Transcript Acquired Drug Resistance

Acquired Drug Resistance
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64 year old female of Hmong ethnicity with long
standing, poorly controlled diabetes. No hx TB
dx/tx.
11/6/08 CXR “active processes in both upper
lobes that are most likely inflammatory in nature”
Sputa AFB smear negative
Plan was to begin empiric treatment after
pulmonary consult
Referred to pulmonologist, but failed
appointments, no treatment
Culture negative, no treatment
Acquired Drug Resistance
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Aug 2009 she collapsed in her home
Arrived at hospital via ambulance, unconscious
Transferred to Doctor’s Hospital in Modesto
Reportedly had cough since the November 2008
exam
Pt reports that she is now “skinny”, implying
weight loss, but none documented
Acquired Drug Resistance
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8/29/09 - Heavily smear (+) with bilateral
infiltrates on CXR
8/31/09 - Began RIPE
Initial isolate pan-sensitive
10/2/09 - EMB discontinued
11/6/09 - PZA discontinued
10/8/09 - Smears become negative
Cultures remain positive
Acquired Drug Resistance
- CXR “Progressive bilateral upper
lobe infiltrates”
 1/27/10 - Smears become 2+ AFB positive
 Subsequently, it was learned that she had
begun vomiting (start date unclear) shortly
after DOT worker left each day
 She did not report this for several months
 1/12/10
Acquired Drug Resistance
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Repeat DST results show:
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Resistance to INH, Rif
Sensitive to EMB, PZA, ETA, CM, AK & LFX
Acquired Drug Resistance
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Hospitalized & expanded regimen started:
 Amikacin, 750 mg 5x wk via PICC (later lowered)
 Moxifloxacin, 400 mg po qd
 Ethambutol, 1200 mg po qd
 PZA, 1250 mg po qd
 Linezolid, 600 mg po qd
 B6, 100 mg po qd
 Zofran for vomiting
Baseline color vision and hearing OK. Glucose levels,
LFTs, and renal functions were excellent throughout
hospital stay
Therapeutic Drug Levels
(MFX collected 4/19/10, all others 4/23/10)
Drug
Dose
2 hr
level
6 hr
level
EMB
1200 mg
po qd
0.90
1.86
PZA
1250 mg
po qd
18.18
29.53
MFX
400 mg
po qd
3.36
2.06
2 hr 3-5 mcg/ml
No 6 hr range
LNZ
600 mg
po qd
3.53
7.02
2 hr 12-24 mcg/ml
AK
550 mg
IV 5d/wk
20.8
7.3
Cmax 35.1
Ref Range
2 hr 2-6 mcg/ml
2 hr 20-60 mcg/ml
Cmax 35-45 mcg/ml