Mechanism of cephalosporin-induced hypoprothrombinemia: relation to cephalosporin side chain, vitamin K metabolism, and vitamin K status

A Case of Significant Coagulopathy Due to Vitamin K Deficiency Caused by the Administration of Cefazolin and Rifampicin and Hyponutrition After a Postoperative Infection of the Lumbar Spine

Postoperative surgical site infection in the lumbar spine is one of the serious complications that sometimes results in death. Herein, we describe a case in which a patient was found to have coagulopathy due to vitamin K deficiency when he was transferred to a hospital for treatment for a postoperative infection of the lumbar spine. The coagulation disorder was caused by antimicrobial agents administered to the patient, who was suffering from hyponutrition. The patient was a 70-year-old man with a history of diabetes mellitus. He was diagnosed with lumbar spinal canal stenosis and underwent posterior decompression of the L2-L5 and S1 laminae at a previous hospital five months before transfer to our hospital. Four months before transfer, purulent discharge was observed from the wound, and methicillin-susceptible Staphylococcus aureus was detected in the wound culture. Cefazolin was administered for two weeks, resulting in initial improvement. However, one month before the transfer, the wound infection recurred, accompanied by bacteremia and a psoas abscess. He had been treated with cefazolin, levofloxacin, rifampicin, trimethoprim, and sulfamethoxazole, but the antibiotics' effects were insufficient. Upon transfer for debridement surgery due to uncontrolled infection, his coagulation parameters were as follows: prothrombin time (PT) 74.0 sec, PT-international normalized ratio (INR) 6.69, PT% 9.0, activated partial thromboplastin time (APTT) 138 sec, fibrinogen (FIB) 664 mg/dl, fibrin degradation products (FDP) 7.1 μg/ml, and protein induced by vitamin K absence-II (PIVKA-II) 34400 mAU/ml. Because we suspected vitamin K deficiency, vitamin K 40 mg was administered as a test dose, and coagulation function improved to PT 16.4 sec, PT-INR 1.30, PT% 65.2, and APTT 79 sec after four hours. The diagnosis of vitamin K deficiency was confirmed, vitamin K was administered for four days, and the coagulation status normalized five days after transfer. Debridement was performed for the left psoas abscess. Cefazolin was administered for eight weeks, and administration was completed. The coagulation abnormality did not recur due to careful attention to his nutrition. We experienced a case of coagulopathy due to vitamin K deficiency caused by antimicrobial agents administered to a hyponourished patient with a postoperative infection of the lumbar spine. The cause of vitamin K deficiency, in this case, was thought to be low nutrition, suppression of vitamin K-producing bacteria by cefazolin and rifampicin, and the use of cefazolin with a methyl-thiadiazole thiol group. It should be kept in mind that severe coagulopathy due to vitamin K deficiency caused by antimicrobial treatment with hyponutrition can occur in postoperative infections.

Vitamin K for Vascular Calcification in Kidney Patients: Still Alive and Kicking, but Still a Lot to Learn

Patients with chronic kidney disease (CKD) suffer disproportionately from a high burden of cardiovascular disease, which, despite recent scientific advances, remains partly understood. Vascular calcification (VC) is the result of an ongoing process of misplaced calcium in the inner and medial layers of the arteries, which has emerged as a critical contributor to cardiovascular events in CKD. Beyond its established role in blood clotting and bone health, vitamin K appears crucial in regulating VC via vitamin K-dependent proteins (VKDPs). Among these, the matrix Gla protein (MGP) serves as both a potent inhibitor of VC and a valuable biomarker (in its inactive form) for reflecting circulating vitamin K levels. CKD patients, especially in advanced stages, often present with vitamin K deficiency due to dietary restrictions, medications, and impaired intestinal absorption in the uremic environment. Epidemiological studies confirm a strong association between vitamin K levels, inactive MGP, and increased CVD risk across CKD stages. Based on the promising results of pre-clinical data, an increasing number of clinical trials have investigated the potential benefits of vitamin K supplementation to prevent, delay, or even reverse VC, but the results have remained inconsistent.

Serum trough concentration threshold and risk factors of cefoperazone-induced coagulopathy in critically ill patients: A retrospective case-control study

PURPOSE

To analyze the risk factors influencing the development of cefoperazone-induced coagulopathy in critically ill patients and determine the threshold of serum trough concentration.

METHODS

A retrospective case-control study was conducted in the intensive care unit patients treated with cefoperazone, and it was approved by the Ethical Committee of Drum Tower Hospital affiliated with the Medical School of Nanjing University (NO.2023-158-01). Patients were divided into the normal group and coagulopathy group based on prothrombin time. The clinical characteristics of the two groups were compared using univariate analysis. The serum concentration threshold and influencing factors of cefoperazone-induced coagulopathy in critically ill patients were analyzed using the receiver operating characteristic curve and multivariate logistic regression analysis.

RESULTS

A total of 113 patients were included, and cefoperazone-induced coagulopathy occurred in 39 patients, with an incidence of 34.5%. These patients experienced significant prothrombin time prolongation around day 6 (median) after cefoperazone application. The serum trough concentration threshold of cefoperazone-induced coagulopathy in critically ill patients was 87.765 mg/l. Multivariate logistic regression analysis revealed that the APACHE II score (p = 0.034), prophylactic use of vitamin K1 (p < 0.001), hepatic impairment (p = 0.014), and Cmin ≥ 87.765 mg/l (p = 0.005) were associated with cefoperazone-induced coagulopathy.

CONCLUSION

Cefoperazone-induced coagulopathy usually occurs on the 6th day of cefoperazone use in critically ill patients. The risk will increase in patients with an APACHE II score > 25, hepatic impairment, and cefoperazone Cmin ≥ 87.765 mg/l. Vitamin K1 is effective in preventing this adverse reaction.

Prospective assessment of the frequency of and risk factors for bleeding events in patients treated with cefazolin

PURPOSE

Major bleedings have been described with cefazolin. The objective was to determine the frequency of bleeding events in cefazolin-treated patients and to identify risk factors for these complications.

METHODS

Monocenter prospective observational study of all consecutive cefazolin-treated patients. Patients benefited from a daily clinical assessment of bleedings and a twice-a-week blood sampling including hemostasis. Bleedings were classified according to the International Society on Thrombosis and Hemostasis classification: major, clinically relevant non-major bleedings (CRNMB) and minor bleedings.

RESULTS

From September 2019 to July 2020, 120 patients were included, with a mean age of 59.4 (± 20.7) years; 70% of them (84/120) were men. At least 1 CRNMB or major bleeding were observed in 10% of the patients (12/120). Compared to patients with no or minor bleeding, patients with CRNMB or major bleeding were, upon start of cefazolin, more frequently hospitalized in an intensive care unit (7/12, 58.3%, vs. 12/108, 11.1%, P < 0.001, respectively) and receiving vitamin K antagonists (4/12, 33.3%, vs. 8/108, 7.4%, P = 0.019, respectively). After multivariate analysis, patients receiving vitamin K antagonists the day prior bleeding and/or treated for endocarditis were factors associated with an increased risk of CRNMB or major bleeding (odd ratio 1.36, confidence interval 95%, 1.06-1.76, P = 0.020 and 1.30, 1.06-1.61, P = 0.015, respectively).

CONCLUSIONS

Bleeding events associated with cefazolin treatment are frequent. Close clinical monitoring should be performed for patients treated for endocarditis and/or receiving vitamin K antagonists. Hemostasis work-up could be restricted to these patients.

Cefazolin-Associated INR Elevation: A Case Report

Purpose: To describe a case of significantly elevated international normalized ratio (INR) in a patient on apixaban receiving treatment with intravenous cefazolin in the setting of coronavirus disease 2019 (COVID-19) infection and malnutrition. Summary: A 74-year-old male patient on apixaban receiving cefazolin for osteomyelitis in the setting of COVID-19 and poor nutritional intake presented with internal jugular tunneled catheter site bleeding and an INR of greater than 22.5. Laboratory abnormalities and bleeding concerns were successfully managed with vitamin K and changing antimicrobial therapy from cefazolin to daptomycin. Follow-up labs one week later demonstrated a sustained improvement in coagulopathy. Conclusion: INR prolongation believed to be secondary to cefazolin can be effectively managed with administration of vitamin K and conversion of antimicrobial therapy to an alternative agent.

Development and validation of a nomogram for predicting cefoperazone/sulbactam-induced hypoprothrombinaemia in Hospitalized adult patients

Cefoperazone/sulbactam-induced hypoprothrombinaemia is associated with longer hospital stays and increased risk of death. The aim of this study was to develop and validate a nomogram for predicting the occurrence of cefoperazone/sulbactam-induced hypoprothrombinaemia in hospitalized adult patients. This retrospective cohort study involved hospitalized adult patients at Xi'an Central Hospital from January 2020 to December 2022 based on the Chinese pharmacovigilance system developed and established by the Adverse Drug Reaction Monitoring Center in China. Independent predictors of cefoperazone/sulbactam-induced hypoprothrombinaemia were obtained using multivariate logistic regression and were used to develop and establish the nomogram. According to the same standard, the clinical data of hospitalized patients using cefoperazone/sulbactam at the Third Affiliated Hospital of Xi'an Medical University from January 1, 2023 to June 30, 2023 were collected as the external validation group. The 893 hospitalized patients included 95 who were diagnosed with cefoperazone/sulbactam-induced hypoprothrombinaemia. Our study enrolled 610 patients: 427 in the training group and 183 in the internal validation group. The independent predictors of cefoperazone/sulbactam-induced hypoprothrombinaemia were surgery (odds ratio [OR] = 5.279, 95% confidence interval [CI] = 2.597-10.729), baseline platelet count ≤50×109/L (OR = 2.492, 95% CI = 1.110-5.593), baseline hepatic dysfunction (OR = 12.362, 95% CI = 3.277-46.635), cumulative defined daily doses (OR = 1.162, 95% CI = 1.162-1.221) and nutritional risk (OR = 16.973, 95% CI = 7.339-39.254). The areas under the curve (AUC) of the receiver operating characteristic for the training and internal validation groups were 0.909 (95% CI = 0.875-0.943) and 0.888 (95% CI = 0.832-0.944), respectively. The Hosmer-Lemeshow tests yielded p = 0.475 and p = 0.742 for the training and internal validation groups, respectively, confirming the goodness of fit of the nomogram model. In the external validation group (n = 221), the nomogram was equally robust in cefoperazone/sulbactam-induced hypoprothrombinaemia (AUC = 0.837, 95%CI = 0.736-0.938). The nomogram model constructed in this study had good predictive performance and extrapolation, which can help clinicians to identify patients at high risk of cefoperazone/sulbactam-induced hypoprothrombinaemia early. This will be useful in preventing the occurrence of cefoperazone/sulbactam-induced hypoprothrombinaemia and allowing timely intervention measures to be performed.

Infective Endocarditis Complicated by Iatrogenic Intracranial Hemorrhage Secondary to Cefazolin-Induced Coagulopathy

Infective endocarditis can be acute or subacute. It can be caused by viral, bacterial, fungal, and sometimes nonbacterial etiologies. It is an important cause of mortality and morbidity in children as well as adolescents, despite advances in management. A 59-year-old male with a past medical history of aortic valve (AV) replacement on warfarin presented to the Emergency Department with dull right flank pain and poor dentition on examination. Computerized tomography (CT) scans of the abdomen revealed the presence of splenic and renal infarcts. Warfarin was held after the international normalized ratio (INR) was noted to be elevated at 11. Following the activation of the sepsis bundle in the ER, he received intravenous fluids (30 cc/kg) and was started on vancomycin and ceftriaxone. On further evaluation, the transesophageal echocardiogram revealed mobile densities on the aortic surface concerning vegetation. Antibiotics were transitioned to cefazolin, gentamycin, and rifampin for the management of prosthetic valve endocarditis. The patient's INR improved to 3.5 on the third day of hospitalization, and heparin was initiated to maintain anticoagulation for the prosthetic valve. However, on the eighth day of hospitalization, the patient developed left-sided weakness and slurred speech. The CT head showed acute frontoparietal intracranial hemorrhage (ICH), with an INR noted to be 5. Heparin was reversed with protamine sulfate, and vitamin K was administered, following which the INR improved to 2.3. The patient was transferred to intensive care, but on the second day of the ICU stay, the INR again shot up to 6 with normal LFTS. The patient received vitamin K, but the INR only improved to 5. Subsequently, antibiotics were changed from cefazolin to nafcillin. INR thus fell to 1.6 in two days after changing the antibiotics. The patient was soon transferred to a higher center for aortic valve replacement. While few case reports have described severe coagulopathy induced by cefazolin, it is particularly seen with impaired renal function; however, our patient's renal function was completely normal. Coagulopathy is due to the drug's effect on intestinal flora and its structural methyl-thiadiazole side chain, which has similar effects as epoxide reductase inhibitors and results in INR elevation. Patients on cefazolin need to be closely monitored for INR levels every day, as there is a high likelihood of developing complications like ICH, as noted in this patient. While the monitoring of cefazolin levels is not necessarily indicated, it is necessary to place patients on fall precautions and monitor INR levels every day, as mentioned above.

Association of Broad-Spectrum Antibiotic Therapy and Vitamin E Supplementation with Vitamin K Deficiency-Induced Coagulopathy: A Case Report and Narrative Review of the Literature

Vitamin K is a lipid-soluble vitamin that is normally maintained within appropriate levels by means of dietary intake and bacterial production in the intestinal microflora. It holds a central role in coagulation homeostasis, and thus its depletion leads to hypocoagulation and haemorrhagic diathesis. The association of antibiotic therapy and vitamin E supplementation with vitamin K deficiency was previously described in animal experiments, clinical studies, and case reports. Broad-spectrum antibiotic therapy potentially leads to intestinal microflora dysbiosis and restriction of vitamin K-producing bacterial populations, resulting in decreased vitamin K levels, whereas antibiotics of the cephalosporin class with 1-N-methyl-5-thiotetrazole (NMTT) or 2-methyl-1,3,4-thiadiazole (MTD) side groups inhibit vitamin K function. Vitamin E supplementation interferes with both the bioavailability and function of vitamin K, yet its mechanisms are not fully understood. We present the case of a 45-year-old male patient, with a history of epilepsy and schizophrenia, catatonically incapacitated and immobilised, who was hospitalised in our centre for the investigation and management of aspiration pneumonia. He demonstrated a progressively worsening prolongation of international normalised ratio (INR), which was attributed to both broad-spectrum antibiotic therapy and vitamin E supplementation and was reversed upon administration of vitamin K. We highlight the need for close monitoring of coagulation parameters in patients receiving broad-spectrum antibiotic therapy, especially those with underlying malnutritive or malabsorptive conditions, and we further recommend the avoidance of NMTT- or MTD-containing antibiotics or vitamin E supplementation, unless absolutely necessary, in those patients.

Management of rare inherited bleeding disorders: Proposals of the French Reference Centre on Haemophilia and Rare Coagulation Disorders

INTRODUCTION

The rare coagulation disorders may present significant difficulties in diagnosis and management. In addition, considerable inter-individual variation in bleeding phenotype is observed amongst affected individuals, making the bleeding risk difficult to assess in affected individuals. The last international recommendations on rare inherited bleeding disorders (RIBDs) were published by the United Kingdom Haemophilia Centre Doctors' Organisation in 2014. Since then, new drugs have been marketed, news studies on surgery management in patients with RIBD have been published, and new orphan diseases have been described.

AIM

Therefore, the two main objectives of this review, based on the recent recommendations published by the French Reference Centre on Haemophilia and Rare Bleeding Disorders, are: (i) to briefly describe RIBD (clinical presentation and diagnostic work-up) to help physicians in patient screening for the early detection of such disorders; and (ii) to focus on the current management of acute haemorrhages and long term prophylaxis, surgical interventions, and pregnancy/delivery in patients with RIBD.

Vitamin requirements during stem cell transplantation: a systematic review

Patients undergoing stem cell transplantation (SCT) are at high risk of malnutrition during the acute post-transplantation period. This systematic review aimed to collate and analyse the evidence for vitamin requirements post-SCT. A systematic search of five databases was conducted to include studies published until March 2021. The review utilised the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) framework. Inclusion criteria consisted of adults undergoing SCT who received vitamin supplementation or had their vitamin levels monitored up to 100 days post-SCT. Studies with paediatric patients or those that looked at vitamin derivates such as folinic acid were excluded. Main outcomes included vitamin deficiency and relevant clinical outcomes. Eleven studies (n = 11) were eligible for inclusion with five rated as neutral quality and six as positive quality. Five studies focused on allogenic SCT, two on autologous SCT and the remaining included a mix of both. Eight studies monitored vitamins levels post-SCT, and seven studies provided vitamin supplementation. Three studies (one provided supplementation) found a high prevalence of vitamin D deficiency (23-60%) prior to SCT. Findings indicate an unclear association between vitamin deficiency and post-SCT complications including acute graft-versus-host-disease, oral mucositis, and mortality. The GRADE certainty of evidence across these outcomes was low or very low. It is unclear if supplementation is needed during SCT, though assessing vitamin D levels prior to transplant should be considered. Further large observational studies or randomised control trials are required to establish vitamin requirements and guide supplementation protocols during SCT.

Neglected vitamin K deficiency causing coagulation dysfunction in an older patient with pneumonia: a case report

BACKGROUND

The development of coagulation disorders can be dangerous and fatal in the older people, especially those with multiple medical conditions. Vitamin K-dependent coagulation disorders are easily overlooked when anticoagulant drugs are not used and the patient shows no signs of bleeding.

CASE PRESENTATION

We report a case of a 71-year-old male suffering from pulmonary infection with severe coagulation disorder without bleeding symptoms. He also had a history of Parkinson's disease, Alzheimer's disease and cardiac insufficiency. Coagulation tests were normal at the time of admission, prothrombin time (PT) is 13.9 (normal, 9.5-13.1) seconds and the activated partial thromboplastin time (APTT) is 30.2 (normal, 25.1-36.5) seconds. But it turned severely abnormal after 20 days (PT: 136.1 s, APTT: 54.8 s). However, no anticoagulants such as warfarin was used and no bleeding symptoms were observed. Subsequent mixing studies with normal plasma showed a decrease in prothrombin times. Vitamin K deficiency was thought to be the cause of coagulation disorders considering long-term antibiotic therapy, especially cephalosporins, inadequate diet and abnormal liver function. After supplementation with 20 mg of vitamin K, coagulation dysfunction was rescued the next day and serious consequences were effectively prevented.

CONCLUSIONS

Overall, timely vitamin K supplementation with antimicrobials that affect vitamin K metabolism requires clinician attention, especially in older patients who are multimorbid, frail or nutritionally compromised, and are admitted to hospital because of an infection that needs antimicrobial therapy are at risk of clotting disorders due to abnormal vitamin K metabolism secondary to altered gut flora, which can exacerbate existing nutritional deficiencies.

Vitamin K Deficiency in the Setting of Blenderized Tube Feeding Regimen in a Teenager: A Case Report

Vitamin K acts a cofactor for the gamma-carboxylation of several proteins in the coagulation cascade. The clinical spectrum of vitamin K deficiency (VKD) can be asymptomatic to a significant bleeding. VKD is classically seen in newborns. However, this can manifest later in patients with risks such as sub-optimal nutrition, fat malabsorption, medications including antibiotics. A 17-year-old male with spinal muscular atrophy (SMA) Type 1, tracheostomy with ventilator dependent, gastrostomy tube feeding was seen by the gastroenterologist following treatment for small intestinal bacterial overgrowth (SIBO). Investigations showed coagulopathy following which he was transferred to the Pediatric ICU. Labs revealed prothrombin time (PT) 114 s [Normal 9.4-12.5 s], INR (International normalized ratio) 12.6 [Normal < 1.1] and partial thromboplastin time (PTT) 90 s [Normal 25.1-36.5 s]. Mixing studies and coagulation assays were consistent with VKD (low Factor VII and Factor IX with normal Factor V). His home blenderized feeding regimen met the caloric requirement but not the adequate intake (AI) values for vitamin K and other minerals. He received intravenous vitamin K (phytonadione) for five consecutive days with resolution of the coagulopathy (PT 13.2 s, PTT 37.1 s, INR 1.2). The patient was discharged on enteral vitamin K and additional supplements following dietary review by a nutritionist. Clinicians should be cognizant of VKD in patients on blenderized tube feeds which may not meet the adequate intake (AI) goals. In patients who are not receiving nutritionally complete formulas or receiving inadequate volumes, it is important to monitor macro and micronutrients.

The Impact of Vitamin K2 (Menaquionones) in Children's Health and Diseases: A Review of the Literature

Vitamin K2 activates vitamin K-dependent proteins that support many biological functions, such as bone mineralization, the inhibition of vascular stiffness, the improvement of endothelial function, the maintenance of strong teeth, brain development, joint health, and optimal body weight. Due to the transformation of food habits in developed countries over the last five decades, vitamin K and, specifically, vitamin K2 intakes among parents and their offspring have decreased significantly, resulting in serious health implications. The therapeutics used in pediatric practice (antibiotics and glucocorticoids) are also to blame for this situation. Low vitamin K status is much more frequent in newborns, due to both endogenous and exogenous insufficiencies. Just after birth vitamin K stores are low, and since human milk is relatively poor in this nutrient, breast-fed infants are at particular risk of a bleeding disorder called vitamin K deficiency bleeding. A pilot study showed that better vitamin K status is associated with lower rate of low-energy fracture incidence. An ongoing clinical trial is intended to address whether vitamin K2 and D3 supplementation might positively impact the biological process of bone healing. Vitamin K2 as menaquinone-7 (MK-7) has a documented history of safe and effective use. The lack of adverse effects of MK-7 makes it the ideal choice for supplementation by pregnant and nursing women and children, both healthy and suffering from various malabsorptions and health disorders, such as dyslipidemia, diabetes, thalassemia major (TM), cystic fibrosis (CF), inflammatory bowel diseases (IBD), and chronic liver diseases. Additionally, worthy of consideration is the use of vitamin K2 in obesity-related health outcomes.

A Comparison of Coagulation Function in Patients Receiving Aspirin and Cefoperazone-Sulbactam With and Without Vitamin K1: A Retrospective, Observational Study

PURPOSE

The study objective was to explore whether prophylaxis with vitamin K₁ improves abnormal coagulation function-associated cefoperazone-sulbactam in patients treated in the long term with low-dose aspirin.

METHODS

This retrospective, observational study assessed patients treated with long-term low-dose aspirin in a naval military hospital in China from 2004 to 2018, including all patients treated concurrently with cefoperazone-sulbactam with or without vitamin K₁. Differences in the coagulation index were analyzed statistically before and after receipt of cefoperazone-sulbactam.

FINDINGS

The cohort included 227 patients. After cefoperazone-sulbactam treatment, the mean (SD) prothrombin time (PT) was 14.07 (3.07) seconds, activated partial thromboplastin time (aPTT) was 35.15 (4.78) seconds, and international normalized ratio (INR) was 1.49 (0.49) in the cefoperazone-sulbactam group, which was significantly higher than the PT of 11.55 (1.29), aPTT of 31.37 (2.20), and INR of 1.12 (0.35) before cefoperazone-sulbactam treatment. No significant difference was in the cefoperazone-sulbactam plus vitamin K₁ group. In addition, no significant difference was found in the thrombin time or fibrinogen level between before and after cefoperazone-sulbactam treatment in both groups. The mean (SD) platelet counts of the 2 groups were 197.34 (71.82) × 10⁹/L and 187.75 (72.66) × 1 0⁹/L after cefoperazone-sulbactam treatment, respectively, which was significantly lower than 231.77 (77.05) × 10⁹/L and 232.08 (84.48) × 10⁹/L before cefoperazone-sulbactam treatment. There were greater proportions of coagulation disorders (prolongation of PT, aPTT, INR, and bleeding) after cefoperazone-sulbactam treatment in the cefoperazone-sulbactam group compared with that in the cefoperazone-sulbactam plus vitamin K₁ group.

IMPLICATIONS

Results indicate that, after adding cefoperazone-sulbactam to the regimens of patients receiving long-term low-dose aspirin, therapy contributed to remarkable increase in abnormal coagulation function and coagulation disorders. Prophylaxis with vitamin K₁ decreased the risk of these abnormalities in blood coagulation parameters associated with cefoperazone-sulbactam in patients taking long-term aspirin.

Fetal intracranial hemorrhage associated with maternal coagulopathy and vitamin K deficiency after biliary drain placement: A case report and literature review

Introduction

Fetal intracranial hemorrhage (ICH) is a rare but serious prenatal diagnosis. Predisposing factors include maternal trauma and fetal coagulation dysfunction. Maternal vitamin K deficiency has been described as an etiology. We present a case of maternal vitamin K deficiency associated with fetal ICH after percutaneous biliary drain (PBD) placement in a complicated cholecystectomy with injury to the common bile duct.

Case presentation

A 21-year-old woman, G2P1, presented at 23 weeks and 3 days of gestation with epigastric pain, nausea and vomiting. Right upper quadrant ultrasound diagnosed cholelithiasis. The patient was managed conservatively and discharged. She returned four days later, at 24 weeks of gestation, with worsening symptoms and ultrasound showing acute cholecystitis. She underwent laparoscopic cholecystectomy. Increasing bilirubin and imaging showed a transected biliary duct that required percutaneous biliary drain (PBD) placement. The patient was discharged and followed up at a high-risk obstetric clinic. Prenatal ultrasound showed bilateral ventriculomegaly with features of ICH. Maternal vitamin K deficiency was confirmed with PIVKA-II testing. The patient received vitamin K supplementation with normalization of the coagulopathy. Delivery occurred at 36 weeks of gestation via cesarean delivery after preterm premature rupture of membranes for fetal macrocrania. The neonate was discharged to a hospice.

Discussion

Maternal and neonatal etiologies for ICH include malabsorption and coagulopathy. Maternal vitamin K deficiency should be considered when coagulopathy is present. This case highlights that maternal vitamin K deficiency due to biliary diversion and malabsorption increases the risk of fetal ICH, which impacts pregnancy and neonatal outcomes.

•

Maternal vitamin K deficiency due to biliary diversion and malabsorption may predisp fetal intracranial hemorrhage.

•

Fetal intracranial hemorrhage may impact pregnancy and neonatal outcomes, particularly if severe.

•

Monitoring maternal coagulation may aid in the diagnosis of maternal vitamin K deficiency.

Cefazolin and rifampin: A coagulopathy-inducing combination

PURPOSE

To identify risk factors that may predispose patients to rifampin- and cefazolin-induced coagulopathy.

SUMMARY

An 86-year-old man with a history of rheumatoid arthritis on chronic prednisone and stage 3 chronic kidney disease, notably not on warfarin, presented to the hospital with a 10-day history of right hip pain, swelling, and drainage after a recent right total-hip arthroplasty. The patient underwent a combination of surgical intervention and medication therapy with rifampin and ceftriaxone. After discharge and at postoperative day 9, ceftriaxone was changed to cefazolin due to increasing alkaline phosphatase levels. Four weeks after the initial debridement, antibiotics, and implant retention, the patient underwent a second irrigation and debridement due to persistent infection. Cefazolin and rifampin therapy was extended. Three days later, the patient presented to the emergency room with significant bleeding at the surgical site and a profoundly elevated prothrombin time and international normalized ratio (INR). No potential contributors were identified. The Naranjo adverse drug reaction probability scale identified cefazolin and rifampin as the probable cause of elevated INR. The Liverpool adverse drug reaction avoidability assessment tool classified this adverse event as "definitely avoidable."

CONCLUSION

Rifampin-containing regimens are often recommended to treat staphylococcal prosthetic joint infections when the implant is retained. In methicillin-susceptible staphylococcal infections, cefazolin is routinely employed as the β-lactam backbone of definitive antimicrobial regimens. Although rifampin- and cefazolin-induced hypoprothrombinemia seems to be rare, adverse consequences of its occurrence may be prevented with appropriate monitoring.

Deranged Coagulation Profile Secondary to Cefazolin Use: Case Report

Cefazolin is a widely used first-generation cephalosporin. While generally well tolerated, several case reports have described severe coagulopathy induced by intravenous (IV) cefazolin. This was seen particularly in patients with impaired renal function, where antibiotic choice is limited and may require specific dose adjustments. Altered renal handling of antibiotics and their metabolites may potentiate toxicity and side effects. We report a case of a 72-year-old Chinese man who had been treated for methicillin-sensitive staphylococcus aureus (MSSA, coagulase-positive) infective endocarditis with cefazolin and, consequently, developed significantly elevated international normalised ratio (INR) while on therapy. This resolved within 48 h after cessation of cefazolin and administration of oral vitamin K. Malnourished patients with pre-existing or acute kidney injury may be at an increased risk of cefazolin-related coagulopathy.

Hemorrhagic Pleural Effusion: A Rare Presentation of Vitamin K Deficiency in an Adult Patient

Nutritionally acquired vitamin K deficiency is a rare condition in adults and can uncommonly present as hemorrhagic pleural effusion. We discuss the case of A 44-year-old apparently healthy man who presented with left-sided pleuritic chest pain two months after experiencing upper respiratory tract symptoms. Imaging revealed a loculated left-sided effusion, and a corresponding thoracentesis yielded exudative hemorrhagic fluid with no microbial growth. Laboratory work-up showed prolonged clotting time with low factors II, VII, and X activity, absence of clotting factor inhibitors, and very low serum vitamin K levels. A five-day course of oral vitamin K and nutritional optimization normalized the clotting profile. Acquired vitamin K deficiency from poor micronutrient intake is rare in adults and can result in hemorrhagic pleural effusion. Vitamin K supplementation can normalize the clotting profile while nutritional counseling helps prevent a recurrence. Malnutrition-induced vitamin K deficiency can occur in the setting of a major depressive disorder in adults. Thorough patient history and physical examination are necessary to promptly identify and reverse the coagulopathy.

Latamoxef induced a severe coagulation disorder in older patients in China: Two case reports

WHAT IS KNOWN AND OBJECTIVE

We present two cases of severe coagulation disorders induced by latamoxef, thereby revealing risk factors of coagulation disorder in latamoxef-treated patients.

CASE SUMMARY

Two very elderly patients developed haemorrhage, and coagulation tests showed a longer prothrombin time (PT), activated partial thromboplastin time (APTT) and a high international normalized ratio (INR). Latamoxef was thought to be responsible for the coagulopathy in these patients, and coagulation disorder was relieved after vitamin-K intake.

WHAT IS NEW AND CONCLUSION

We report on two cases of coagulopathy in patients given latamoxef. Advanced age, deficiency in vitamin-K intake, poor nutritional status, abnormal coagulation history, ongoing anti-coagulation/anti-aggregation therapy, renal dysfunction and polypharmacy are possible contributory factors, and should be looked out for when prescribing latamoxef.

The effect of cefoperazone sulbactam and piperacillin tazobactam on mortality in Gram-negative nosocomial infections

Cefoperazone-sulbactam (CS) and piperacillin-tazobactam (TZP) are used in the treatment of Gram-negative nosocomial infections (NIs). We aimed to compare the effects of these two antibiotics on mortality and treatment success. Patients treated with CS or TZP empirically for at least three days with suspicion of NI were included in this retrospective study. In total, 308 (154 patients in both treatment arms) patients were analyzed. Treatment success rate in CS and TZP group respectively (50% vs 51.2%, p = 0.18), 28-day mortality rate (46.1% vs 42.8%, p = 0.56) and antibiotic-related side effects (50.6% vs 46.1%, p = 0.42) were similar except prolonged prothrombin time (19.4% vs 6.4%; p = 0.001). According to this study results, CS and TZP have equal effectivity and safety for the empirical treatment of Gram-negative NIs. CS may be an appropriate alternative to TZP for antibiotic cycling or mixing strategy to reduce antibiotic resistance.

The Association Between Cephalosporin and Hypoprothrombinemia: A Systematic Review and Meta-Analysis

Cephalosporins that contain the N-methylthiotetrazole side chain (NMTT-cephalosporin) have been reported to be associated with coagulation-related adverse events; however, a comprehensive evaluation regarding the association is lacking. A systematic review and meta-analysis were conducted to assess the safety profile of NMTT-cephalosporins with respect to hypoprothrombinemia and bleeding. The MEDLINE, Embase, Cochrane, and RISS databases were systematically searched for clinical studies up to October 2018. The association between NMTT-cephalosporins and hypoprothrombinemia was estimated using an odds ratio (OR) with a 95% confidence interval (CI). A total of 15 studies on cefamandole, cefoperazone, cefotetan, cefmetazole, and moxalactam were identified and included in the meta-analysis. Hypoprothrombinemia (OR 1.676, 95% CI 1.275–2.203) and prothrombin time (PT) prolongation (OR 2.050, 95% CI 1.398–3.005) were significantly associated with NMTT-cephalosporins, whereas bleeding was not (OR 1.359, 95% CI 0.920–2.009). Subgroup analyses revealed that cefoperazone (OR 2.506, 95% CI 1.293–4.860), cefamandole (OR 3.247, 95% CI 1.083–9.733), and moxalactam (OR 3.367, 95% CI 1.725–6.572) were significantly associated with hypoprothrombinemia. An Antimicrobial Stewardship Program led by a multidisciplinary team could play a critical role in monitoring cephalosporin-related hypoprothrombinemia or PT prolongation in patients with underlying clinical conditions at risk for bleeding. The multidisciplinary team could also assist in communicating the potential safety concerns regarding NMTT-cephalosporin use with healthcare professionals to decrease the risk of adverse events.

Randomized Noninferiority Trial of Cefoperazone-Sulbactam versus Cefepime in the Treatment of Hospital-Acquired and Healthcare-Associated Pneumonia

Cefoperazone, a third-generation cephamycin with broad-spectrum antibacterial activity and the ability to permeate bacterial cell membranes, is active against commonly encountered multidrug-resistant pathogens for hospital-acquired pneumonia (HAP) and health care-associated pneumonia (HCAP). To clarify the clinical effects of cefoperazone-sulbactam in the treatment of HAP and HCAP, we conducted an open-label, randomized, noninferiority trial that recruited patients aged ≥18 years suffering HAP/HCAP. Participants were randomly assigned to the cefoperazone-sulbactam (2 g of each per 12 h) or cefepime (2 g per 12 h) arm. Clinical and microbiological responses were evaluated at early posttherapy and test-of-cure visits. Recruited patients were allocated to subpopulations for intent-to-treat (n = 154), per-protocol (n = 147), and safety (n = 166) analyses. Intent-to-treat analysis demonstrated that (i) at the early posttherapy visit, 87.3% of patients receiving cefoperazone-sulbactam and 84.3% of patients receiving cefepime achieved clinical improvement or cure (risk difference of 3.0%; 95% confidence interval [CI], -9.0% to 15.0%), and (ii) at the test-of-cure visit, 73.1% of patients receiving cefoperazone-sulbactam and 56.8% of patients receiving cefepime were assessed as cured (risk difference of 16.3%; 95% CI, 0.0% to 33.0%). These results indicated the noninferiority of cefoperazone-sulbactam to cefepime, which was confirmed by per-protocol analysis. The chest radiographic consolidation/infiltration resolution rate, microbiological eradiation rate, and percentage of adverse events were comparable in both groups. Serious adverse events were rare, and none was judged to be related to the study drugs. Cefoperazone-sulbactam at 2 g every 12 h was noninferior to cefepime at 2 g every 2 h for patients with HCAP.

Diversity of Gut Microbiota Affecting Serum Level of Undercarboxylated Osteocalcin in Patients with Crohn's Disease

Several reports have indicated a possible link between decreasing plasma levels of vitamin K and bone mineral density. It has been suggested that intestinal bacteria contribute to maintenance of vitamin K. Several factors are involved in the reduction of vitamin K in patients with Crohn’s disease (CD). We aimed to assess the relationship between gut microbiota and alternative indicators of vitamin K deficiency in patients with CD. We collected the feces of 26 patients with clinically inactive CD. We extracted 16S rRNA from the intestinal bacteria in the feces and amplified it by polymerase chain reaction. The generated polymerase chain reaction product was analyzed using a 16S metagenomic approach by Illumina Miseq platform. Serum undercarboxylated osteocalcin concentration was used as an alternative indicator of vitamin K deficiency. There was a significant negative correlation between serum undercarboxylated osteocalcin and mean Chao1 index in cases of low activity. The diversity of the gut microbiota was significantly lower, and Ruminococcaceae and Lachnospiraceae were significantly decreased in the vitamin K-deficient group in comparison to the vitamin K-normal group. Taken together, these data suggested the significance of investigating the gut microbiota even in patients with clinically inactive CD for improving patients’ vitamin K status.

Fatal Vitamin K-Dependent Coagulopathy Associated with Cefoperazone/Sulbactam: A Case Report

This case report describes a suspected and fatal adverse reaction involving vitamin K-dependent coagulopathy that might be associated with cefoperazone/sulbactam (CPZ/SAM), a combined antimicrobial formulation. We reported a patient diagnosed with acute cerebral infarction and secondary pulmonary infection who was treated with an intravenous infusion of CPZ/SAM at 3 g twice daily. After receiving treatment with CPZ/SAM, the patient developed a fatal adverse reaction of CPZ-induced hemorrhage. The Naranjo assessment score in this report was 5, suggesting that the patient's coagulation function disorder was potentially associated with the use of CPZ/SAM. To prevent vitamin K-dependent coagulopathy caused by CPZ/SAM, it is suggested to avoid cephalosporins in patients with a high risk of bleeding unless the need for cephalosporins is compelling.

A Case of Alveolar Bleeding from Clotting Abnormality by Cefmetazole

Cephalosporins are one of the most commonly used first-line antibiotics. In this report, we describe the case of a patient who developed alveolar bleeding due to clotting abnormality following the use of cefmetazole, one of cephalosporins containing an N-methylthiotetrazole (NMTT) side chain. Compared to other antibiotics, cephalosporins with an NMTT side chain cause a higher degree of bleeding events. The bleeding tendency is caused by the depletion of vitamin K-dependent clotting factors via inhibition of the vitamin K epoxide reductase. This mechanism of action is the same as warfarin. Recent years have seen an increase in the number of patients using direct oral anticoagulants that do not require coagulation tests. As a consequence, there may be an increase in the number of bleeding events due to anticoagulant drugs and such antibiotics coprescription. Therefore, this case is an instructive lesson.

Hypocoagulation induced by broad-spectrum antibiotics in extensive burn patients

BACKGROUND

Patients with extensive burns usually develop pro-coagulation soon after the injury if there is no sepsis occurred. We describe the case of an extensive burn adult suffering from hypocoagulation not related to sepsis, but secondary to antibiotic treatment.

CASE PRESENTATION

Here, we report a case of an adult male patient suffering from flame burns of 45% total body surface area (40% full thickness) combined with inhalation injury. Hypocoagulopathy with soaring prolonged activated partial thromboplastin time value occurred on third week post-burn while systemic infection had been under control by application of broad-spectrum antibiotics. Investigations showed that not the infection but vitamin K-related coagulation factor deficiency were responsible for unexpected bleeding. However, supplemental vitamin K was not the key as we expected, which prompted us trying to decode the underlying cause of coagulation disturbance in this patient and pick out the most effective treatment for live-saving. After the withdrawal of highly suspected broad-spectrum antibiotic, Meropenem®, disturbed vitamin K related coagulation factors gradually restored to their optimal levels so as to maintain normal coagulation status. Therefore, surgical procedures without further risk of bleeding could be carried out in time for wound recovery. The patient was discharged on post-burn day 67 and transferred to a secondary hospital for his rehabilitation.

CONCLUSION

Hypocoagulopathy may be devoted to different reasons other than sepsis in extensive burns. Early recognition of the cause for coagulation disturbance is critical to make appropriate treatment and save patients' lives. This case illustrated the importance of unveiling the mist cause for coagulation disturbance occurred in extensive burn patient, which paved the way for optimal life-saving treatments. And we also recommend burn surgeons to be alerted to antibiotic-induced vitamin K deficiency-related coagulopathy among critical burn patients.

A Case Report of Intraoperative Coagulopathy Secondary to Chronic Vitamin K Deficiency

Dietary Vitamin K is a well-known anti-hemorrhagic agent that plays an integral role in the coagulation pathway. Vitamin K is involved in synthesis of coagulation factors; II, VII, IX and factor X. Vitamin K deficiency leads to bleeding diathesis. Hemorrhages usually present in deep soft tissue, rather than mucosal or epithelial membranes, bleeding that is generally caused by disorders of platelets. Major causes of vitamin K deficiency include; medications and diseases involving fat metabolism with a resultant fat malabsorption. Warfarin and Cephalosporins are one of the commonly prescribed medications that lead to vitamin K deficiency. Disease affecting fat metabolism pathway, such as; diseases of the pancreas (cystic fibrosis), short gut syndrome and certain pathologies of the biliary tree. Vitamin K deficiency is more common in newborns. In adults it is uncommon because of its ubiquitous nature and the abundance of its sources. Hemorrhagic disorders in adults due to Vitamin K deficiency are not commonly encountered in practice. We are presenting a case of an adult who presented with a compartment syndrome secondary to a traumatic intramuscular bleeding. Our case highlights the importance of considering vitamin K deficiency in the differential diagnosis of unexplained hemorrhages resulting from a coagulopathy.

Negative Impact of Prolonged Antibiotics or Persistent Diarrhea on Vitamin K1 Levels in 2-24 Weeks aged Egyptian Infants

Background

To evaluate the hazard of prolonged antibiotic therapy and/or persistent diarrhea on vitamin K1 (VK1) level and bleeding profile in infants (2–24 weeks).

Methods

A one-year case-control study, conducted at Ain Shams University, Egypt. 338 infants (2–24 weeks) were recruited and divided into 3 groups (1:1:3 ratios); group A (n=67) patients who received antibiotics for ≥10 days, group B (n=67) who had persistent diarrhea ≥ 14 days and group C (n=204) age- and gender- matched infants who had not either received antibiotics nor had diarrhea. All subjected to clinical assessment, bleeding history and had their complete blood count (CBC), PT and PTT, liver transaminases and VK1 level assayed.

Results

There was a significant increase in frequency of VKDB (vitamin K deficiency bleeding) and abnormal bleeding profile in cases than control group. There was significant negative correlation between VK1 level and duration of diarrhea, length of antibiotics used and bleeding profile. Antibiotic usage has hazardous effect on VK1 level in those with diarrhea; more patients were receiving antibiotic in those with persistent diarrhea and VKDB (N=55) than those with persistent diarrhea and normal VK1 (N=12). The longer duration of antibiotic therapy the lower level of VK1. Combining cephalosporin/penicillin therapy and/or diarrhea, in particular, had an impact on VK1 level.

Conclusion

VKDB, a preventable cause of life-threatening hemorrhage, is still a major health problem in Egyptian infants, where persistent diarrhea and misuse of antibiotics are prevalent, necessitate a booster dose of VK in those high risk infants.

Oral anticoagulation and vitamin K deficiency

A 61-year old woman with atrial fibrillation developed macrohaematuria during anticoagulant treatment with a direct oral factor Xa inhibitor for stroke prevention. Abnormal results of coagulation assays were first interpreted as an effect of the anticoagulant. However, upon further testing diagnosis of vitamin K deficiency was established. After vitamin K supplementation, coagulation tests normalized and macrohaematuria disappeared. Treatment with broad spectrum antibiotics for urinary tract infection was finally established as a rare cause for vitamin K deficiency in the patient.

Kidney and haemostasis

Renal insufficiency is characterized by thrombocytopathy, caused by the accumulation of water soluble and protein bound waste products of protein metabolism, which are not adequately eliminated by the kidney. The kidneys also excrete drugs and their metabolites, which accumulate if dosages are not adjusted to the renal function and may cause clinically relevant bleeding (i. e. synthetic penicillins, vitamin K antagonists, new oral anticoagulants). Therefore, each patients kidney function (GFR) ought to be evaluated by the KDIGO guidelines. The survival of chronic renal patients is lowered by increasing cardiovascular complications. Particularly frequent is non-valvular atrial fibrillation. The recommended prophylaxis with vitamin K antagonists for renal insufficiency is hampered by increased bleeding as well as by augmented (coronary) vascular and valvular calcification. It is not known yet whether prophylaxis with vitamin K may prevent this complication. Conclusion: Because new oral anticoagulants are equally or even more effective and cause less bleeding, they may be favoured in future and even in end-stage renal failure if more is known about dosing, safety and efficacy. The measurement of serum FGF 23 concentration may be helpful as a marker for their use.

Assessment of Micronutrient Status in Critically Ill Children: Challenges and Opportunities

Micronutrients refer to a group of organic vitamins and inorganic trace elements that serve many functions in metabolism. Assessment of micronutrient status in critically ill children is challenging due to many complicating factors, such as evolving metabolic demands, immature organ function, and varying methods of feeding that affect nutritional dietary intake. Determination of micronutrient status, especially in children, usually relies on a combination of biomarkers, with only a few having been established as a gold standard. Almost all micronutrients display a decrease in their serum levels in critically ill children, resulting in an increased risk of deficiency in this setting. While vitamin D deficiency is a well-known phenomenon in critical illness and can predict a higher need for intensive care, serum concentrations of many trace elements such as iron, zinc, and selenium decrease as a result of tissue redistribution in response to systemic inflammation. Despite a decrease in their levels, supplementation of micronutrients during times of severe illness has not demonstrated clear benefits in either survival advantage or reduction of adverse outcomes. For many micronutrients, the lack of large and randomized studies remains a major hindrance to critically evaluating their status and clinical significance.

Hypoprothrombinemia and severe perioperative haemorrhagic complications in cardiac surgery patients treated with high-dose cefazolin for infective endocarditis

Endocarditis is a serious and common disease that requires prolonged antimicrobial therapy. The recent shortage of oxacillin has led to the use of other antimicrobial agents such as cefazolin to treat endocarditis due to methicillin-sensitive Staphylococcus aureus. We describe four cases of life-threatening haemorrhagic complications (fatal in two cases) in patients treated with high-dose cefazolin. All of these patients with major bleeding presented with hypoprothrombinemia secondary to hypovitaminosis K. This adverse event may be due to inhibition of vitamin K epoxide reductase and/or gamma-glutamyl-carboxylase by the 2-methyl-1,2,3-thiadiazol-5-thiol group of cefazolin. This inhibition may result in hypoprothrombinemia by altering the synthesis of vitamin K-dependent coagulation factors. The increasing use of cefazolin, especially at a high dose and for a prolonged period of time, should be accompanied by regular monitoring of coagulation, including prothrombin index, and vitamin K supplementation.

Cefoperazone Induced Gastrointestinal Bleeding

Cefoperazone is a beta-lactam antibiotic which is frequently used in treating a variety of gram positive and gram negative infections. The chemical structure of cefoperazone contains a side chain of N-methylthiotetrazole which can inhibit vitamin K metabolism resulting in hypoprothombinemia. We report a case of cefoperazone induced coagulopathy manifesting as gastrointestinal bleeding. A Naranjo assessment score of 5 was obtained, indicating a probable relationship between the patient's coagulation function disorder and her use of the suspect drug.

Use of Hypoprothrombinemia-Inducing Cephalosporins and the Risk of Hemorrhagic Events: A Nationwide Nested Case-Control Study

Objective

Existing data regarding the risk of hemorrhagic events associated with exposure to hypoprothrombinemia-inducing cephalosporins are limited by the small sample size. This population-based study aimed to examine the association between exposure to hypoprothrombinemia-inducing cephalosporins and hemorrhagic events using National Health Insurance Research Database in Taiwan.

Design

A nationwide nested case-control study.

Setting

National Health Insurance Research database.

Participants

We conducted a nested case-control study within a cohort of 6191 patients who received hypoprothrombinemia-inducing cephalosporins and other antibiotics for more than 48 hours. Multivariable conditional logistic regressions were used to calculate the adjusted odds ratio (aOR) and 95% confidence interval (CI) for hemorrhagic events associated with exposure to hypoprothrombinemia-inducing cephalosporins (overall, cumulative dose measured as defined daily dose (DDD), and individual cephalosporins).

Results

Within the cohort, we identified 704 patients with hemorrhagic events and 2816 matched controls. Use of hypoprothrombinemia-inducing cephalosporins was associated with increased risk of hemorrhagic events (aOR, 1.71; 95% CI, 1.42–2.06), which increased with higher cumulative doses (<3 DDDs, aOR 1.62; 3–5 DDDs, aOR 1.78; and >5 DDDs, aOR 1.89). The aOR for individual cephalosporin was 2.88 (95% CI, 2.08–4.00), 1.35 (1.09–1.67) and 4.57 (2.63–7.95) for cefmetazole, flomoxef, and cefoperazone, respectively. Other risk factors included use of anticoagulants (aOR 2.08 [95% CI, 1.64–2.63]), liver failure (aOR 1.69 [1.30–2.18]), poor nutritional status (aOR 1.41 [1.15–1.73]), and history of hemorrhagic events (aOR 2.57 [1.94–3.41]) 6 months prior to the index date.

Conclusions

Use of hypoprothrombinemia-inducing cephalosporins increases risk of hemorrhagic events. Close watch for hemorrhagic events is recommended when prescribing these cephalosporins, especially in patients who are at higher risk.

The influence of alcoholic liver disease on serum PIVKA-II levels in patients without hepatocellular carcinoma

Background/Aims

Prothrombin induced by vitamin K deficiency or antagonist II (PIVKA-II) is a widely used diagnostic marker for hepatocellular carcinoma (HCC). We evaluated the correlation between alcoholic liver disease (ALD) and serum PIVKA-II levels in chronic liver disease (CLD) patients.

Methods

We retrospectively reviewed the medical records of 2,528 CLD patients without HCC. Among these patients, 76 exhibited serum high PIVKA-II levels of >125 mAU/mL (group 1). We categorized 76 control patients matched by age, sex, and the presence of liver cirrhosis from the remaining patients who were negative for serum PIVKA-II (group 2).

Results

Group 1 revealed increased antibiotic usage (23.7% vs 2.6%, p<0.001) and incidence of ALD (60.5% vs 14.5%, p<0.001) as well as elevated aspartate aminotransferase (52.5 IU/L vs 30.5 IU/L, p=0.025) and γ glutamyl transpeptidase (67.5 IU/L vs 36.5 IU/L, p=0.005) levels compared with group 2. Further, group 1 was significantly associated with a worse Child-Pugh class than group 2. In the multivariate analysis, ALD (odds ratio [OR], 7.151; p<0.001) and antibiotic usage (OR, 5.846; p<0.001) were significantly associated with positive PIVKA-II levels.

Conclusions

Our study suggests that ALD and antibiotics usage may be confounding factors when interpreting high serum PIVKA-II levels in patients without HCC. Therefore, serum PIVKA-II levels in patients with ALD or in patients administered antibiotics should be interpreted with caution.

Role of prophylactic vitamin K in preventing antibiotic induced hypoprothrombinemia

OBJECTIVE

To determine prophylactic role of single dose of vitamin K in prevention of antibiotic induced hypoprothrombinemia.

METHODS

This prospective comparative study included critically ill children in age group 2 mo to 12 y, admitted to a tertiary care hospital in India, likely to receive prolonged antibiotic therapy. One hundred twenty children, 60 in each group (A & B) were enrolled in the study. Patient allocation was done on alternate basis. Group A children received prophylactic vitamin K while group B did not. Baseline coagulation studies and other investigations were done in all children. Coagulation studies were repeated on day 10 and day 14 of antibiotic therapy and in between if required clinically. Children who developed deranged INR were given therapeutic vitamin K. If deranged INR returns to normal at 12 h of vitamin K administration then it indirectly confirms vitamin K deficiency. Analysis was done by fisher's t test and chi square test.

RESULTS

In children on prolonged antibiotic therapy, vitamin K deficiency was a common problem (15%). It was common in male sex, severe grade of protein energy malnutrition (PEM), N-methylthiotetrazole (NMTT) group containing antibiotics use and duration of antibiotic more than 10 d. It was same in children whether they received or did not receive prophylactic vitamin K on day 1 of antibiotic therapy (95% CI; p value 0.79).

CONCLUSIONS

Vitamin K deficiency is common problem in patients on prolonged antibiotic therapy. There is no role of single dose of prophylactic vitamin K in preventing antibiotic induced hypoprothrombinemia.

A case report of a pregnancy-related death caused by primary antiphospholipid antibody syndrome

Primary antiphospholipid antibody syndrome (APS) is a rare clinical event in the People’s Republic of China. As APS is easily neglected or misdiagnosed, a delayed treatment can result. The patient reported here was a 32-year-old female who died by systemic venous thrombosis on day 11 after a cesarean section delivery. Luckily, the baby survived. A blood test demonstrated that the patient’s platelets were decreased at 19 weeks of gestation. Anti-cardolipin antibody and antiβ2GP1 (anti-β2-glycoprotein-I antibody) were positive at 36 weeks and 2 days of gestation. This patient was diagnosed with APS. Unfortunately, as physicians, we could not provide proper treatment as the patient’s relatives were concerned that the proposed treatment would have negative effects on the infant’s health. This clinical case strongly suggests that physicians need to appreciate that APS is a very serious condition, especially for pregnant women, and that proper treatment should be provided as early as possible to avoid a bad outcome, despite the fact that a cure for this disease is not currently available.

Necrotizing Esophagitis and Bleeding Associated With Cefazolin

OBJECTIVE

To report the case of a patient who presented with rare necrotizing esophagitis related to cefazolin-associated coagulopathy. A review of the literature is also provided.

CASE SUMMARY

A 53-year-old male patient was admitted for management of septicemia and femur osteomyelitis. Long-term cefazolin treatment was initiated after cultures and sensitivity revealed methicillin-sensitive Staphylococcus aureus. The patient was given intravenous cefazolin 2 g every 24 hours. On day 15 of cefazolin treatment, the patient presented to the emergency department complaining of black coffee ground emesis. On upper-gastrointestinal endoscopy, the patient was determined to have necrotizing esophagitis. He was found to have an international normalized ratio (INR) of 8.11 and prothrombin time (PT) of 89.2 s. Intravenous vitamin K, fresh frozen plasma, and packed red blood cells were administered. The INR was rechecked 4 hours later and found to have decreased to 1.55 with a PT of 17 s. The patient did not have medical conditions or take medications that could have caused bleeding.

DISCUSSION

Based on the Naranjo algorithm, it was determined that cefazolin had a "probable" relationship. Increased bleeding risk has been associated with other cephalosporins, although much less commonly with cefazolin. Possible mechanisms and implications are discussed.

CONCLUSIONS

High-risk patients being treated with cefazolin therapy should be monitored for potentially severe adverse events, including bleeding and necrotizing esophagitis.

Prevalence and correlates of vitamin K deficiency in children with inflammatory bowel disease

Although vitamin K deficiency has been implicated in adult inflammatory bowel disease (IBD), its prevalence in pediatric IBD remains unknown. We carried out a cross-sectional study in 63 children with Crohn's disease (CD) and 48 with ulcerative colitis (UC) to assess the prevalence of vitamin K deficiency and to search for potential correlation between vitamin K status and pediatric IBD activity. Vitamin K status was assessed using protein induced by vitamin K absence-II (PIVKA-II; ELISA). Prevalence of vitamin K deficiency was 54.0% in CD and 43.7% in UC. Vitamin K deficiency was more common in patients with higher CD activity, in CD patients with higher mass Z-scores, and less common among children with CD treated with infliximab. Relation of vitamin K deficiency to pediatric IBD clinical course and treatment demand further research.

Recent trends in the metabolism and cell biology of vitamin K with special reference to vitamin K cycling and MK-4 biosynthesis

In contrast to other fat-soluble vitamins, dietary vitamin K is rapidly lost to the body resulting in comparatively low tissue stores. Deficiency is kept at bay by the ubiquity of vitamin K in the diet, synthesis by gut microflora in some species, and relatively low vitamin K cofactor requirements for γ-glutamyl carboxylation. However, as shown by fatal neonatal bleeding in mice that lack vitamin K epoxide reductase (VKOR), the low requirements are dependent on the ability of animals to regenerate vitamin K from its epoxide metabolite via the vitamin K cycle. The identification of the genes encoding VKOR and its paralog VKOR-like 1 (VKORL1) has accelerated understanding of the enzymology of this salvage pathway. In parallel, a novel human enzyme that participates in the cellular conversion of phylloquinone to menaquinone (MK)-4 was identified as UbiA prenyltransferase-containing domain 1 (UBIAD1). Recent studies suggest that side-chain cleavage of oral phylloquinone occurs in the intestine, and that menadione is a circulating precursor of tissue MK-4. The mechanisms and functions of vitamin K recycling and MK-4 synthesis have dominated advances made in vitamin K biochemistry over the last five years and, after a brief overview of general metabolism, are the main focuses of this review.

Development of immunization trials against Klebsiella pneumoniae

Klebsiella pneumoniae is the most common cause of nosocomial respiratory tract and premature intensive care infections, and the second most frequent cause of Gram-negative bacteraemia and urinary tract infections. Drug resistant isolates remain an important hospital-acquired bacterial pathogen, add significantly to hospital stays, and are especially problematic in high impact medical areas such as intensive care units. Many investigations worldwide proved the increasing resistance of such pathogen, resulting in an average rate of 1.63 outbreak every year. A variety of preventive measures were applied to reduce such incidences. Immunotherapy and passive immunization researches as well found their way to the treatment of Klebsiella. During the last 40 years, many trials for constructing effective vaccines were followed. This up-to-date review classifies such trials and documents them in a progressive way. A following comment discusses each group benefits and defects.

Integrated safety summary of FOCUS 1 and FOCUS 2 trials: Phase III randomized, double-blind studies evaluating ceftaroline fosamil for the treatment of patients with community-acquired pneumonia

OBJECTIVES

Ceftaroline fosamil, the prodrug of the active metabolite ceftaroline, is a broad-spectrum, parenteral cephalosporin approved for treatment of moderate to severe bacterial infections, including community-acquired pneumonia (CAP). This report provides an integrated safety summary of the ceFtarOline Community-acquired pneUmonia trial versuS ceftriaxone (FOCUS) 1 and 2 trials (registration numbers: NCT00621504 and NCT00509106).

METHODS

Patients hospitalized with CAP requiring intravenous therapy and having Pneumonia Outcomes Research Team (PORT) risk class scores of III or IV were randomized (1:1) to receive 600 mg of ceftaroline fosamil administered intravenously every 12 h or 1 g of ceftriaxone administered intravenously every 24 h for 5-7 days. All patients were followed for treatment-emergent adverse events (TEAEs) occurring from the start of the initial study drug infusion up to the test-of-cure visit; serious adverse events (SAEs) including deaths occurring up to the late follow-up visit or within 30 days after the last dose were additionally recorded. Scheduled laboratory testing was conducted up to the test-of-cure visit; unscheduled testing continued up to the late follow-up visit.

RESULTS

A total of 1228 patients (613 in the ceftaroline fosamil group and 615 in the ceftriaxone group) received any amount of drug and were included in the safety analysis. The incidences of TEAEs (47.0% versus 45.7%), SAEs (11.3% versus 11.7%), discontinuations (4.4% versus 4.1%) and deaths (2.4% versus 2.0%) were similar between the ceftaroline fosamil and the ceftriaxone groups, respectively. Diarrhoea (4.2%), headache (3.4%) and insomnia (3.1%) were the most commonly reported TEAEs in patients treated with ceftaroline fosamil. The distribution of TEAEs based on severity was also similar between groups, and the majority of patients in both treatment groups (∼75%) had either no TEAEs or only mild TEAEs.

CONCLUSIONS

The data from the FOCUS 1 and FOCUS 2 trials presented in this integrated safety summary demonstrate that ceftaroline fosamil is well tolerated, with a tolerability profile similar to ceftriaxone and the cephalosporin class overall, with no unexpected safety concerns being identified.

Molecular structure, vibrational spectroscopic, first order hyperpolarizability and HOMO-LUMO studies of 7-amino-8-oxo-3-vinyl-5-thia-1-azabicyclo[4.2.0]oct-2-ene-2-carboxylic acid

The FT-IR and FT-Raman spectra of 7-amino-8-oxo-3-vinyl-5-thia-1-azabicyclo[4.2.0]oct-2-ene-2-carboxylic acid (7AVCA) were recorded in the region 4000-400 cm(-1) and 3500-10 cm(-1), respectively. Quantum chemical calculations of energies, geometrical structure and vibrational wavenumbers were carried out by ab initio HF and density functional theoretical methods invoking 6-311G(d,p) basis set. The differences between the observed and scaled wavenumber values of most of the fundamentals are very small. The electric dipole moment (μ) and the first order hyperpolarizability (β0) values have been computed quantum mechanically. The calculated results show that 7AVCA may have microscopic nonlinear optical (NLO) behavior with non-zero values. A detailed interpretation of the FT-IR and FT-Raman spectra of 7AVCA is reported. The theoretical IR and Raman spectra of 7AVCA have also been constructed. The calculated HOMO and LUMO energies show that the charge transfer occurs within the molecule.

Drug Interactions Between Antibiotics and Select Maintenance Medications: Seeing More Clearly Through the Narrow Therapeutic Window of Opportunity

OBJECTIVE

Infections often occur while treating patients with long-term medications for chronic illnesses. Treating these infections with systemic antibiotics often leads to pharmacokinetic and pharmacodynamic interactions between the antimicrobials and one or more of the maintenance medications. Previously optimized long-term regimens may become either subtherapeutic or super-therapeutic, with deleterious consequences. This article discusses some of the most significant and commonly encountered antibiotic drug interactions that may occur with medications with "narrow therapeutic windows" including warfarin, phenytoin, carbamazepine, theophylline, and the two calcineurin inhibitors. Given the logistics of many consultant pharmacists' practices, it may not always be possible for them to react prospectively when these combinations are prescribed at their facilities. Therefore, there are several things the pharmacist can do: provide regular and comprehensive inservice raining on this topic, be available as needed to answer patient-specific questions, and provide readily available charts and other educational materials that help identify and characterize these important interactions.

DATA SOURCES

A Medline search of the English literature was performed in October/November 2003, going back to 1980 for the commonly used antibiotics and drug interactions stated in this text. In some cases, cross referencing of articles reviewed also led to older publications. Textbooks dealing with drug interactions also were used as initial sources. However, whenever possible, any data quoted within the text were verified from the original research paper.

STUDY SELECTION

Pharmacokinetic studies, case reports, and general review articles published in the English medical literature were all selected for review. In cases where review articles were cited that summarize groups of data from previous original research papers, the authors made the best possible effort to verify the accuracy by referring to the original research papers.

DATA SYNTHESIS

Because of the breadth of the topic in terms of all the antibiotics discussed, the interacting medications that pertained to each antibiotic, and the lack of homogeneity among the various types of papers (most of which were case reports), most analyses include broad-based summaries based on the aggregate findings of the authors.

CONCLUSION

The addition of antibiotics to a stabilized medical regimen can result in either potentiation or antagonism of the clinical effects of narrow-therapeutic-window medications such as warfarin, phenytoin, theophylline, calcineurin inhibitors, carbamazepine, and numerous other agents. As usual in the clinical arena, awareness is the first step in appropriate management of these encounters.