BCPS 2013: Infectious Diseases

My infectious disease review.  I've already talked about pneumonia and may be revising these to go from the direction of the bugs and then the drugs again.  One thing I will say:  Invanz is not active against MRSA, ampicillin-resistant enterococci, Pseudomonas aeruginosa or Acinetobacter species.  Hear me?  :)

BCPS ID Review

Pneumonia	CAP	HAP
Organisms	M. pneumonia, S. pneumonia, H.flu, C. pneumonia, Legionella, Viruses	S. aureus, Pseudomonas, Enterobacter, Klebsiella pneumo, Candida, Acinetobacter, Serratia, E.coli, S.pneumonia
Treatment	Healthy no Abx in previous 3 months Macrolide (clarith or azith) OR doxycycline Cormorbidity or Abx in previous 3 months FQ (moxi, gemi, levo 750mg) Macrolide (or doxy) + [High-dose amox 1g tid OR amox/clav 2g bid OR ceph ] (ceftriaxone, cefuroxime, cefpodoxime)	Early onset (< 5 days) 3rd ceph (ceftriaxone, cefotaxime) FQ (levo, moxi, cipro) Amp/sulbactam Ertapenem Late onset (> 5 days or RF for MDR)    Ceftazidime OR cefepime + AG or FQ (cipro, levo) Imi, mero, or dori + AG or FQ (cipro, levo) Pip/taz + AG or FQ (cipro, levo)    + Vanco/linezolid only if MRSA risk factors
Duration	At least 5 days	7 days (14 days for Pseudomonas)

Influenza: Type A (Annual, H1N1, H1N2), Type B

Prophylaxis:  if outbreak and cannot receive vaccine

1. Amantadine, Rimantadine 5-7 weeks

2. Neuraminidase inhibitors: Oseltamivir 75-150mg daily x6wks; 75mg daily x7days within 2 days of contact

Zanamivir 10mg daily through inhalation x4wks

Treatment: only if severe symptoms or at risk for complications

1. Amantadine, Rimantadine- only against Type A, decreases symptoms 1 day  *do NOT use for at risk for complications

Dosing: 100mg bid x3-7 days [Elderly 100 daily]; ADJUST FOR RENAL DISEASE (amantadine> rimantadine)

AE: CNS, GI, peripheral edema, orthostatic hypotension

2. Oseltamivir- decreases symptoms 1-1.5 days

Dosing: 75mg bid x5days [CrCl <30 75mg daily]

AE: GI

3. Zanamivir- decreases symptoms 1-1.5 days

Dosing: 2 inhalations (5mg/inhalation) bid x5days

AE: bronchospasm, cough

UTIs	Treatment	Other	Comment
Uncomplicated cystitis	Nitrofurantoin 100mg bid      X 5 days TMP/SMX DS bid x 3 days Or Fosfomycin 3 gm once Duration: 3 days vs 5	Alternatives: Amox-clavulanate, cefdinir, cefaclor, or cefpodoxime x 3-7d or FQ x 3 d
Pregnancy	Amoxicillin Nitrofurantoin Cephalexin TMP/SMZ Duration: 7 days	AVOID: FQ Tetracyclines AG TMP/SMZ (esp 3rd trimester	Pregnant women should be screened for UTI even if asymptomatic
Recurrent cystitis	Relapse: treat 2-6 weeks	Reinfection <2/yr: pt initiated x3days 3+/yr: post-intercourse TMP/SMZ SS, cephalexin 250mg, nitro 50-100mg 3+/yr: daily or 3x/wk	3+/yr other can also use TMP 100mg, or Norfloxacin 200mg
Uncomplicated Pyelonephritis	Not requiring hospital: Cipro 500mg BID x 7d Cipro ER 1000mg daily x 7d OR Levo 750 mg daily x 5d OR TMP-SMX DS bid x 14d Hospitalized: IV FQ Aminoglycoside with or w/o ampicillin OR extended-spectrum cephalosporin or an extended-spectrum pcn with or without an aminoglycoside or carbapenem	Not requiring hospital: Or Oral beta-lactam (less effective) plus initial IV ceftriaxone 1gm OR IV 24-hour dose of aminoglycoside	For pts without N/V and not immunocompromised
Complicated UTIs	FQ levo x 5 days AG x 5-14 days	Extended spectrum Beta lactam
Catheter-related UTIs	Symptomatic pts x 7-10 days and cath removal	Assymptomatic pts should NOT be treated	E.coli, Candida, Enterococcus, Pseudo, Kleb pneumo, Enterobacter
Prostatitis	Acute: Duration 4 weeks TMP/SMZ Cephalosporins FQ	Chronic: 1-4 months TMP/SMZ FQ
Epididymitis	>35 yr: TMP/SMZ, FQ x 10 days- 4 weeks	< 35 yr: Ceftriaxone 250mg IM AND doxycycline 100mg bid x 10 days

Skin and Soft Tissue Infections

Cellulitis	Nafcillin, Oxacillin, Dicloxacillin x5-10 days	Alternatives: Clinda, BL combos, 1st ceph	Vanco/Linezolid for MRSA PCN G if streptococcal
Erysipelas	Penicillin G, Clindamycin x 7-10 days
Necrotizing Fasciitis	B lactam combo + clinda  + cipro Carbapenems Cefotaxime + clinda OR metron	Streptococcal: High dose IV PCN + clindamycin	ABX not curative, surgical debridement necessary!
DM Foot Infection	Deep:  1-2 weeks Amp/sulbac, Ticar/clav, Pip/taz Ertapenem FQ + [clindamycin OR metron] Cefoxitin 3rd ceph + [clinda OR metron]	Shallow: treat like cellulitis PCN, 1st ceph, etc.	Topical: Becaplermin 0.01% Human platelet derived growth factor, improves healing from 35-50% Surgery also important

Osteomyelitis: treat for 4-6 weeks (chronic IV 6-8 weeks + 3-12 months PO)

1. Neonates: Nafcillin + [cefotaxime OR AQ]

2. Infants: Cefuroxime OR ceftriaxone OR [Nafcillin + cefotaxime]

3. Peds (>3yr): Nafcillin OR Cefazolin OR Clindamycin

4. Adults: Nafcillin OR Cefazolin OR Vancomycin

5. Pts with Sickle Cell Anemia: Nafcillin + Ampicillin

6. Prosthetic Joint Infections: Vancomycin + rifampin OR Nafcillin + rifampin

CNS Infections: Meningitis

Empiric: 7-14 days

1. Neonates: Ampicillin + AQ OR + cefotaxime

2. 1 month- 50 yrs: 3^rd ceph (cefotaxime, ceftriaxone) + Vanco

3. >50 yrs: 3^rd ceph +Vanco + ampicillin

4. penetrating head trauma: Vanco + cefepime, ceftazidime, meropenem

Pathogen Known: MOSTLY PCN G 4mill units IV q4h OR Ampicillin 2g q4h, alt: 3^rd ceph, vanco, mero, FQ

Corticosteriods: Dexamethasone 0.15 mg.kg q6h x2-4 days; give 10-20 mins before (or at time of ) Abx

Benefit in: Peds with H.flu and Adults with S. pneumo

Brain Abscess: Treat based on source: mostly metron + 3^rd Ceph                               Unknown source: Vanco + Metron+ 3^rd ceph

Endocarditis: Strep, Staph, Entero, HACEK    Duration: 4-6 weeks (8+ weeks with VRE)

Strep: PCN G ± gent, Ceftriaxone ± gent, Vanco

Staph: Oxa/nafcillin ± gent (+ rifampin if prosthetic valve), Cefazolin ± gent (+ rifampin if prosthetic)

MRSA: Vanco (+ rifampin if prosthetic); may also use Vanco in severe PCN allergy

Entero: [PCN G or ampicillin or vanco]  + [gent or streptomycin]                 VRE: linezolid, Quin/Dalf

HACEK: ceftriaxone, Amp/sulbactam, FQ

PPx: dental and resp tract procedures: Amoxicillin 2g PO 1 hr prior                          PCN Allergy: Clinda, azith/clarith

Perotonitis/ Intra-Abdominal Infections

Mild-Mod: cefoxitin, Ticar/clav, ertapenem, moxifloxain,tigecycline;  [cipro/levo +metronidazole],

[cefazolin/ cefuroxime/ceftriaxone/cefotaxime + metronidazole]

Severe, healthcare acquired, High-risk: Pip/Taz, [ceftazidime/cefepime +metronidazole], imi/cil, mero, dori, [cipo/levo +

metronidazole (not for healthcare acquired)]

Duration: 4-7 days, [injuries repaired in 12hr can be treated for only 24 hr]

C. difficile: diagnose by presence of endotoxins

Initial Therapy:  Mild to moderate initial episode:  Metronidazole 500mg PO/IV tid x 10-14days OR Vanco 125mg PO QID x 10-14days

Severe initial episode:  Vancomycin 125 mg PO QID for 10-14 days

Severe complicated CDI: Vancomycin 500mg PO plus Metronidazole IV 500mg Q8H

Recurrences:  First recurrence:  Same as for initial episode

Second recurrence: Vancomycin tapered/pulsed

Medical/Surgical PPX

Procedure	Treatment	Comment
Gastric/duodenal	Cefazolin 1-2g	Indicated: morbid obesity, esophe obstruction, decreased gastric pH or motility
Biliary	Cefazolin 1-2g	Indicated with (without?): acute cholecystitis, obstr. jaundice, common duct stones, >70yr
Appendectomy	Cefoxitin 1-2g Cefazolin 1-2g  + metronidazole OR amp/sulbactam	If perforated treat x 3-7 days
Colorectal	Cefoxitin 1-2g Cefazolin + metronidazole OR amp/sulbacam Gent/tobra 1.5mg/kg + clinda 600mg/metron 0.5-1g ± neomycin +erythromycin/ metronidazole	PO/IV may be better bc PO only may cause Cdiff Mechanical bowel prep is not recommended
Obstetrics/GYN	Hysterectomy: Cefazolin/cefoxitin 1-2g Caesarian: cefazolin 1-2g	Caesarian: administer AFTER cord clamped
Cardiothoracic	Cardiac surg/Pulm resection: cefazolin/cefur oxime 1-2g Vascular surg: cefazolin 1g q8h x3doses	For all: Use Vanco if MRSA risk
Orthopedic	Cefazolin 1-2g (or cefur or vanco)	Indicated: surgery involves prosthetics
Head/Neck	Cefazolin 1-2g Amp/sul 1.5-3g Gent 1.5mg/kg + clinda 600-900mg	Indicated: major surgery when incision through oral or pharyngeal mucosa
Urologic	NOT recommended	If (+) urine culture, treat then operate

And because pseudomonas is always mentioned:

Pseudomonas aeruginosa

Drugs of Choice:  Piperacillin-tazobactam, Imipenem, Meropenem, Ceftazidime, Cefepime, Amikacin, Gentamycin, Tobramycin, Ciprofloxacin

Alternatives:  Timentin, Aztreonam, Levofloxacin

Third-Line agents:

Comments:  (Gram-negative bacilli).   Consider using two agents from two different classes as empiric treatment in critically ill patients if P. aeruginosa is suspected. Once susceptibilities known, narrow to one drug according to susceptibility report.

LeapFrog vs Consumer Reports

What hospital is the best in your area? Which hospital is the safest? Many times the public uses word-of-mouth from their friends and families to choose. A lot of times our own insurance policies determine which hospital we choose. Consumer Reports just rolled out their own version of safety rankings comparable to another version LeapFrog Group that was released last year.

In June, Leapfrog Group, a Washington D.C.-based hospital safety advocacy group, created its own safety rankings, but unlike Consumer Reports’ numerical scores, Leapfrog used A, B and C letter grades, similar to New York City’s restaurant grading system that only has three grades.

The director of the Consumer Reports Health Ratings Center, John Santa M.D., explained the report as a type of advocacy. “We’re doing this in part because 12 years ago the Institute of Medicine made the same suggestions that we’re making. This kind of information needs to be publicly reported, these problems need to be solved, but the hospitals still haven’t done it,” he said. There are differences in reporting between the two groups. “We each looked at some different measures,” said Leah Binder, CEO of the Leapfrog Group. “Particularly, they [Consumer Reports] looked at patient satisfaction measures and rates of CT scans. We didn’t look at those things. We looked at injuries, errors and accidents only. It’s kind of like having two different book reviews. Different reviewers have different interests.”

This is a good thing in that it helps educate the public about hospital safety. This is a bad thing is that the guidelines for determining safety is different from study to study. Where does your hospital rank?

Meet Mr. MRSA

I thought I would introduce you to an infectious organism every week!  Today, the lucky "bug" as they are referred to in the medical community is methicillin resistant staphylococcus aureus (MRSA). If I was a common layperson in the field of medicine, I would view this microorganism as a very nasty flesh eating entity.  I thought I would shed some light about MRSA.  Whether you are dealing with a soft tissue infection, pneumonia, central nervous system infection, endocarditis (heart), or bone and joint, the treatment differs.

Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body. It's tougher to treat than most strains of staphylococcus aureus -- or staph -- because it's resistant to some commonly used antibiotics.

The symptoms of MRSA depend on where you're infected. Most often, it causes mild infections on the skin, causing sores or boils. But it can also cause more serious skin infections or infect surgical wounds, the bloodstream, the lungs, or the urinary tract.

Though most MRSA infections aren't serious, some can be life-threatening. Many public health experts are alarmed by the spread of tough strains of MRSA. Because it's hard to treat, MRSA is sometimes called a "super bug."  Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body. It's tougher to treat than most strains of staphylococcus aureus -- or staph -- because it's resistant to some commonly used antibiotics.

The symptoms of MRSA depend on where you're infected. Most often, it causes mild infections on the skin, causing sores or boils. But it can also cause more serious skin infections or infect surgical wounds, the bloodstream, the lungs, or the urinary tract.

Though most MRSA infections aren't serious, some can be life-threatening.  Many public health experts are alarmed by the spread of tough strains of MRSA.  Because it's hard to treat, MRSA is sometimes called a "super bug." 

Also just news today... an almost instant test in detecting MRSA.

Skin and soft-tissue infections

1.  Abscess  - incision and drainage
2. Purulent cellulitis
   • Clindamycin 300-450 mg PO TID (C diff)
   • Bactrim 1-2 DS tablets BID (pregnancy category C/D)
   • Doxycycline 100 mg BID (pg category D and not recommend for children under 8)
   • Minocycline 200 mg x 1, then 100 mg PO BID
   • Linezolid 600 mg BID (expensive)
3.  Nonpurulent cellultis
   • Beta lactam (cephalexin and dicloxacillin) 500 mg QID
   • Clindamycin 300-450 mg TID
   • Beta lactam and/or Bactrim or a tetracycline – amoxicillin 500 mg TID
   • Linezolid 600 mg BID
4. Complicated SSTI
   • Vancomycin 15-20 mg/kg/dose IV every 8-12 hours
   • Linezolid 600 mg PO/IV BID
   • Daptomycin (cubicin) 4 mg/kg/dse IV QD
   • Telavancin 10 mg/kg/dose IV QD
   • Clindamycin 600 mg PO/IV TID
5. Bacteremia
   • Vancomycin 15-20 mg/kg/dose IV every 8-12 hours
   • Daptomycin 6 mg/kg/dose IV QD
6. Infective endocarditis, native valve – same as bacteremia
7. Infective endocarditis prosthetic valve
   • Vancomycin and gentamicin and rifampin – 15-20 mg/kg/dose IV every 8-12 hrs,                                          i.      1 mg/kg/dose IV every 8 h,  300 mg PO/IV every 8 h
8.  Persistant bacteremia
9. Pneumonia
   • Vancomycin 15-20 mg/kg/dose IV every 8-12 hours        
   • Linezolid 600 mg PO/IV BID
   • Clindamycin 600 mg PO/IV TID
10. Osteomyelitis (Bone and Joint Infections)
    • Vancomycin 15-20 mg/kig/dose IV every 8-12 hours
    • Daptomycin 6 mg/kg/day IV QD
    • Linezolid 600 mg PO/IV BID
    • Clindamycin 600 mg PO/IV TID
    • TMP-SMX and rifampin – 3.5-4.0 mg/kg/dose PO/IV every 8-12 h
11. Septic arthritis
    • Vancomycin 15-20 mg/kg every 8-12 hours
    • Daptomycin 6 mg/kg/day IV QD
    • Linezolid 600 mg PO/IV BID
    • Clindamycin 600 mg PO/IV TID
    • Bactrim 3.5-4.0 mg/kg/dose PO/IV every 8-12 hours
12. Meningitis
    • Vancomycin 15-20 mg/kg/dose IV every 8-12 hours
    • Linezolid 600 mg PO/IV BID
    • Bactrim 5 mg/kg/dose PO/IV every 8-12 hours
13. Brain abscess, subdural empyema, spinal epidural abcess
    • Vancomycin 15-20 mg/kg/dose every 8-12 hours
    • Linezolid 600 mg po/iv BID
    • Bactrim 5 mg/kg/dose PO/IV every 8-12 hours
14. Septic thrombosis of cavernous or dural venous sinus
    • Vanc same
    • Zyvox
    • Bactrim same

Pharmacy Perfection

One of the biggest things I struggle with as a pharmacist is the idea of a profession that requires absolute perfection in everything you do; yet I am human. There is not a lot of room for error because it can detrimentally affect a patient. I remember back when I was as green as the spring grass freshly graduated from pharmacy school in 1999. I landed my first job with K-Mart, not exactly the job that I had dreamed of while I was attending pharmacy school, but they paid for my relocation from one city to another. They also did not do a lot of volume in the particular store where I was assigned. I do not remember the name of the pharmacist that worked there opposite from me initially. What I do remember about her is the words that came out of her mouth almost at her introduction, “I have never made an error while being a pharmacist.” I was too naïve at the time to realize that there was no way she was telling the truth. We are human; we will make mistakes. And at the time K-Mart did not have any mandates in place on flow or any bar-coding scanning to ensure more safety as Walgreens and CVS had. They were way behind the times as far as technological advances go.

I believe one of my first errors was dispensing Adalat CC 30 mg when the prescriptions called for 60 mg. Yes, I felt SICK. But over time I have come to realize that there are things you can do as a pharmacist to be more accurate whether it be hospital, retail, or anything in between.

According to a 2006 report by the Institute of Medicine, medication errors cause harm to roughly 1.5 million patients annually.5 Millions more are caught prior to administration, before they reach the patient. Not only do medication errors adversely impact the patient population, they are estimated to cost billions of dollars in additional treatment costs. Read more: http://www.uspharmacist.com/content/c/31431/

Here are some tips to help you become more accurate

1. Concentrate. Don’t allow distractions to stop your flow of thinking. If a technician comes up to you and needs something right away, go ahead, but realize when you start back on the order, you need to continue the exact same flow from beginning to end. Don’t try to “pick up where you left off.”

2. Do the same thing every single time. Consistency.

3. Do a second double check after you are finished checking. If that means pulling up the profile on the computer screen and holding up the order or pulling it back up electronically, just double check at the very end.

4. Any time you are going outside the usual, there is a higher incidence for errors. For example, if you have to build something from scratch in the computer on a new medication, you can be sure you are more likely to mess up on something else within the order than normal.

5. If you work retail, utilize every program they have to improve accuracy. In the hospital, just do another last review of MAR prior to moving to the next order. If in doubt; ask. It’s always better to phone the office if you work in retail or phone the nurse if you work in hospital to bounce off what you are seeing.

The most important thing is to make sure you have enough staff to safely fill medications and orders.

How to Make the Transition from Retail to ANYTHING Else

You've finally reached the end of the line in retail.  You've had enough of the rude public, the non-pharmacist managers, and the corporate cuts.  You are ready to have an hour lunch (maybe) and normal bathroom breaks.  You are ready to feel a little more professional.  Sorry, retail pharmacists, you know it's true.  Yes, you probably make more money than me, but at least I'm not worried about my health.  (I was working retail in a terrible part of town.  All of the good areas were full with waiting lists of pharmacists ready to transfer out just like me.  I just chose a quicker path). The first thing that is entering your mind as I'm noticing on a couple of comments here is that you think a special amount of training is required.  Let's first think about hospital pharmacy.  You can transfer from retail to hospital pharmacy fairly easily.  Hospitals can train you.  There is a lot to learn, yes, but I was up-to-speed in two months.  I worked five years in retail, if that helps at all.

You will have to learn about the hospital's formulary, allergy list, and perhaps coumadin and pharmacokinetic dosing again.  You will certainly have a lot of pharmacists willing to help.  There will be no more jerks in line waiting on you to hand them their papersack with drugs; you will merely have a function to be a part of the team that helps to heal the acutely and chronically ill.  You will revisit sterile technique to mix IVs, chemo, and TPN. (I hope, though it seems the hospitals I worked in didn't observe this at all!)

And most importantly... you will have a life back.  No more driving home from work in retail and a customer follow you home.  No more jerks waiting until 3 minutes before close to get 10 prescriptions filled... all new.

I don't regret leaving retail at all.  I do regret losing the knowledge of some of the new drugs since graduation, but it's worth it for peace of mind and life.

I hope that helps.

Are You Kidding Me?

My mouth just dropped open.  It's obvious to me that physicians do NOT read medication reconciliation forms for home meds at all.  The ones that do, kudos, but the ones that don't make my job more interesting and at times really get to me. Case-in-point:  50-something presenting to the hospital with lower GI bleed.

The doctor signed off to CONTINUE HER HOME MED OF PHENTERMINE FOR WEIGHT LOSS.  Are you kidding me?

I guess the nurse could have written "Purina Dog Chow - take one cup by mouth daily" and the physician would have signed off on it.

Way to go Joint Commission on putting in a requirement with no means of adhering to any sort of THINKING for anyone involved.

Except for the pharmacist of course to wade through the BS and find what is really needed.

I really like the one where the physician wanted to continue the patient's viagra while in the hospital.  THAT should keep the nurses on the floor on their toes running from a man who is looking for some fun.  Not good.

Medication reconciliation forms.  The bane of my existence.

Illegal alien...

I found it strange this morning to get an order for a drip that usually will run a fairly long amount of time.  In other words, we will compound a large volume to run, but I was told to just make a 250 mL bag of it.  Turns out the man in the hospital today is in his early 40's, an illegal alien, and they are keeping him from completely crashing to harvest his organs. So who shows up to sign the papers for that one?  Does the family receive American citizenship for his valor?

To answer a question...

A comment was left on my blog asking me what did a work at home pharmacist do?  Good question!  I'm sure that most of the world has one image when thinking of a pharmacist.  The neighborhood retail pharmacist standing behind a counter with a phone propped on one shoulder (bad ergonomic posture) while typing in a prescription into a computer where the computer does all the brain work, etc...  There are many other pharmacist jobs out there... so many more that I want to take the time to address a few.  I am sure I will leave out some, so feel free to comment and leave more examples, if you wish. 1.  Hospital Pharmacist (staff) - the staff hospital pharmacist usually reviews orders that are entered from the chart.  In some settings the hospital pharmacist enters and reviews the orders from the charts, checks for drug interactions, appropriate doses, etc...  They also check carts that are filled with drugs for stock on each of the floors.  They also enter all chemotherapy orders (finding more mistakes, usually since dosage can be calculated by body surface area, etc...), mix chemotherapy and prepare, mix and prepare total parenteral nutrition (in layman's terms "IV food") that contains dextrose, lipids, amino acids, and a variety of electrolytes and salts, etc... that even within themselves have to be a specific concentration and even mixed in a certain order to prevent precipitation.  Precipitation in the vein is a bad thing.  They also mix and check IVs ranging from the easy vancomycin in sodium chloride to IVIG.  Some hospitals have staff pharmacists performing kinetics checks to make sure that the little 90 year old woman can renally (that's with the kidneys) clear certain drugs like vancomycin, tobramycin, and levaquin. 

2.  Specialty pharmacists in a hospital setting - Here we go, these are the pharmacists that did a residency - working for half of the pay for a year or more - learning a speciality.  Critical care pharmacists, infectious disease pharmacists, coumadin pharmacists, on and on and on...  These guys don't help much with the day-to-day stuff.  They usually do a lot of speeches, have pharmacist students under them during the year, have more of a 9-5 job, etc...  It's too narrow a spectrum for me, but it's definitely a brainer side of pharmacy.

3.  Work at home pharmacist - a lot of companies are centralizing their operations and in doing so the order entry/review front end work can be done from home.  Some companies that have many hospitals are condensing all of this into one job at home.  Depending on the company, you can be checking front end orders from charts that are scanned into a computer program like Pyxis all the way to handling one or two specialty drugs. 

4.  Retail pharmacist - makes a lot of money.  A lot of headaches.  A lot of stress.  And I never ever got to take a pee.  I remember most days holding my pee for 12 hours at a time all the while listening to the public bitch about their higher copay.  The real issue is that Eckerd, Walgreens, CVS, etc...  don't give you enough help hours so there's this frenzied pace of working that leads to the horrid mistakes you hear about on the news.  There's some good retail situations, but I found them few and far between.  Perhaps I am a wuss.

5.  Long term care pharmacist - front end and fulfillment responsibilities for servicing nursing homes.  Omnicare is your biggest player with Pharmerica/Kindred right behind.  Can be a good schedule. 

6.  Consultant pharmacist - the pharmacist that travels about nursing homes and residential places checking charts required by law and destroying expired controlled medications.  Making recommendations, etc... 

7.  Drug rep - Drug expert at one or two drugs - don't have to be a pharmacist.  Learns exactly what the drug company tells you.  Carries around charts and studies to look smart.  Gives away pens, free lunches, and sponsors speeches about the drug.  My personal opinion can be attacked here, but I feel this job is a conflict of interest for the public.  Some docs don't do their homework and what their drug rep tells them is what they believe.  Even if it is false.  Even if it is misled.  There are some good drugs out there, though.  I just bet the Avandia drug rep is a little nervous right now.

8.  Drug Information Center - mans an information center to answer questions from anyone, universities, and the public about drug questions, pill identification, etc...  The ability to know how to research and find what is needed.

9.  Pharmacy professor - self explanatory.

10.  Home Infusion pharmacist - takes call for new admits going home from the hospital on some sort of IV medication whether it be TPN, desferal pump, or an IV antibiotic... it's all IVs... no tablets, etc...  but a nice little clinical niche.

 I'm sure I'm leaving some out... but I wanted to at least let the world know pharmacists are more than the retail version.