A case report of intravenous posaconazole in hepatic and renal impairment patient with invasive Aspergillus terreus infection: safety and role of therapeutic drug monitoring

Pitchaya Dilokpattanamongkol,Rasda Boonprasert,Methee Chayakulkeeree,Porpon Rotjanapan,Panadda Panusitthikorn

doi:10.1186/s40360-017-0115-z

Pitchaya Dilokpattanamongkol, Rasda Boonprasert + Show 3 more

Open Access

https://doi.org/10.1186/s40360-017-0115-z

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Abstract

BackgroundInvasive aspergillosis (IA) is a fatal infectious complication among immunocompromised patients. Aspergillus terreus, the fourth common species can be difficult to treat due to a unique resistance pattern. To date, there has been no report on safety and dose adjustment when intravenous posaconazole is selected in hepatic and renal impairment patient. We present a rare case of intravenous posaconazole use in a hepatic and renal impairment patient with invasive A. terreus pulmonary infection. To our knowledge, this is the first report of intravenous posaconazole use in IA due to A. terreus with hepatic and renal impairment focusing on drug safety and role of therapeutic drug monitoring (TDM).Case presentationA 37-year-old previously healthy man with diagnosis of dengue hemorrhagic fever and shock complicated with hepatic and renal impairment proposed to have proven invasive A. terreus pulmonary infection is described. Due to lack of good clinical response and concern of potential adverse effects whilst on intravenous voriconazole, intravenous posaconazole 300 mg every 48 h was chosen with confirmed therapeutic plasma concentrations. Despite the death of the patient and IA deemed uncontrollable, there were no significant side effects attributable to intravenous posaconazole use demonstrated over a period of 34 days.ConclusionsIntravenous posaconazole use with TDM implementation maybe a safe alternative option to standard therapy. Therapeutic plasma posaconazole level may be reached at lower dosing regimen in renal and hepatic impairment patient. However, explanations of clinical failure on this patient with immunodeficiency state were multifactorial.

Highlights

Invasive aspergillosis (IA) is a fatal infectious complication among immunocompromised patients
Intravenous posaconazole may be a good option for IA treatment when Minimum inhibitory concentration (MIC) is noted to be less than 0.25 milligram per liter (mg/L) and plasma concentration above 1.0 mg/L in the setting that renal and/or liver impairment would be a limitation to voriconazole use [14, 15]
The findings demonstrated a decline in aspartate transaminase (AST) and alanine transferase (ALT) levels significantly after posaconazole use (p =0.005 and 0.028, respectively)

Summary

Conclusions

Intravenous posaconazole use at conventional dose in critically ill patients with reduced liver and renal functions may cause unexpectedly elevated posaconazole plasma level but potential adverse events were not observed in correlation with presumptive “supra-and therapeutic values” in this case report. Reduction of maintenance dosage with guidance of TDM may be necessary in order to avoid unaware adverse effects. Posaconazole therapy was not a success in this case study and the explanation is likely multifactorial. Interventions, serum GM and plasma posaconazole levels.

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