On-call scenario 3: Resolution
What an on-call pharmacist could advise...
There are several ways forward. The preferred option is to use an alternative antibiotic. Your hospital CAP guidelines might suggest an alternative, or you might need to seek expert microbiology advice.If there are no suitable alternatives, then on balance, despite the contraindication, you might decide with the doctor that using the combination of citalopram with clarithromycin is in the patient’s best interests. This will involve a careful and detailed assessment of their risk factors for developing QT-interval prolongation such as their cardiac history and their electrolyte status. The lowest effective dose of clarithromycin should be used and the patient should undergo ECG monitoring. The patient’s response to treatment should be checked at regular intervals, and the antibiotic reviewed as appropriate.
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Follow up
The next day ensure that you explain your decision to the clinical pharmacist caring for the patient and any further action required (such as ensuring the patient is monitored and reviewed appropriately). Document your advice and find out what happened to the patient, so you can record this too. Think about sharing your experience with your on-call colleagues and find out what they would have done faced with a similar situation.The Interactions tutorial may be worth looking at if this scenario has made you feel uncertain about your core knowledge in this area.