Levofloxacin failure in a patient with pneumococcal pneumonia.

OBJECTIVE: To report a case of levofloxacin failure in a patient with a penicillin-sensitive Streptococcus pneumoniae pneumonia. CASE SUMMARY: A previously healthy, immunocompetent, 53-year-old white man presented with penicillin-sensitive S. pneumoniae pneumonia. The patient was empirically placed on levofloxacin monotherapy, which was continued due to a local penicillin shortage. When the patient failed to improve, further susceptibility testing was ordered. The organism was found to have a penicillin minimum inhibitory concentration (MIC) of 0.023 microgram/mL and a levofloxacin MIC of 6 micrograms/mL. Effective antimicrobial therapy was delayed, as clinicians did not anticipate fluoroquinolone resistance. DISCUSSION: Newer fluoroquinolones such as levofloxacin have good activity against most S. pneumoniae isolates and are used for the treatment of pneumonia. Although resistance to these agents is rare, it has been reported. Current guidelines from the National Committee for Clinical Laboratory Standards do not recommend initial fluoroquinolone susceptibility testing. CONCLUSIONS: As fluoroquinolone resistance may not be identified by susceptibility patterns to other antibiotics, early fluoroquinolone susceptibility testing and increased awareness of resistance may aid clinicians in their treatment of pneumococcal disease.

Survey of ASHP-accredited pharmacy residency programs.

The results of a survey of the requirements and features of pharmacy residency programs are reported. The survey was mailed on March 5, 1999, to the directors of 414 pharmacy practice and specialty residency programs with ASHP accreditation as of March 1, 1999. Included were questions on stipends, staffing requirements, and benefits. Information not typically included in the ASHP residency directories was also sought. Three hundred surveys were returned, for a 72% response rate. Of the responding programs, 174 (58%) were pharmacy practice programs and the rest specialty programs. The specialties with the largest number of respondents were primary care (30 of 126, or 24%) and drug information (23, or 18%). The practice setting varied widely, but a university-based practice site was most frequent (122 of 300 programs, or 41%). The overall median stipend range was $28,000-$28,999; stipends varied relatively little by geographic region but were highest in New York and New Jersey. Most residency programs had a staffing requirement, which averaged eight hours per week. A substantial part of residents' time was spent on drug distribution and patient care activities, such as medical rounds and patient counseling. The most common benefits reported were paid time off, health and medical coverage, and reimbursement for specific professional expenses. Ultimately, the creation of an Internet-accessible electronic database will maximize the availability and timeliness of such information and minimize the cost and labor involved in updating currently available resources. A survey of ASHP-accredited residency programs yielded data that provide a valuable supplement to the information in ASHP residency directories.

Therapeutic dilemma: the use of anticonvulsants in HIV-positive individuals.

ARTICLE ABSTRACT: The concurrent use of anticonvulsants and antiretrovirals is a poorly studied area that poses a therapeutic dilemma for the clinician caring for HIV-positive patients requiring both classes of medications. Anticonvulsants and antiretrovirals may interact through multiple mechanisms including competition for protein binding, enhanced or reduced liver metabolism, and increased viral replication. The authors present many of the challenges faced by clinicians caring for HIV-positive patients who may require anticonvulsant therapy.

The use of valproic acid in HIV-positive patients.

OBJECTIVE: To review the use of valproic acid in HIV-positive patients. DATA SOURCES: Clinical literature was accessed through a MEDLINE search (January 1966-November 1998). Key search terms included HIV, AIDS, seizures, valproic acid, and glutathione. DATA SYNTHESIS: Patients with HIV often develop neurologic manifestations; therefore, valproic acid may be considered in the management of this population. It has been demonstrated that valproate may increase viral burden by potentiating replication. An evaluation of studies addressing the use of valproic acid in HIV-positive patients was conducted. CONCLUSIONS: The potential for valproate-induced increases in viral replication exists. Although further studies are warranted, clinicians should exercise caution when using valproate in HIV-positive patients.