lymph node also
revealed an atypical CD4+ T-cell population. These findings sup-
ported the pathologic diagnosis of angioimmunoblastic T-cell lym-
Continued on Page 5






A Clinical Case continued from Page 4


phoma (AITL). The patient was started on standard CHOP (cy-
clophosphamide, doxorubicin, vincristine and prednisone)
chemotherapy and received 2 cycles of this regimen, but declined to
continue treatment and was lost to follow-up. Two months after her
last cycle, she was admitted to the medical intensive care unit with
fulminant MRSA septic shock and died within 24 hours.

S Figure 1: Lymph node
biopsy showing a polymor-
phous lymphoid infiltrate
with clusters of im-
munoblasts having abun-
dant pale cytoplasm,
increased mitotic figures,
eosinophil infiltrate, and
prominent vascularity
(hematoxylin and eosin
stain; magnification, 40x).





M Figure 2: Lymph node
ri biopsy showing positive
CD3 staining of large lym-
4 is phoid cells consistent with
. "angioimmunoblastic T-cell
llymphoma (immunoperoxi-
l ddase stain; magnification,
1 -60x).








DISCUSSION
AITL, also referred to as angioimmunoblastic lymphadenopathy
with dysproteinemia (AILD), is a relatively rare disease, accounting
for only 1%-2% of non-Hodgkin lymphoma and about 15% of pe-
ripheral T cell lymphoma 1. It is a typically a disease of middle aged
to elderly adults, with a median age of 64 at presentation and a slight
male predominance, 2 3 although it has also been described in the
pediatric population.
AITL is thought that this disease evolves sequentially from a dys-
functional idiopathic immune response, progressing to a malignant
monoclonal disease. Polymerase chain reaction and in situ hy-
bridization analysis have implicated latent Epstein-Barr virus, cy-
tomegalovirus, Cryptococcus species, Mycobacterium tuberculosis,
hepatitis C virus, and human immunodeficiency virus have been
implicated as possible inciting infections. Trisomy 3, trisomy 5, and
+X are the most common chromosomal abnormalities detected.
The initial presentation of AITL is usually vague, with patients re-
porting waxing and waning maculopapular pruritic rashes, night
sweats, weight loss, diffuse lymphadenopathy, ascites, and gener-
alized malaise, although all organ systems may be involved. These
nonspecific symptoms are frequently misdiagnosed as other der-


matologic, rheumatologic, or collagen-vascular disorders. Skin in-
volvement is a prominent feature; it has been suggested that the pe-
culiar quadrangular erythematopurpuric rash sparing the skin-folds
(the socalled deck-chair sign) may be specific for the cutaneous in-
volvement of AITL 4. These patients are also prone to uncommon
and recurrent infections because of the reduced number of circulat-
ing T cells and reversal of the CD4:CD8 ratio.
Abnormalities of laboratory measures, especially of autoimmune
parameters with pancytopenia, should raise suspicion for AITL. Dif-
fuse polyclonal hypergammaglobulinemia on serum protein elec-
trophoresis, Coombs-positive hemolytic anemia, antinuclear
antibodies, antismooth muscle antibodies, anticardiolipin antibod-
ies,and cryoglobulins can also be detected.
Accurate diagnosis requires biopsies of involved skin, lymph
nodes, and bone marrow, although the results may often be sug-
gestive and not confirmatory.
Treatment options include CHOP, CVP cyclophosphamidee, vin-
cristine, and prednisone), VAP (vincristine, Adriamycin, and pred-
nisolone), COP-BLAM cyclophosphamidee, vincristine, prednisone,
bleomycin, doxorubicin, and procarbazine), IMVP-16 (ifosfamide,
methotrexate, and VP-16), thalidomide, fludarabine, 2
chlordeoxyadenosineand recently, bevacizumab (Avastin) and
alemtuzumab (Campath).
Complete remissions have been reported after the use of inter-
feron alfa, cyclosporin A, and recently, purine analogues in a few
patients. Fewer than one-third of patients can be expected to have
long-term remission, even after multiagent chemotherapy.
Although many patients have an initial remission, most will ex-
perience a relapse and die of infectious complications, with mean
survival being 15-36 months. Many patients also eventually experi-
ence evolution into high-grade aggressive lymphomas. High-dose
chemotherapy followed by allogeneic stem cell transplant remains
the best chance for long-term remission 56.


REFERENCES
1. The Non-Hodgkin's Lymphoma Classification Project: a clinical evaluation of
the International Lymphoma Study Group classification of non-Hodgkin's lym-
phoma. Blood 1997;89:3909-3918.
2. Harris NL, Jaffe ES, Stein H et al. A revised European-American classification
of lymphoid neoplasms: a proposal from the International Lymphoma Study
Group. Blood 1994;84:1361-1392.
3. Dunleavy K, Wilson WH, Jaffe ES. Angioimmunoblastic T cell lymphoma:
pathobio- logical insights and clinical implications. Curr Opin Hematol
2007;14:348-353.
4. Ferran M, Gallardo F, Baena V, Ferrer A, Florensa L, Pujol RM. The 'deck chair
sign' in specific cutaneous involvement by angioimmunoblastic T cell lymphoma.
Dermatology 2006;213:50-52.
5. Hast R, Jacobsson B, Petrescu A, Hjalmar V. Successful treatment with fludara-
bine in two cases of angioimmunoblastic lymphadenopathy with dysproteinemia.
Leuk Lymphoma 1999;34:597-601.
6. Rodriguez J, Conde E, Gutierrez A, et al. Prolonged survival of patients with an-
gioimmunoblastic T-cell lymphoma after high-dose chemotherapy and autolo-
gous stem cell transplantation: the GELTAMO experience. Eur J Haematol
2007;78:290-296.






RX UPDATES


Kate Priddy, Pharm.D.

Vancomycin-induced Oto- and
Nephrotoxicity.

Reprinted with some editing from Drug Update, February, 2010
with permission.
The arsenal of antimicrobials available to clinicians was signifi-
cantly increased in number and strength in 1958.1 Within one year's
time, vancomycin, methicillin, and cephalothin entered the market
largely due to the urgency created by emerging Staphylococcal re-
sistance patterns.'
Vancomycin, a glycopeptide antibiotic, was originally discovered
in a sample of dirt containing Amycolatopsis Orientals. Isolates from
A. orientalis were found to inhibit the late stages of cell wall syn-
thesis in dividing gram-positive bacteria, even in the presence of lab-
oratory-induced resistance 2
The original formulation of vancomycin distributed from the lab-
oratory and tested in patients was unpurified and responsible for
many of the otic and renal adverse reactions observed in patients.'13
(The formulation was also responsible for the original nickname
"Mississippi Mud.") Although vancomycin was the first FDA-ap-
proved agent able to successfully treat infections from highly resist-
ant bacteria, the perceived toxic effects ultimately relegated its use
to that of a second-line option for patients with serious p-lactam al-
lergies or treatment-resistant infections.1,3

ADVERSE EFFECT PROFILE
Beginning in the 1980s, clinicians began to demonstrate a renewed
interest in vancomycin as an effective and relatively tolerable ther-
apeutic agent for serious infections.4 The lingering concern of ad-
verse renal and otic effects was met with increased monitoring of
vancomycin serum concentrations (a practice that remains in place
today).1'3
The adverse effect profile observed in patients treated with early
formulations of vancomycin included irritation, chills, and rash.2,4
While the purification process and slower infusion rates minimized
these reactions, vancomycin continued to be associated with otic
(e.g., cochlear toxicity, vestibular toxicity) and renal adverse effects
(e.g., nephrotoxicity, interstitial nephritis).2,4

OTOTOXICITY
After sixty years of vancomycin use in clinical practice, only low-
grade evidence (i.e., case reports) hints to a correlation between the
two events. Moreover, the majority of the cases of ototoxicity oc-
curred in an era when vancomycin was associated with a high level
of impurities.
In 2009, the American Academy of Audiology released a position
statement and clinical practice guidelines for monitoring ototoxic-
ity.5 The guidelines do not provide agent-specific rec-ommenda-
tions, but do focus on appropriate auditory assessments and
monitoring programs. Detection of ototoxicity in the absence of eas-
ily recognizable signs and symptoms is an arduous task consider-
ing hearing loss typically occurs at high frequencies (>4000 Hz).4
Studies reporting vancomycin-induced ototoxicity should be care-
fully scrutinized to determine how and when audiologic assessment
occurred.5,6 The analysis of eighty-nine patients receiving van-
comycin therapy (average treatment duration of 27 days) showed a
12% rate of high-frequency hearing loss, with a significant increase
in incidence in patients aged 53 years and older. 7 Although the data
observed in the study may suggest an association between age and


incidence of ototoxicity, key limitations prevent a general accept-
ance of the authors' conclusion: total daily vancomycin dose for all
patients did not reflect use of high-dose vancomycin, the temporal
relationship of trough measurement and vancomycin administra-
tion was not assessed, and the authors used an inaccurate level of
measurement when assessing hearing loss.
The most recent guidelines from the Infectious Disease Society of
America (IDSA) and the American Society of Health-System Phar-
macists (ASHP) recommend monitoring of serum vancomycin lev-
els when other ototoxic agents are used concomitantly. However,
routine monitoring of monotherapy is not recommended as a nec-
essary method to prevent ototoxicity (Level III/Grade B recom-
mendation) due to the rare occurrence and lack of correlation with
serum drug concentrations.4 Treatment should be discontinued if
symptoms of toxicity occur.

NEPHROTOXICITY
The IDSA/ASHP define vancomycin-induced nephrotoxicity as
multiple increases in serum creatinine concentration greater than 0.5
mg/dL (or >50%) from baseline after several days of vancomycin
therapy without an alternative explanation (Level II/Grade B).4 In-
terstitial nephritis is a serious and rare adverse event that generally
presents when vancomycin is used in combination with an amino-
glycoside.8 In contrast to vancomycin-induced ototoxicity, van-
comycin-induced nephrotoxicity is typically reversible upon
discontinuation of vancomycin.4
In the 1980s, vancomycin quickly became the drug of choice in pa-
tients requiring treatment for MRSA.1,2,4 Because vancomycin use
rapidly increased over a relatively short period of time, changes in
the resistance pattern and minimal inhibitory concentration (MIC) of
typically susceptible organisms was observed.1,2,4 Interestingly, it has
been speculated that the increased incidence of vancomycin-in-
duced nephrotoxicity is indirectly related to resistance patterns and
high MICs necessitating the need for higher vancomycin doses.,10
Although popular medical and pharmacy textbooks continue to
list nephrotoxicity in vancomycin's adverse effect profile, the med-
ical literature is unclear and limited in its ability to support an asso-
ciation. A comprehensive review of the medical literature can be
found in the February 2010 issue of The American Journal of Medi-
cine.10

DOSING
Vancomycin is dosed according to actual body weight (ABW).4
Although data is limited in obese patients, initial doses should be
calculated using an ABW, with subsequent doses adjusted based on
serum vancomycin concentrations. Vancomycin dosages of 15 to 20
mg/kg (based on ABW) given every 8 to 12 hours are required for
most patients with normal renal function to achieve the suggested
serum concentrations when the MIC is <1 mg/L.4

MONITORING
While some investigators have found vancomycin therapeutic
drug monitoring to be associated with decreased nephrotoxicity, the
IDSA/ASHP guidelines do not support monitoring peak concen-
trations to decrease the frequency of nephrotoxicity (Level I/Grade
A).4 The most recent guidelines only recommend monitoring of
trough concentrations in patients with a therapeutic vancomycin
goal of 15 to 20 mg/dL (Level III/Grade B) or who have a high risk
of toxicity (e.g., receiving concurrent nephrotoxins, Level III/Grade
B; unstable renal function, Level II/Grade B; treatment duration of
> 3 to 5 days, Level II/Grade B)4
Trough samples should be obtained 30 minutes before the fourth
dose in patients with normal renal function to ensure that target con-
Continued on Page 7





RX Update continued from Page 6

centrations are attained (Level II/Grade B).4 After concentrations are
within the desired range, subsequent monitoring should be based
on clinical judgment (Level III/Grade B).4 However, if a sustained
vancomycin trough concentration of 15 to 20 mg/L is desired, at
least once-weekly measurements are recommended (Level
III/Grade B) or more frequently in hemodynamically unstable pa-
tients.4

RELATIONSHIP BETWEEN TROUGH CONCENTRATIONS, RESIST-
ANCE, AND THERAPEUTIC FAILURE
Vancomycin is most effective as a bactericidal antibiotic at con-
centrations three to five times the organism's MIC.4 A low serum
vancomycin concentration (<10 mg/L) has been shown to be di-
rectly correlated with the emergence of vancomycin-intermediate S.
aureus (VISA) and inducible heterogeneous VISA (hVISA), a resist-
ant strain with a seemingly susceptible MIC value of 0.5 to 2 mg/L.4
Currently, there is no mechanism for determining the presence of
hVISA. This is particularly concerning given the risk of treatment
failure.

SUMMARY
Vancomycin-induced ototoxicity and nephrotoxicity is uncom-
mon. Patients receiving an aminoglycoside are at greatest risk. Mon-
itoring has not been shown to be effective in preventing ototoxicity
or nephrotoxicity. However, monitoring of trough concentrations in
the prevention of toxicity is recommended in patients with a thera-
peutic vancomycin goal of 15 to 20 mg/dL or in patients who have
a high risk of toxicity. Otherwise, trough concentrations should be
monitored only to ensure efficacy.


References
1. Levine DP. Vancomycin: a history. Clin Infect Dis. 2006; 42:55-12.
2. Murray BE, Nannini EC. Glycopeptides (vancomycin and teicoplanin),
streptogramins (quinupristin-dalfopristin), and lipopeptides (daptomycin).
In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Ben-
nett's prin-ciples and practice of infectious diseases. 7th ed. Philadel-phia:
Elsevier Inc; 2009.
3. Griffith RS. Introduction to vancomycin. Rev Infect Dis. 1981; 3:S200-4.
4. Rybak M, Lomaestro B, Rotschafer JC, et al: Therapeutic monitoring of
vancomycin in adult patients: A consensus review of the American Society
of Health-System Pharmacists, the Infectious Diseases Society of America,
and the Society of Infectious Diseases Pharmacists. Am J Health Syst
Pharm 2009; 66(1):82-98.
5. Durrant JD, Campbell K, Fausti S, et al. American Academy of Audiol-
ogy position statement and clinical practice guidelines: ototoxicity moni-
toring [Internet]. Reston, VA: American Academy of Audiology; [cited
2009 Dec 30]. 25 p. Available from: http://www.audiology.org/re-
sources/documentlibrary/Documents/OtoMonPositionGuideline.pdf.
6. Shields RK, Martello JL, Potoski BA. Is vancomycin ototoxicity a signifi-
cant risk? Antimicrob Agents Chemother. 2009; 53:4572-3.
7. Forouzesh A, Moise PA, Sakoulas G. Vancomycin ototoxicity: a reevalu-
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Am J Med. 2010; 123:182.el-7.


I NEWS & NOTES 1


Exemplary Teachers Awards
Fourteen faculty members in the Department of Medi-
cine were chosen to receive the 2010 University of Florida
College of Medicine Exemplary Teachers Award.
The awardees include (arranged alphabetically): Drs.
Irene Alexandraki, Doug B. Chapman, Donald A. Conetta,
Malcolm T. Foster, Jeffrey G House, Robert J. Kim, Steven
J. Lavine, Ghania Masri, Senthil R. Meenrajan, Alan B
Miller, Juan C Munoz, Pramod K. Reddy, Manish Relan,
and Elisa M. Sottile.
This award is given in recognition of outstanding teach-
ing contributions of individual faculty members. The
awardees will receive a plaque, a lapel pin and a financial
award determined by the compensation plan's incentive for
outstanding teaching.
Congratulations to the awardees.

Our residents shine at the American College
of Physicians Florida Chapter 2010 Associ-
ates Meeting in Orlando
Atman Shah had an oral presentation entitled, "Com-
parative Study of the Clinical and Tumor Characteristics in
Women with Breast Cancer of Different Age Groups."
Sudha Koduru also had an oral presentation entitled,
"Abiotrophia Spp. Endocarditis Presenting as Non-ST Ele-
vation Myocardial Infarction."
Hasan Riaz presented a poster titled "Auto-immune he-
molytic anemia and hodgkin's disease".


At this meeting our all-intern Doctor's Dilemma Team
received a silver medal for their performance. The team in-
cluded Reshma Ramlal, Chandrikha Chandrasekharan,
and Rohan Samson.

Golden Apple Award
At the College of Medicine Senior Awards Banquet, the
Golden Apple Award for the most outstanding clinical rota-
tion was presented to the Department of Medicine by the
Class of 2010.
Congratulations and thanks to all the Department's Jack-
sonville faculty, whose teaching efforts clearly contributed
to the receipt of this award, which will be recognized on our
campus on the perpetual Golden Apple plaque located in the
LRC Atrium.

Faculty appointed as Editors
Dr. Charles Heilig (Nephrology) and Dr. Arshag D.
Mooradian (Endocrinology) were recently appointed as sec-
tion editors of the American Journal of Therapeutics. The
journal is an indispensable resource for all prescribing physi-
cians who want to access pharmacological developments in
cardiology, infectious disease, oncology, anesthesiology,
nephrology, toxicology, and psychotropics without having
to sift through stacks of medical journals. The journal fea-
tures original articles on the latest therapeutic approaches as
well as critical articles on the drug approval process and
therapeutic reviews covering pharmacokinetics, regulatory
affairs, pediatric clinical pharmacology, hypertension, me-
tabolism, and drug delivery systems.


























































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