Regardless if you have a psychiatric diagnosis and not, you can have infections and other physical disorders. My experience is that too little focus is put on these patients' physical disorders. In the early years alcohol and penicillin were recommended not to be taken together. This was not due to any interaction between alcohol and penicillin but it was a precaution that sailors and others with sexually transmitted disorders could forget to take their antibiotics when drunk.

This question underscores the importance of Infectious Disease consults on psychiatric wards and having an internist with expertise in infectious disease available at free-standing psychiatric facilities.

Tx for an answer Theodore. But are You sure that their knowledge about psychiatric medication is appropriate (there are many X combinations).? Because, it is known that inappropriate prescribing can lead to lower response on psychiatric medication or adverse events (e. g. agomelatin and ciprofloxacin). My opinion is that the best option to reduce medical errors is to include a clinical pharmacist or pharmacologist.

In the context of the psychiatric hospital where I work, there is a primary care doctor/internist who monitors for infections and prescribes antibiotics and is not overprescribing. If I enter any medical orders at admission that include previously prescribed antibiotics, the pharmacy reminds me of the duration to be entered and a computer pop-up screen will let me know of potential drug-drug interactions so that a choice can be made as to continue with monitoring for potential interactions or consulting with the internist and pharmacist as to potential alternatives.

Dear Lawrence,

this is a good strategy! I support this kind of teamwork. Absolutely, the medical errors are reduced. Electronic (digital) charts are good things, because clinician (prescriber) and pharmacist (dispensing, checking, reviewing) can check what is prescribed and therefore a communication before administration to the patient is possible. 

According to the recent data a collaborative care in more appropriate in term of efficacy and safety, especially where drug adherence is under question. In Eastern and Central Europe this system is seen rarely, which is not good for patients' safety.

Today for example on psychiatric department, where I work as clinical pharmacist, we switched from escitalopram to sertraline, because ciprofloxacin was introduced in high dose. Also dose reduction of ciprofloxacin was made, because of patient's kidney failure etc ... I think well educated psychiatric clinical pharmacist is highly advisable especially in psychiatry, where are many combinations and polypharmacy under question.

Dear Lawrence please see my article on this topic, where answer on question is given (why clinical pharmacist is important in this field).

Regards,

Mathew

http://www.ncbi.nlm.nih.gov/pubmed/25123143

Dear Matthew,

Thank you for the article. I will remember that. i agree teamwork is very important to provide good patient care.

Regards,

Larry

Pharmacist accompanying ward rounds could be useful? I have seen conference presentations in the UK (about UK hospitals, not specifically psychiatric wards or units) that suggest this is both cost-effective and improves health outcomes such as reduction in antibiotic-associated diarrhoea, and so on. 

Thanks Michael. Very nice opinion. I totaly agree with You. A collaborative care is more beneficial for the patients and payers than work of clinicians alone. Especially in psychiatry (where usually polypharmacy is seen) and infections (where we should be very careful within antibiotic consumption) are very important part of the collaborative care, where clinical pharmacists are always on the wards.

For the inclusion of clinical pharmacists in the teratment team and their impact on health outcomes Please see: Cappelletty D, Jacobs D. Evaluating the impact of a pharmacist's absence from an antimicrobial stewardship team. Am J Health Syst Pharm. 2013 Jun 15;70:1065–1069.

i will add some links (see below).

Regards,

Mathew

http://www.ncbi.nlm.nih.gov/pubmed/12432976

http://www.ncbi.nlm.nih.gov/pubmed/11837551

I can add to this from a practical standpoint. I have worked in many hospital settings around the country. Each place used different techniques for addressing non-urgent medical issues when a person is inpatient for psychiatric care. For simple cases, sometimes the psychiatrist or resident will handle the prescribing.  In such a setting, the knowledge of DDI and proper use would vary considerably, depending on the training and experience of the doctor.  Many psychiatrists who work in inpatient settings have additional training in medicine so they can cover such occasions. 

A "consultation" from an outside provider is the only other way to provide prescription coverage, and sometimes the consultations can be a day (or more) later, making this a problematic choice, especially in some remote locations.

Most psychiatric hospitals/ units tend to have a PA or NP that provide regular coverage (daily or a few times a week), and again, proper use knowledge would vary. It would almost be unheard of to employ a clinical pharmacist or a full-time internist, pediatrician, or family doctor. Most places simply aren't large enough to support this level of extra care, and it seems unlikely that the services would be covered by insurance.

Given the variability in reimbursement, there can be a big difference between the model of care (team) at a large academic or private-pay center, compared to small units or community hospitals.

there is a tendency to use gentamicin/vancomycin in an attempt to avoid MRSA...but these drugs have other problems (e.g., vestibulopathy) so should also be used with great caution

Dear Lewis,

Thanks for your opinion. However, gentamicin can be used in psychiatric patients, because this is antibiotic which is useful for Pseudomonas A. treatment, which is often necessary in elderly psychiatric patients and has good activity towards E. Coli and resistance is small.  Gentamicin is one of the drugs, which has great effectiveness acording to the some bacterias and is especially safe in psychiatric patients, because of its low possibility of drug-drug interactions with psychopharmaceuticals, especially those with a metabolism via CYP1A2 and/or CYP3A4 systems (e.g. carbamazepine, quetipaine, olanzapine etc ... ) and drugs which has possibility of QT prolongation (most psychiatric drugs). These issues are especially problematic If You add quinolones or macrolides to the treatment with psychopharmaceuticals. Nitrofurantoin, which is first line for E. Coli accordnig to the last guidelines should be used with great caution in psychiatric patients, mostly because of its potential for CNS serious adverse effects (hallucinations, delusions etc ... ). Use of nitrofurantoin can produce or induce use of antipsychotics, because of its adverse effects. The safest medications in psychiatric patients, who usually have received psychiatric polypharmacy, are penicilines and gentamicin.

I think this is one of the key issues for cooperation between clinical pharmacist and psychiatrists within psychiatric wards.

Regards,

Mathew

 Giving artificial milk is more dangers than worrying about a short course of antibiotics

Regardless if you have a psychiatric diagnosis and not, you can have infections and other physical disorders. My experience is that too little focus is put on these patients' physical disorders. In the early years alcohol and penicillin were recommended not to be taken together. This was not due to any interaction between alcohol and penicillin but it was a precaution that sailors and others with sexually transmitted disorders could forget to take their antibiotics when drunk.

I agree with you! Awareness of effects and adverse side effects of such drugs is crucial.