Case Studies (April 2018)

CASE 1

NK is a 34-year-old woman with a history of intravenous (IV) drug use who presents to the hospital with generalized weakness, chills, and fatigue, and is found to have a temperature of 102°F, a heart rate of 107 beats per minute, and a white blood cell count of 15,000/ mcL. Urine and blood cultures are obtained at admission. NK’s physician initiates empiric therapy with IV micafungin 100 mg daily. A few days later, NK’s blood cultures come back positive for Candida krusei. After 5 days of daily treatment with 100 mg of IV micafungin, NK reports feeling better and is found to be afebrile; repeat blood cultures are negative and she is deemed ready for discharge. The physician would like to switch NK to oral fluconazole for 2 weeks of outpatient treatment. NK has no other significant past medical history or drug allergies.

As the pharmacist rounding with the team, what would you recommend to the physician?

CASE 2

MK is a 45-year-old man who presents to your pharmacist- led vaccination clinic for his annual influenza vaccine. With a past medical history significant for HIV, MK is currently taking a once daily oral combination pill that includes 600 mg of efavirenz, 200 mg of emtricitabine, and 300 mg of tenofovir disoproxil fumarate. His latest CD4 count is >500 cells/mm3. Upon review of MK’s vaccination history, you discover that he is up-to-date on his pneumococcal, tetanus, diphtheria and pertussis; Hepatitis B; measles, mumps, and rubella; and varicella zoster vaccinations.

Besides the influenza vaccine, what other vaccination(s) would you recommend for MK?

SEE THE ANSWERS ON PAGE 2. ANSWERS

Case 1: According to the 2016 Infectious Diseases Society of America guidelines on the management of infections due to Candida, voriconazole is the recommended step-down oral therapy for bloodstream infections due to C. krusei. Although fluconazole is commonly used as step-down therapy for candidemia caused by other species, all C. krusei isolates are resistant to it. Thus, the pharmacist should recommend NK receive 200 mg of oral voriconazole twice daily for 2 weeks instead of fluconazole.

Case 2: Oropharyngeal thrush, also known as oropharyngeal candidiasis, is a common In November 2016, the Advisory Committee on Immunization Practices released a statement recommending that all HIV-infected individuals older than 2 months receive the meningococcal conjugate vaccine. This advice is based on several observational studies showing an increased risk for meningococcal infection among individuals infected with HIV. MK should be offered 2 doses of the MenACWY conjugate vaccine, which protects against serogroups A, C, W, and Y. The doses should be spaced 8 to 12 weeks apart, and MK should receive a booster dose every 5 years thereafter.

Mr. Kristollari is a PharmD candidate from the University of Connecticut School of Pharmacy in Storrs, Connecticut. Dr. Weeda is an outcomes research fellow at the University of Connecticut School of Pharmacy in Storrs, Connecticut. Dr. Coleman is a professor at the University of Connecticut School of Pharmacy in Storrs, Connecticut.