Torsades de pointes vs. sepsis—can you avoid both?

Patient case: 88 y.o. longstanding female patient of ours drops off an Rx from Emerg for Cipro 500mg twice daily for 5 days. As my staff intakes the Rx from patient, she asks the usual: “What are we treating? Any new allergies?” Prior to asking the patient to have a seat while we work on it, she notices an unusual note on the Rx in the MD’s writing: Pharmacist to please call MD prior to dispensing, urgent. She then tells the patient “there’s a note that the pharmacist is to call the Emerg doc. Do you know what’s going on? It will take longer than usual, so we’ll call you when it’s ready.” The patient: “no but he was concerned. Ok thank you.” My staffer gives me the Rx. She tells me patient states it’s for a UTI that’s been going on for 16 days. Prior to calling the MD, I look the pt up on clinical connect, the provincial health repository for patients’ integrated data. Urine culture and sensitivity done by primary care provider office 16 days ago shows Klebsiella Aerogenes with a note from lab that states “due to beta lactamase-producing bacteria, assume resistance to all beta lactams including penicillins and all cephalosporins, except IV carbapenem.” Nitrite +, leukocytes +. I also see repeat Culture and Sensitivity tests (C&S) from Emerg. I look at the patient’s medical file in our pharmacy system. She was treated with cephalexin 500mg four times daily for 1 week, on the same day that the C&S was ordered. I quickly think to myself, no wonder the patient went to Emerg today with symptoms, that antibiotic was resistant. I dig a little deeper into her chart: Allergies: sulfa —throat swellingMed conditions: peripheral edema, afib, depressionRx meds: amiodarone 200mg/day (increased from 200mg 6 days/week by cardiologist 2 months ago), digoxin 0.25mg/day (started 2 months ago by cardiologist), bisoprolol 10mg/day, furosemide 40mg/day, apixaban 5mg twice daily, escitalopram 10mg/day. My note from Nov 2023, two months ago, states that after speaking with the patient and her daughter, I learned that the patient was seen by her cardiologist for continuous afib and arrhythmia despite being on high dose beta blocker, so the cardiologist increased the amiodarone and added digoxin. I now have an idea of what MD would like to discuss. I examine QT risks for pt: she’s 88 y.o., female, has afib, on a plethora of QT-prolonging drugs, with a difficult-to-treat bacteria that can only be treated by bigger gun antibiotics. I try to search for a recent ECG to look for QT #. Nothing in the last six months that’s viewable and nothing in Emerg. I call Emerg. “Hey Dr. X it’s Samier the pharmacist calling from Dellar’s pharmacy in Tweed. You wanted to chat about this pt who you prescribed cipro for. What’s up?” “Thanks so much for calling me back. I wasn’t sure when the pt was going to drop off the Rx and wanted you to have a look first and call me when you were free. What other meds is the pt on other than amiodarone? I’m concerned about her cultures and giving Cipro with amiodarone. Can’t give sulfatrim because of her sulfa allergy. No other alternative and I didn’t admit her. ” I read out the pt med list. I ask if there’s an ECG done that potentially hasn’t yet been uploaded to the clinical viewer. His response “I didn’t do an ECG. As you know, makes sense why the keflex didn’t work. Let’s reduce amiodarone to 100mg/day x 6 days then go back to usual dose after.” I then say “I don’t think we should do that. Pt had recent cardio appt two months ago due to uncontrolled rate and rhythm and had to increase amiodarone dosage and add digoxin. Also amiodarone has a long half life of 50+ days, so adjusting dose now will likely not make much clinical difference, although it may make you feel better.” Dr. X: “Yes, but if I ask the patient to come back to Emerg, it’ll be another six hour wait at least.” My response: “OK I will contact her family doc to order an ECG stat and we’ll go from there. I’ll take care of it and coordinate.” Dr. X: “Thank you so much. And sorry for making you deal with this, when she left Emerg it didn’t sit right with me.”By this point, the patient and daughter, her POA, have called numerous times to ask if Rx is ready yet. I advise my staff to tell them we’ll call when it is, it’s a complicated case and we want to ensure pt safety and the optimal plan for her. (Keep in mind we’re also doing over 100 Rx’s, another hospital discharge, OTC consults and some injection appts made weeks ago.) I call the family doc and explain the situation. I ask if he has a recent QTC. He says last one was over a year ago and cannot see the one done by cardio at the appt two months ago. We discussed nitrofurantoin and how it won’t work—either likely not effective and would not cover pyelo, given the extended duration of symptoms. I request she be seen in clinic asap for an ECG. I fear with the duration of infection of greater than two weeks, and the type of bacteria involved which can have a mortality rate of 20% (according to a recent article I read about enterobacter infections), and her advanced age, it could quickly turn into pyelonephritis or sepsis and be a much more complicated issue. At this point it’s 4:55pm. Family doc said they can’t tonight as the clinic is closing in five mins but his secretary will book her in tomorrow morning first thing at 8:30 a.m. and he’ll call me with results. I tell him I’m off tomorrow but gave my cell so I can deal with it and close the loop. I called the patient and caregiver to explain all of the above. Essentially, the reason why the first antibiotic didn’t work is because the bacteria causing the UTI is resistant to it. The drug the Emerg doc prescribed would work, but can affect her fragile heart, and we don’t want to risk it. Interestingly, the daughter explained how three months ago in October 2023, the patient was prescribed cipro for two weeks by a urologist. At the time, during her cardio appt one month later in November, they thought the Cipro may have been a contributor to her worsening heart rate and rhythm symptoms leading to dose increases. They appreciated my call. I suggested the daughter stay the night with the patient, check her temperature every couple of hours, monitor for any signs of delirium or confusion, and if any occur to call 9-1-1. At 5:30pm, when we closed, I had to leave for my mom’s birthday surprise dinner at a restaurant. My drive from work is 1.5 hours and freezing rain had started. I had to stay to document everything prior to leaving for the staff and pharmacist to know what to do tomorrow when the patient comes in and based on results of ECG. For example, if QT > 480 or >500, we may have to ask the patient to go to the hospital again, or ask the family doc to page infectious disease consult. Fortunately I had just read the 2023 CCS QT prolongation guideline. At 9:30 a.m. the next day, the family doc calls. He says “Thank God QT is at 399. I don’t know what we would have done if it was elevated.” My response: “Thank God indeed. I don’t know either, I was researching it all night. This is best case scenario. Let’s do cipro 500mg twice daily but for 1 week, not 5 days per emerg Rx, as pyelo would need at least 1 week treatment. Please write QT interval on Rx. Family doc: “Sounds good. I’ll fax it in. Good team work.” “Thank you, you too!” Lessons to learn from this case: Patients are complex, and with many comorbidities; it makes balancing effective treatment with patient safety hard. It also makes the job funThis intervention was only successful because:I had adequate staffing to support the flow of all other non urgent prescriptions that came through during the time while I was dealing with the aboveI have access to Clinical ViewerI know the family doc and have his cell #I know how the health system works so can navigate my resources to deal with itOntario has very fragmented healthcare and it’s quite concerning for all of us. Why don’t I have access or a copy of the patient’s cardio consult from November 2023 or urology consult from Oct 2023?Pharmacists do a hell of a lot of things behind the scenes. I am the owner, so I’m content with my remuneration. But for all other pharmacists, they deserve more. We need to be recognized for this. If I hadn’t explained to the patient exactly what I did, they would have thought I just dispensed what the doctor wrote. So you must tell your patients what you do for them. Not to blow your own horn, but to educate the public, one patient at a time.

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Torsades de pointes vs. sepsis—can you avoid both?

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Samier Kamar

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