Losing faith in evidence-based medicine: Etomidate and sepsis

In an era where evidence-based medicine is the goal, it is vitally important for practitioners to understand how to prioritize and interpret the onslaught of data coming at us.

This fact was driven home for me with a recent publication. Several weeks ago an article was published in Critical Care Medicine entitled “Etomidate is associated with mortality and adrenal insufficiency in sepsis: A meta-analysis.”

The point of this post is not to debate if etomidate should be used to intubate septic patients. Etomidate very well may kill people with sepsis. I just don’t know from the data currently available. Using this meta-analysis as an example, the goal is to point out two important areas where we could stand to sharpen our literature evaluation skills.

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2016-11-11T18:43:14-08:00Nov 20, 2012|Infectious Disease, Tox & Medications|

Mythbuster: Urgent dialysis following IV contrast?

Have you ever had to promise the radiologist that you would arrange emergent dialysis for your end-stage renal disease (ESRD) patient after receiving IV contrast?

This myth is even perpetuated in the field of nursing. In fact, what prompted this post was overhearing this very topic discussed between a nurse and a recent graduate nurse trainee.
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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2019-02-19T18:47:01-08:00Oct 31, 2012|Renal, Tox & Medications|

How many times have you given your patient IM ceftriaxone for that presumed gonococcal infection? … still counting? Many of us learned (or at least thought we learned) that ceftriaxone has to be administered IM to get the ‘depot’ effect.

Myth Busted

There doesn’t appear to be a true depot effect. IV and IM ceftriaxone have very similar pharmacokinetic profiles. Let me prove it to you, straight from the FDA-approved ceftriaxone package insert.

Table 1: Average plasma concentration (mcg/mL) as measured over time after 500 mg of ceftriaxone administration

Ceftriaxone route	0.5 hr	1 hr	2 hr	4 hr	6 hr	8 hr	12 hr	16 hr	24 hr
IV	82	59	48	37	29	23	15	10	5
IM	22	33	38	35	30	26	16	unknown	5

Table 2: Average urine concentration (mcg/mL) as measured over time after 500 mg of ceftriaxone administration

Ceftriaxone route	0-2 hrs	2-4 hrs	4-8 hrs	8-12 hrs	12-24 hrs	24-48 hrs
IV	526	366	142	87	70	15
IM	115	425	308	127	96	28

The plasma concentrations are almost identical after IM and IV administration through 24 hours (Table 1).
Even the urinary concentrations are similar up to 24-48 hours after a dose (Table 2).
The volume of distribution is the same for both parenteral routes, too. This means that its penetration into the “affected area” is similar.
According to a 2012 CDC Report the minimum inhibitory concentration (MIC) for N. gonorrhoeae strains to ceftriaxone is 0.125 mcg/mL. IV therapy provides concentrations above this resistance cutoff well after 24-48 hours, similar to IM therapy.

Trick of the Trade

If the patient already has an IV line, we can give IV ceftriaxone for gonorrhea instead of IM.

In fact, the Japanese Society for Sexually Transmitted Diseases has recommended monotherapy with a single IV dose of 1 g ceftriaxone since 2008. (Aoki 2021)

While most of the time patients with STD (or STI, if you prefer) complaints don’t have an IV line established, occasionally they do. My hospital stocks 1 gm and 2 gm premixed IV bags of ceftriaxone, so we could potentially just give 1 gm IV in these rare cases to ensure adequate levels (even 500 mg might be just fine).

Of course, the other way to avoid the painful injection is to mix the ceftriaxone with lidocaine… or avoid contracting gonorrhea altogether.

Disclaimer

This post is intended for educational purposes to explore the kinetic data for IM and IV therapy. The CDC guidelines should be followed for treatment of STDs.

References

Product Information: ROCEPHIN(R) IV, IM injection, ceftriaxone sodium IV, IM injection. Genentech USA, Inc. (per Manufacturer), South San Francisco, CA, 2010.
Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010;59(RR-12):1-110. [PMID: 21160459]. Free MMWR PDF download.

Original: October 9, 2012; Last Updated: December 24, 2021

By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2022-02-03T10:29:27-08:00Oct 9, 2012|Infectious Disease, Tox & Medications, Tricks of the Trade|

Tricks of the Trade: Calcium gel for hydrofluoric acid burns

A 41 y/o m presents to your ED after an occupational exposure to 30% hydrofluoric acid (HF). The thumb and index finger of his right hand were affected. Upon visual examination, the site of exposure looks relatively benign but the patient is complaining of extreme pain. Beyond giving opioids, what can you do?

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2020-01-28T04:04:14-08:00Sep 11, 2012|Tox & Medications, Trauma, Tricks of the Trade|

Trick of the Trade: Oral naloxone for opioid-induced constipation

Opioids are amazingly effective for pain control. Patients on chronic opioids, however, often struggle with constipation. These patients may fail supportive treatment with enemas and laxatives.

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By Michelle Lin, MD|2016-11-11T18:44:08-08:00Aug 28, 2012|Tox & Medications, Tricks of the Trade|

Apart from benzodiazepines, the opiate urine drug screens (UDS) are probably the most frequently utilized and misunderstood.

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2016-11-11T18:44:08-08:00Aug 27, 2012|Tox & Medications|

Peeing into the wind? Urine drug screens, part 1 (benzodiazepines)

Let’s be honest. When was the last time results from urine drug screens (UDS) changed your management plan? Many times it takes hours for the patient to give the urine sample anyway. And, with all of the false positives out there, how do we know what the heck the result is actually telling us?

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2016-11-11T18:44:14-08:00Aug 20, 2012|Tox & Medications|

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