Intravenous Levofloxacin Research Articles

ANALYSIS OF COST EFFECTIVENESS OF ANTIBIOTIC USE IN TYPHOD FEVER PATIENTS AT KARTINI RANGKASBITUNG HOSPITAL IN 2022

The high prevalence rate of typhoid fever is one of the health problems in Indonesia. Antibiotic therapy is the only therapy that can be used to treat the main cause of typhoid fever. Antibiotics are a type of drug therapy that requires a lot of budgets to procure. This study aims to find out the most cost-effective type of antibiotic for treating typhoid fever. This research was conducted at Kartini Rangkasbitung Hospital using observational research methods with a cross-sectional approach. The data used uses secondary data conducted retrospectively. This research uses medical record data and cost data. This study was divided into three groups, namely ciprofloxacin tablets, intravenous ceftriaxone, levofloxacin tablets and intravenous levofloxacin. Based on the calculation results, the ACER value of ceftriaxone is IDR 2,955,250, the ACER value of IV levofloxacin is IDR 2,727,306, and the ACER value of levofloxacin tablets is IDR 3,047,337. The ICER value from the comparison between levofloxacin tablets and ceftriaxone is IDR 43,250. The most cost-effective antibiotic is the antibiotic levofloxacin in intravenous form.

A multicentre, randomised, double-blind, double-dummy, parallel-controlled, phase 3 clinical trial assessing the efficacy and safety of intravenous nemonoxacin malate vs. levofloxacin for community-acquired pneumonia in adult patients

Nemonoxacin malate is a novel non-fluorinated quinolone for oral and intravenous (IV) administration. This phase 3, multicentre, randomised, double-blind, double-dummy, parallel-controlled clinical trial (NCT02205112) evaluated the efficacy and safety of IV nemonoxacin vs. levofloxacin for the treatment of community-acquired pneumonia (CAP) in adult patients. Eligible patients were randomised to receive 500 mg nemonoxacin or levofloxacin via IV infusion, once daily for 7-14 days. The primary endpoint was the clinical cure rate at the test-of-cure (TOC) visit in the modified intent-to-treat (mITT) population. Secondary efficacy and safety were also compared between nemonoxacin and levofloxacin. Overall, 525 patients were randomised and treated with nemonoxacin (n = 349) or levofloxacin (n = 176). The clinical cure rate was 91.8% (279/304) for nemonoxacin and 85.7% (138/161) for levofloxacin in the mITT population (P > 0.05). The clinical efficacy of nemonoxacin was non-inferior to levofloxacin for treatment of CAP. Microbiological success rate with nemonoxacin was 88.8% (95/107) and with levofloxacin was 87.8% (43/49) (P > 0.05) at the TOC visit in the bacteriological mITT population. The incidence of drug-related adverse events (AEs) was 37.1% in the nemonoxacin group and 22.2% in the levofloxacin group. These AEs were mostly local reactions at the infusion site, nausea, elevated alanine aminotransferase/aspartate aminotransferase (ALT/AST), and QT interval prolongation. The nemonoxacin-related AEs were mostly mild and resolved after discontinuation of nemonoxacin. Nemonoxacin 500 mg IV once daily for 7-14 days is effective and safe and non-inferior to levofloxacin for treating CAP in adult patients.

Mycoplasma pneumoniae pneumonia – challenges related to diagnosis and treatment in children

Introduction. Pneumonia is a common infectious disease among children, very familiar to pediatricians and a major cause of hospitalization worldwide. Mycoplasma pneumoniae (M. pneumoniae) - atypical pathogen, is estimated to be responsible for approximately 30-40% of community-acquired pneumonias. The aim of the paper was to underline the diagnostic and treatment difficulties in a case of pneumonia with M. pneumoniae in a school-aged boy, with multiple presentations in the Emergency Service for respiratory difficulties. Material and method. We present the case of a 7 years and 10-month-old male patient, admitted to our clinic for wheezing, cough and dyspnea. Results. The clinical exam at admission pointed out influenced general status, wheezing, thoraco-abdominal swing, intercostal draft, sibilant and crackles, oxygen saturation 89%, tachycardia 134 beats/minute. The blood tests revealed mild leukocytosis, with neutrophilia, slightly increased inflammatory biomarkers. Considering the general status and the presence of functional respiratory syndrome, steroid and symptomatic anti-inflammatory treatment is initiated. However, the general condition remains stable, which required the widening of the spectrum of investigations with the performance of a chest CT noticing a pneumonic condensation with an air bronchogram located at the level of the right upper lobe. Considering the stationary respiratory functional syndrome and the radiological appearance of the pneumonia as well as the age, we performed serology for atypical germs and identified a positive titer of Ig M antibodies for M. pneumoniae by instituting Azithromycin po., but after 3 days, the evolution remains stationary, thus we changed the treatment with intravenous Levofloxacin, with a favorable subsequent evolution. Conclusions. Pneumonia with atypical pathogens such as M. pneumoniae is a well-defined and well-known pathology in the literature, but it still remains a condition that imposes multiple difficulties related to the diagnosis and therapeutic management of pediatric cases.

First reported human case of isolation of Vagococcus fluvialis from the urine of a former zoo clerk in Japan: a case report

BackgroundVagococcal infections are extremely rare in humans. There are limited studies on the optimal methods for identification, antimicrobial susceptibility testing, and clinical manifestations of vagococcal infections. Herein, we report a patient with a urinary tract infection who had Vagococcus fluvialis in the urine.Case presentationAn 84-year-old man presented to our urology department with a fever that had persisted for several days. He previously worked as a zoo clerk. The patient underwent a left nephroureterectomy for ureteral cancer 5 years ago, and total cystectomy and right cutaneous ureterostomy for muscle-invasive bladder cancer 1 year prior. He was empirically treated with 500 mg of levofloxacin intravenously every 24 h for the urinary tract infection. V. fluvialis was detected in his urine samples and Pseudomonas aeruginosa was detected in his urine and blood samples. Two bacterial species were identified using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. He was administered intravenous levofloxacin for approximately 1 week, followed by oral levofloxacin for another week, after which the infections were eradicated.ConclusionsTo the best of our knowledge, this is the first report of V. fluvialis detected in human urine in Japan. Vagococcus spp. is commonly isolated from fish or animals, and based on the patient’s work history, it is possible that the patient was a carrier because of transmission from animals.

Luteibacter jiangsuensis blood stream infection: a first case report

BackgroundLuteibacter jiangsuensis is a gram-negative aerobic bacillus that was first isolated from soil samples at a pesticide factory in China and reported in 2011. Here, we describe the first case of L. jiangsuensis infection in human.Case presentationA 59-year-old Japanese woman undergoing treatment for Crohn’s disease was admitted to our hospital with fever. Clinical examination indicated catheter-related bloodstream infection. The catheter was removed and meropenem was initiated. Morphologically identical glucose non-fermentative gram-negative bacilli were detected from two sets of aerobic blood culture and catheter-tip cultures. MALDI-TOF mass spectrometry failed to identify the bacterium, which was later identified as L. jiangsuensis by 16 S rRNA gene sequencing. Antimicrobial susceptibility test revealed that the isolate was resistant to carbapenem, therefore meropenem was switched to intravenous levofloxacin (500 mg/day). After 14 days of treatment with levofloxacin, the patient was discharged.ConclusionsThis is the first case of L. jiangsuensis infection in human. The strain was identified by 16 S rRNA gene sequence analysis.

COVID-19としての入院診療中に，日本紅斑熱と診断し救命し得た1例

COVID-19 is manifested by various symptoms and needs to be distinguished from other diseases. We report the case of a patient with Japanese spotted fever (JSF) who was admitted with a diagnosis of COVID-19. The patient was a 72-year-old woman with high fever whose SARS-CoV-2 rapid antigen test was positive. She also had rashes on her trunk and extremities, including on her palms and soles. We treated her as a COVID-19 patient, viewing her rashes as a complication of COVID-19 or a drug eruption. However, her fever and rashes persisted. Her medical history revealed a history of mowing, which involves a high risk of tick bites, and we discovered an eschar on her left popliteal fossa. We then suspected JSF and treated her with intravenous minocycline and levofloxacin as a severe case. PCR testing of specimens from the eschar was positive for Rickettsia japonica. A confirmatory SARS-CoV-2 PCR test and an anti-nucleocapsid antibody test were negative. We ultimately diagnosed the patient with JSF, not COVID-19. The number of JSF patients in Japan has increased in recent years. Since the clinical presentation of JSF patients and COVID-19 patients is similar, a careful medical history and physical examination are necessary to make the differential diagnosis.

Intravenous metronidazole-, levofloxacin-containing triple therapy for treating patients with Helicobacter pylori-related active peptic ulcer complications: A pilot study.

The aim of this pilot study was to evaluate the efficacy and safety of intravenous use esomeprazole, metronidazole, and/or levofloxacin in the treatment of Helicobacter pylori (H.pylori)-associated peptic ulcer complications. Inpatients with peptic ulcer complications who were not able to take oral medicine were randomly assigned to three groups: triple therapy (esomeprazole, levofloxacin, metronidazole) and dual therapy (esomeprazole, levofloxacin/metronidazole) for 7 days. After intravenous treatment, all patients received open-label oral esomeprazole 20 mg bid for another 1 month. All subjects were followed up for gastroscopy at the seventh day of intravenous treatment to confirm the ulcer healing and 13 C-urea breath test to confirm successful H.pylori eradication 4-6 weeks after completion of oral esomeprazole therapy. The H.pylori eradication rate of both LEV-dual therapy (33.3%, 95% CI: 9.7%-70.0%) and MTZ-dual therapy (50%, 95% CI: 21.5%-78.5%) was significantly lower than that of triple therapy (95%, 95% CI: 71.1%-97.4%) (p=.003, .016). There were no significant differences in the adverse effects among all treatment groups, and the adverse effects were rare. The intravenous triple regimen, consisting of proton-pump inhibitor, metronidazole, and levofloxacin, could be considered in patients of H.pylori-associated peptic ulcer complications if oral medicine cannot be provided.

Brain Abscess with Unusual Organism Staphylococcus hemolyticus in a Renal Transplant Recipient - A Case Report

The immunosuppressive medications in renal transplant recipients are associated with increased risk of infections, leading to significant morbidity and mortality. Here, we report a case of focal brain abscess, presented to us, 8 months after deceased donor renal transplantation with headache and altered mentation. Patient had a history of fungal pneumonia 3 months before presenting illness and received intravenous liposomal amphotericin B, for 6 weeks. On evaluation, he was found to have brain abscess, with mild graft dysfunction. Computerized tomography-guided stereotactic aspiration of the brain abscess was done which grew Staphylococcus hemolyticus. Intravenous catheter placed for 6 weeks for antifungal therapy for the management of previous fungal pneumonia was thought to be cause of staphylococcal infection. He was managed with intravenous clindamycin and levofloxacin for 6 weeks as per antibiogram and immunosuppressive medications were reduced. After 6 months of follow-up, patient was asymptomatic with normal renal function and minimal immunosuppressive medications.

Risk of Legionnaires' Disease from Cleaning Grease Traps

A 61-year-old man presented with a 3-days' history of fever and headache. On admission, his body temperature was 40°C, pulse rate was 99/min, and respiratory rate was 25/min. Serum CRP was elevated, and chest X-ray showed an opacity in the left upper lung field. Under the suspected diagnosis of community-acquired pneumonia, the patient was initiated on treatment with ampicillin/sulbactam, and oxygen supplementation via a nasal cannula at 2L/min. A review of the history revealed that his current occupation was maintenance of grease traps, which are chambers for removing grease from food waste before it enters the sewer pipe. Four days before onset of his symptoms, he had worked on a very dirty restaurant grease trap while wearing a poorly equipped face mask. Legionnaires' disease was suspected, and urinary antigen testing revealed a positive result. Sputum culture and PCR were also positive for Legionella pneumophila serogroup 1, the most common causative Legionella genus of acute pneumonic illness. The antibiotic was switched to intravenous levofloxacin at 500mg/day on day 2 of admission, and the patient's symptoms improved.

Epidural phlegmon and iliopsoas abscess caused by Salmonella enterica bacteremia: A case report.

Introduction and importanceIliopsoas abscesses (IPA) are rare and typically present with a non-specific triad of fever, back pain, and antalgic gait. Staphylococcus aureus is the organism responsible for nearly 90 % of IPA cases. We present a case of primary IPA with progression to osteomyelitis and discitis due to Salmonella enterica bacteremia, an exceedingly rare etiology occurring in an otherwise healthy individual.Case presentationThis patient presented with fever, back pain, and hip pain. Initial imaging and laboratory workup did not reveal any source of infection. He became septic within 72 h of admission, and blood cultures were confirmed as Salmonella enterica. However, the etiology of the infection remained unclear. Computed Tomography (CT) imaging revealed a right-sided psoas abscess measuring 7 mm × 7 mm and an epidural phlegmon. He was discharged home with intravenous ceftriaxone and levofloxacin. However, the patient was readmitted due to L2-L3 osteomyelitis and discitis with an eccentric disc bulge causing compression of the right L3 nerve root and neutropenia.Clinical discussionThis case in unique in the fact that this occurred in a healthy patient with no significant risk factors or exposure to this bacteria. Additionally, this case highlights the rapid progression of IPA and the spread to adjacent spinal structures with the potential to cause nerve compression with successful medical management.ConclusionSalmonella enterica is rare cause of iliopsoas abscess. This case emphasizes the importance of including iliopsoas abscesses as a differential diagnosis in patients with a high index of clinical suspicion.

Population pharmacokinetics and dose optimization of intravenous levofloxacin in hospitalized adult patients

Although levofloxacin has been used for the last 25 years, there are limited pharmacokinetic data to guide levofloxacin dosing in adult patients. This study aimed to develop a population pharmacokinetic model of levofloxacin for adult hospitalized patients and define dosing regimens that attain pharmacokinetic/pharmacodynamic target associated with maximum effectiveness. Blood samples were drawn from 26 patients during one dosing interval. Population pharmacokinetic modelling and dosign simulations were performed using Pmetrics®. Pathogen minimum inhibition concentration (MIC) distribution data from the European Committee on Antimicrobial Susceptibility Testing database was used to analyse fractional target attainment (FTA). A two-compartment model adequately described the data. The final model included estimated glomerular filtration rate (eGFR) to describe clearance. The population estimate for clearance was 1.12 L/h, while the volume of distribution in the central compartment and peripheral compartments were 27.6 L and 28.2 L, respectively. Our simulation demonstrated that an area under free concentration–time curve to MIC ≥ 80 was hardly achieved for pathogens with MIC ≥ 1 mg/L. Low FTA against Pseudomonas aeruginosa and Streptococcus pneumoniae were observed for patients with higher eGFR (≥ 80 mL/min/1.73m2). A daily levofloxacin dose of 1000 mg is suggested to maximise the likelihood of efficacy for adult patients.

Measuring the QT/QTc Interval in the Presence of Wide QRS Complexes

Scenario: The electrocardiographic (ECG) rhythm strip below (leads V1 and II) is from a 68-year-old woman with pneumonia who was admitted to the step-down unit from a long-term care facility. Vital signs upon arrival included blood pressure, 107/61 mm Hg; body temperature, 98.9 °F (37.2 °C); heart rate, 68/min; respiratory rate, 21/min; and oxygen saturation (SpO2), 96% on 4 L of oxygen. The attending physician ordered intravenous levofloxacin based on culture of a blood sample collected in the emergency department. Per unit policy, because intravenous levofloxacin is known to prolong the QT/QTc, the nurse must measure and document the QT/QTc before starting the medication in order to determine whether QT/QTc prolongation occurs after administration. How should the QT/QTc be measured in this patient?Sinus rhythm, right bundle branch block (RBBB), possible prior anteroseptal myocardial infarction (MI), and old inferior wall MI.When measuring the QT/QTc in a patient with BBB (RBBB, in this case), because ventricular depolarization is delayed (ie, left to right ventricle), the QT/QTc is prolonged (compare “normal QRS” above). Therefore, the QT/QTc measured in patients with BBB (right or left) has to be adjusted to avoid overestimation. The Bogossian method can be used in patients with BBB, where the modified QT (QTM) is calculated using QT – (QRS/2).1 The QTM is then used to calculate the QTc to account for heart rate using the Bazett formula, or QTM/RR. In this example, QT/QTc would be calculated as follows: QTM = 440 – (160/2) = 360 milliseconds, and RR is 800 milliseconds or 0.8 seconds, so QTc=0.36/0.8=0.402 seconds or 402 milliseconds, which is within the normal range. In comparison, whereas the QT interval is within normal range without using the Bogossian formula, when corrected for heart rate the QTc was prolonged (ie, QTc without Bogossian correction = 0.44/0.8 = 0.492 seconds = 492 milliseconds); hence, adjusting QTc to account for the RBBB in this patient was important.In patients with RBBB, while conduction down the right bundle branch is “blocked,” an initial r wave should be present in lead V1, resulting in the classic rsR’ pattern associated with RBBB (see normal QRS above). However, in patients with a prior septal wall MI, the initial r wave will not be present because depolarization is disrupted in this myocardial region, as is seen in this example. Acute ischemia may be present when examining lead V1 because one would expect the ST segment to be sloping downward and not to be isoelectric with the PR interval. A Q wave is also seen in lead II, which is ~40 milliseconds, suggesting that this patient may also have a prior inferior wall MI, although this feature may be associated with the RBBB.Based on the QT/QTc calculated using the Bogossian correction and Bazett formulas, the antibiotic can be administered to this patient safely. However, QT/QTc should be measured every 8 to 12 hours as it can become prolonged after antibiotic administration. Because of the ECG waveform changes suggestive of prior septal and inferior wall MI and possible acute ischemia, a 12-lead ECG should be obtained to rule out these conditions. In this patient, prior inferior wall (abnormal Q wave in leads III and aVF) and septal wall (missing r wave in lead V2) MI was confirmed. The 12-lead ECG also showed possible acute myocardial ischemia in the other precordial leads; hence, a cardiac workup (ie, cardiac troponin blood test, serial ECGs, and echocardiogram) was ordered. The QT/QTc measured in lead V1 of the 12-lead ECG did not differ from the above measurement. Careful continuous ECG monitoring for ventricular arrhythmias (ie, torsades de pointes, ventricular tachycardia/fibrillation) is paramount in this patient because of the possibility of QT/QTc prolongation and ECG changes suggestive of acute ischemia. Ultimately, this patient was treated for both pneumonia and myocardial ischemia. She did not have QT/QTc prolongation or ventricular arrhythmias and was discharged back to the long-term care facility.

Clinical use of antiviral, antibiotic and immunomodulatory drugs in hospitalized COVID-19 patients: a retrospective study in Bandung, Indonesia

Background: Evidence of highly effective repurposed drugs for coronavirus disease 2019 (COVID-19) is insufficient. However, empirical therapy using antiviral, antibiotic and immunomodulatory drugs is massive. Studies evaluating the clinical use of these drugs in Indonesia are sparse. Methods: We performed a retrospective study using medical records of hospitalized COVID-19 patients from July 2020 to March 2021 in Bandung, Indonesia. Data were collected at relevant timelines: age, sex, comorbid condition, peripheral oxygen saturation (SpO2), and hematology at admission; antiviral, antibiotic, and immunomodulator treatment during hospitalization; length of stay hospitalization (LOS) and death at discharge. Clinical use of the drug regimens included dose, frequency, and duration of therapy. The main outcome of hospitalization care was LOS and death. Results: Out of 249 patients, 43.3% had a comorbid condition, 74.7% had non-severe COVID-19 (SpO2 ≥ 90%), and almost all received antiviral or antibiotic agents. Remdesivir was the most frequent drug composing various antiviral regimens. Patients receiving a combination of remdesivir and favipiravir had lower SpO2 compared to those receiving oseltamivir (p=0.01). The short LOS was associated with remdesivir alone (p=0.03), the combination of favipiravir and oseltamivir (p=0.01), and the combination of intravenous levofloxacin and ceftriaxone (p<0.0001). Immunomodulatory drugs (methylprednisolone, dexamethasone, tocilizumab) were used in 47.1% of patients with low SpO2 (p=0.001). Its use was associated with prolonged LOS (p=0.0043). The increased risk of death in patients treated with the combination of remdesivir and favipiravir (OR 4.1;95%CI 1.4-12.2), and immunomodulatory drugs (OR 6.2; 95%CI 1.7-23.3) was confounded by the baseline characteristics of older age, comorbid condition, SpO2 level, and low lymphocyte number. Conclusions: Some treatment regimens were associated with short LOS, but there were drug regimens which might increase the risk of death. Further study should control the clinical conditions of COVID-19 patients at admission to confirm the outcome of death following drug therapy.

ONE STEP AWAY FROM ANOTHER HOSPITAL OUTBREAK: TALE OF ELIZABETHKINGIA MENINGOSEPTICA

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Elizabethkingia meningoseptica is a gram-negative nonmotile, oxidase-positive bacillus mainly found in water and soil and in hospitals and has been linked to nosocomial infections and neonatal meningitis [1]. However, immunocompromised adults are also at risk of systemic infections. Given its resistance to carbapenems and growing number of reported nosocomial infections with E. meningoseptica, it is critical to have suspicion for this organism when considering nosocomial infections in deteriorating patients on conventional empiric antibiotic therapy. CASE PRESENTATION: A 34 year-old female with rheumatoid arthritis on hydroxychloroquine, and immune thrombocytopenic purpura with prior splenectomy, prior septic shock due to pneumonia with streptococcus mitis and streptococcus oralis presented to the emergency department with 12 hours of fever, myalgia and fatigue. She was febrile to 102.6 F, tachycardic to 165 with leukocytosis to 21, normal urine analysis and chest x-ray, and a negative Covid-19 and influenza test. Blood cultures were collected and she was started on vancomycin and cefepime for empiric coverage. Blood cultures grew a gram negative organism. Computed tomography of the abdomen showed signs of enteritis. Infectious disease team discontinued vancomycin and cefepime was continued while awaiting speciation and susceptibilities. However, the patient continued to have intermittent fever with leukocytosis. Elizabethkingia meningioseptica was isolated from her blood with resistance to meropenem and cefepime. Intravenous Levofloxacin was started and sulfamethoxazole/trimethoprim was added to her regimen. Her repeat blood cultures remained negative. She was discharged on IV levaquin and oral sulfamethoxazole/trimethoprim with close follow up in infectious disease clinic. DISCUSSION: E. meningoseptica is a gram-negative nonmotile, oxidase-positive bacillus mainly found in water and soil [2] In hospital settings, saline, lipid and chlorhexidine gluconate solutions have been identified as sources of infection [3]. In adults, nosocomial infections in susceptible patients such as those with malignancy, on steroid therapy, diabetics, neutropenic patients, and organ transplant patients, account for the majority of the cases [2].Currently there are uncertainties regarding the best course of treatment, susceptibility testing methods and minimal inhibitory concentration (MIC) breakpoints. However, vancomycin, fluoroquinolones, and minocycline have been used as the mainstay of treatment. CONCLUSIONS: As the reported number of nosocomial infections with E. meningoseptica increases, the inherent multi-drug resistance nature of this gram negative organism to common antibiotics used for empiric gram negative coverage, mandates raising awareness regarding potential outbreaks in hospital settings. REFERENCE #1: Gungor S., Ozen M., Akinci A., Durmaz R. A Chryseobacterium meningosepticum outbreak in a neonatal ward. Infect Control Hosp Epidemiol. 2003;24(8):613–617. [PubMed] [Google Scholar] [Ref list] REFERENCE #2: Shinha, Takashi, and Rakesh Ahuja. "Bacteremia due to Elizabethkingia meningoseptica." IDCases vol. 2,1 13-5. 17 Jan. 2015, doi:10.1016/j.idcr.2015.01.002 REFERENCE #3: S.S. Jean, W.S. Lee, F.L. Chen, T.Y. Ou, P.R. Hsueh, Elizabethkingia meningoseptica: an important emerging pathogen causing healthcare-associated infections, Journal of Hospital Infection, Volume 86, Issue 4,2014, Pages 244-249, ISSN 0195-6701, DISCLOSURES: No relevant relationships by Nami Moradi, source=Web Response No relevant relationships by Paloma Rivero Moragrega, source=Web Response

FENTANYL-INDUCED PERSISTENT ENCEPHALOPATHY

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Fentanyl is a synthetic opioid routinely used for sedation and analgesia in the intensive care unit (ICU). Though typically safe when used vigilantly for ICU-level care, it can sometimes cause serious adverse effects such as acute encephalopathy that usually improve with supportive care. We present a rare case of persistent encephalopathy caused by fentanyl. CASE PRESENTATION: An 85-year-old functionally independent woman with a history of chronic obstructive pulmonary disease (COPD) on 2 L oxygen, hypertension, and hypothyroidism presented with shortness of breath and dry cough for four days. She was intubated and mechanically ventilated for worsening respiratory distress and hypercapnia. She required deep sedation with maximum doses of fentanyl infusion 200 mcg/hr and propofol infusion 60 mcg/kg/min, and vasopressor support with norepinephrine for two days to maintain her blood pressure. Sputum cultures grew Haemophilus influenza. She was treated with 7 days of intravenous levofloxacin for tracheobronchitis and COPD exacerbation. She also received intravenous methylprednisolone and breathing treatments. Her respiratory status gradually improved and she was weaned down to minimal ventilator FiO2 and PEEP and sedation in five days, but she stayed unresponsive. Seven days off sedation, she had a partial return of consciousness but had altered mentation, quadriplegia, and absence of reflexes bilaterally. She showed minimal response to painful stimuli in all limbs. CT and MRI of the head and C-spine showed no acute pathology. Cerebrospinal fluid analysis and cultures ruled out infectious (including viral, bacterial, and fungal) etiologies. 12-hour EEG was consistent with metabolic encephalopathy. After multidisciplinary evaluation, her encephalopathy was attributed to fentanyl. Patient was eventually extubated after 16 days. One month later, she had mild improvement of neurological status with orientation only to person. She was able to slightly squeeze examiner's fingers in both hands, and foot plantar and dorsiflexion was 4/5 bilaterally with the rest of motor strength 0/5 in all extremities. She was discharged to a nursing home with unchanged neurological status. DISCUSSION: Fentanyl has a rapid onset and short duration of action making it sedation of choice in ICU. Acute encephalopathy is infrequently associated with other synthetic opioids like oxycodone and methadone [1,2]. Fentanyl uncommonly causes delayed hypoxic leukoencephalopathy which develops few days to weeks after exposure [3]. Acute persistent encephalopathy from fentanyl is rare and can lead to significant functional impairment. CONCLUSIONS: It is important for clinicians to be aware of persistent encephalopathy caused by fentanyl. Sedation should be used with caution especially in elderly patients. Intermittent pushes or shorter duration of use may prevent this rare complication. REFERENCE #1: Morales Odia Y, Jinka M, Ziai WC. Severe leukoencephalopathy following acute oxycodone intoxication. Neurocrit Care. 2010;13(1):93-97. REFERENCE #2: Haghighi-Morad M, Naseri Z, Jamshidi N, Hassanian-Moghaddam H, Zamani N, Ahmad-Molaei L. Methadone-induced encephalopathy: a case series and literature review. BMC Med Imaging. 2020;20(1):6. REFERENCE #3: Kim J, Hyung SW, Seo J, Lee H, Yu HJ, Sunwoo MK. Delayed post-hypoxic leukoencephalopathy caused by fentanyl intoxication in a healthy woman. Dement Neurocognitive Disord. 2020;19(4):170-172. DISCLOSURES: No relevant relationships by Qasim Jehangir, source=Web Response No relevant relationships by Yi Lee, source=Web Response No relevant relationships by Ali Najar, source=Web Response No relevant relationships by Jonathan Toot, source=Web Response

A Rare Cause of Severe Hypoglycaemia

A 67-year old woman presented with an unwitnessed fall and decreased oral intake. She had a learning disability, hypertension, epilepsy, asthma, chronic iron deficiency anaemia, mild lymphopenia, osteoporosis and treated uterine cancer. After clinical review, she was treated for Hospital-acquired pneumonia (following a recent hospital admission) with possible aspiration. She was noted to have hyponatraemia secondary to dehydration. She was commenced on intravenous Levofloxacin and Metronidazole along with supportive care, based on antibiotic guidance due to her known allergy to penicillin.On day 3 of admission, she was found unresponsive with a capillary blood glucose of 0.6 mmol/L, which improved with 10% glucose infusion. The low blood glucose was attributed to poor oral intake. However, her serial blood sugar results demonstrated persistent hypoglycaemia for 72h needing further intravenous glucose infusions. A medication review was undertaken and Levofloxacin was discontinued. After 24hrs of discontinuation, the hypoglycaemic episode resolved. A short synacthen test showed a normal cortisol response. There were no further episodes of hypoglycaemia. Conclusion As her persistent hypoglycaemia resolved on discontinuation of Levofloxacin, a diagnosis of fluoroquinolone induced hypoglycaemia was reported to MHRA. Fluoroquinolones are thought to induce hypoglycaemia by increasing the insulin release via blockade of adenosine triphosphate-sensitive K+channels in the β cells of the pancreas. This effect may not be clinically evident in all patients because of physiologic mechanisms that regulate blood glucose levels. Health professionals should be aware of the potential risk of severe hypoglycaemia with the use of Fluoroquinolones which are a first or second-line treatment for common infective processes. Fluoroquinolones should be stopped immediately and switch to a non-Fluoroquinolones antibiotic if possible. In elderly patients with compromised oral intake or in those with other comorbidities, regular blood glucose monitoring should be carried out to avoid life-threatening hypoglycaemic episodes.

Effect of ciprofloxacin vs levofloxacin on QTc-interval and dysglycemia in diabetic and non-diabetic patients.

Levofloxacin and ciprofloxacin are more commonly used amongst fluoroquinolone class and the question of cardiac safety and glucose hemostasis of this class has been raised. To compare intravenous levofloxacin and ciprofloxacin regarding their risk on QTc prolongation and dysglycemia in diabetic and non-diabetic patients. A randomised prospective study at Beni-Suef university hospital was conducted on 200 adult patients over 6months. The patients received intravenous levofloxacin 750mg once daily or ciprofloxacin 400mg twice daily. Electrocardiogram and fasting blood glucose were obtained from each patient before starting the antibiotic, 24hours, 72hours after the first dose, and 72hours after antibiotics cessation. The results of the current study showed the relative risk for QTc prolongation with levofloxacin was more than ciprofloxacin by about 4 and 1.5 times in diabetic and non-diabetic patients, respectively. The relative risk for dysglycemia with levofloxacin was 2.28 and 1.39 times more than ciprofloxacin in diabetic and non-diabetic patients, respectively. The present study showed that the risk for QTc prolongation and hyperglycemia was greater with levofloxacin than ciprofloxacin in diabetic and non-diabetic patients. In addition, the risk for hypoglycemia was greater with levofloxacin than ciprofloxacin in non-diabetic patients.

Effect of Oral Moxifloxacin vs Intravenous Ertapenem Plus Oral Levofloxacin for Treatment of Uncomplicated Acute Appendicitis

Antibiotics are an effective and safe alternative to appendectomy for managing uncomplicated acute appendicitis, but the optimal antibiotic regimen is not known. To compare oral antibiotics with combined intravenous followed by oral antibiotics in the management of computed tomography-confirmed uncomplicated acute appendicitis. The Appendicitis Acuta (APPAC) II multicenter, open-label, noninferiority randomized clinical trial was conducted from April 2017 until November 2018 in 9 Finnish hospitals. A total of 599 patients aged 18 to 60 years with computed tomography-confirmed uncomplicated acute appendicitis were enrolled in the trial. The last date of follow-up was November 29, 2019. Patients randomized to receive oral monotherapy (n = 295) received oral moxifloxacin (400 mg/d) for 7 days. Patients randomized to receive intravenous antibiotics followed by oral antibiotics (n = 288) received intravenous ertapenem (1 g/d) for 2 days followed by oral levofloxacin (500 mg/d) and metronidazole (500 mg 3 times/d) for 5 days. The primary end point was treatment success (≥65%) for both groups, defined as discharge from hospital without surgery and no recurrent appendicitis during 1-year follow-up, and to determine whether oral antibiotics alone were noninferior to intravenous and oral antibiotics, with a margin of 6% for difference. Among 599 patients who were randomized (mean [SD] age, 36 [12] years; 263 [44%] women), 581 (99.7%) were available for the 1-year follow-up. The treatment success rate at 1 year was 70.2% (1-sided 95% CI, 65.8% to ∞) for patients treated with oral antibiotics and 73.8% (1-sided 95% CI, 69.5% to ∞) for patients treated with intravenous followed by oral antibiotics. The difference was -3.6% ([1-sided 95% CI, -9.7% to ∞]; P = .26 for noninferiority), with the confidence limit exceeding the noninferiority margin. Among adults with uncomplicated acute appendicitis, treatment with 7 days of oral moxifloxacin compared with 2 days of intravenous ertapenem followed by 5 days of levofloxacin and metronidazole resulted in treatment success rates greater than 65% in both groups, but failed to demonstrate noninferiority for treatment success of oral antibiotics compared with intravenous followed by oral antibiotics. ClinicalTrials.gov Identifier: NCT03236961; EudraCT Identifier: 2015-003633-10.

Dual-route-administration versus single-route-administration of polymyxin B in VAP caused by MDR Klebsiella pneumoniae: An observational study

Background: Ventilator-associated pneumonia (VAP) in critically ill patients of intensive care units (ICUs) is associated with high rate of mortality and morbidity, and VAP caused by multidrug-resistant (MDR) gram-negative bacteria (GNB) such as, Klebsiella pneumoniae (KP) is a life threatening infectious event. In MDR KP-associated VAP (MDR-KP-VAP) infections, KP is generally found only sensitive to few last-line potential antibiotics including polymyxin B. Intravenous polymyxin B in MDR-KP-VAP treatment is practiced worldwide but, nebulized polymyxin B is a direct-to-infection site therapy. The objective of this study was to evaluate the clinical outcomes of dual-route (intravenous and nebulization) administration of polymyxin B versus single-route (intravenous) administration in MDR-KP-VAP treatment. Methods and materials: This observational study was conducted on 121 mechanically ventilated patients with MDR-KP-VAP infection where KP was resistant to penicillins, cephalosporins, aminoglycosides and fluoroquinolones but, only sensitive to polymyxin B. Polymyxin B intravenously and nebulization was administered to 64 patients in one group (PIVNL group) whereas 57 patients of another group (PIV group) found only intravenous polymyxin B for MDR-KP-VAP treatment. Intravenous levofloxacin was coexisted with polymyxin B therapies in both groups’ patients. Group-wise therapeutic outcomes were compared prospectively. Results: The microbiological eradication rate was higher (92.1%, n = 64) in PIVNL group than the PIV group (70.1%, n = 57) (p value = 0.002). PIV group showed higher secondary bacterial infection rate (19.2%, n = 57) than PIVNL group (6.2%, n = 64) (p value = 0.030), and 30-day mortality rate was also found higher in PIV group patients (15.7%, n = 57) than PIVNL group (7.8%, n = 64) (p value = 0.171). In terms of adverse drug reaction (ADR), polymyxin B-induced bronchospasm events were found (4, 6.2%, n = 64) in PIVNL group whereas nil in PIV group, and nephrotoxicity events were similarly happened in PIVNL (3, 4.6%, n = 64) and PIV group (3, 5.2%, n = 57). Conclusion: The emergence of MDR gram-negative bacterial infections in mechanically ventilated patients is an appalling issue worldwide and to treat with few last-line antibiotics is a do-or-die challenge at this moment. In this study, simultaneous intravenous administration of polymyxin B with its nebulization in MDR-KP-associated VAP patients exhibited better clinical success than with intravenous polymyxin B alone.

<i>Legionella </i>Causing Lung Abscess in an Immunocompetent Patient

Legionella lung abscess (LLA) is known to develop from pneumonia and Legionnaires’ disease in immunocompromised patients and aspiration. Literature review showed reports of aspiration pneumonia in immunocompetent patients; however, no such was found between LLA and immunocompetency. A 53-year-old male with history of depression and paraumbilical hernia presented for chest pain, which was right sided, started acutely, constant, radiated to the back, and exaggerated with taking deep breaths. The patient denied all other symptoms. Social history was only pertinent for being an active 35 pack-year smoker. The patient was recently admitted one month ago for viral meningitis from Echovirus. On physical exam, the patient was vitally stable, had absent breath sounds in the right middle lobe, and was significantly tender at the right anterior chest. Labs revealed elevated sedimentation rate and C-reactive protein. Imaging demonstrated a right middle lobe lung abscess. Throughout the hospital course, Legionella pneumophila serogroup 1 (LPS1) was found to be positive on urine antigen, sputum polymerase chain reaction, and sputum cultures. The patient was switched to intravenous levofloxacin and ampicillin-sulbactam. Upon symptomatic resolution, the patient was discharged home with recommendations for a follow-up chest computed tomography and diagnostic bronchoscopy. We hypothesize that smoking causes neutrophilic stasis within the lung and the development of the LLA. Treatment includes intravenous long term antibiotics and possibly drainage.