Vancomycin-Induced Thrombocytopenia: A Narrative Review

Delayed-onset eptifibatide-induced thrombocytopenia

PURPOSE

We present a unique case of delayed-onset, profound eptifibatide-induced thrombocytopenia that occurred 5 days after initiation of the drug.

SUMMARY

Eptifibatide is a platelet glycoprotein IIb/IIIa receptor inhibitor with indications for use in patients with acute coronary syndromes. Eptifibatide-induced thrombocytopenia is uncommon but well studied and typically occurs within 24 hours of initiation of the drug. In the case described here, a 62-year-old male with a past history of coronary artery disease (including percutaneous coronary intervention within the past 12 months) was started on eptifibatide at a dosage of 2 µg/kg per minute for management of significant thrombus burden prior to a planned cardiac revascularization procedure; heparin for anticoagulation was also initiated. About 5 days after initiation of eptifibatide, the patient developed severe thrombocytopenia, with the platelet count dropping precipitously from 249 × 103/µL on admission to less than 1 × 103/µL. After eptifibatide and heparin therapy were discontinued and the patient was switched to argatroban, the platelet count recovered to 38 × 103/µL over the next 2 days. An eptifibatide platelet antibody assay was positive for IgG-mediated reactions consistent with eptifibatide-induced thrombocytopenia. Scoring of this case with the Naranjo scale yielded a score of 4, suggesting a possible adverse reaction to eptifibatide.

CONCLUSION

This is the first published case report of profound eptifibatide-induced thrombocytopenia occurring more than 24 hours after eptifibatide initiation and serves to bring awareness that a delayed reaction can occur.

Bleeding Complications in Vancomycin-Induced Thrombocytopenia: A Real-world Postmarketing Pharmacovigilance Analysis

PURPOSE

Vancomycin and linezolid are first-line drugs used for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections. Vancomycin is well known as the best alternative drug when linezolid-induced thrombocytopenia occurs. However, several cases with vancomycin-induced thrombocytopenia, especially with bleeding complications, have been reported recently, which has attracted attention. The objective of this study is to assess the potential relevance between vancomycin and bleeding complications in thrombocytopenia.

METHODS

This is a real-world pharmacovigilance study conducted in October 2022 using the US Food and Drug Administration Adverse Event Reporting System (FAERS) database. We performed a disproportional analysis to assess the risk of bleeding complications in vancomycin-induced thrombocytopenia by calculating reporting odds ratios (RORs) and information components (ICs), with a weak signal defined as a lower limit of the IC 95% CI of 0 to 1.5, a middle signal defined as a lower limit of the IC 95% CI of 1.5 to 3.0, and a strong signal defined as a lower limit of the IC 95% CI of >3.0.

FINDINGS

There were 21,854 cases in the FAERS database that listed vancomycin as a suspected drug from quarter 1 of 2004 to quarter 2 of 2022. There were 800 cases of vancomycin-induced thrombocytopenia and 125 cases of bleeding complications in vancomycin-induced thrombocytopenia. Teicoplanin, tigecycline, and vancomycin (3 middle signals) were sequentially less associated with thrombocytopenia than linezolid (strong signal). However, bleeding complications in thrombocytopenia were significant associated with vancomycin (ROR = 9.641; 95% CI, 8.105-11.468; IC = 3.184; 95% CI, 2.929-3.440 [middle signal]), followed by linezolid (ROR = 9.350; 95% CI, 7.318-11.947; IC = 3.106; 95% CI, 2.745-3.466 [middle signal]), teicoplanin (ROR = 6.399; 95% CI, 2.869-14.272; IC = 2.059; 95% CI, 0.881-3.283 [weak signal]), and daptomycin (ROR = 2.784; 95% CI, 1.496-5.180; IC = 1.287; 95% CI, 0.374-2.201 [weak signal]). Tigecycline and daptomycin were the least likely anti-MRSA drug to cause thrombocytopenia (middle signal and weak signal, respectively) and bleeding complications in thrombocytopenia (no signal and weak signal, respectively). Middle signals of bleeding complication in vancomycin-induced thrombocytopenia were found in all group except those <45 to ≥80 years of age (weak signal).

IMPLICATIONS

Bleeding complications in thrombocytopenia were significantly associated with vancomycin use, and the risk was highest among all the anti-MRSA drugs. Physicians should be aware of this possible serious adverse reaction.

Vancomycin-Induced Thrombocytopenia in a 35-Year-Old Female With Pneumonia: A Case Report

Vancomycin is one of the most empirically used antibiotics in severely ill patients in hospitalized settings. Vancomycin-induced thrombocytopenia (VITP) is a rare and potentially life-threatening complication that requires immediate recognition. Platelet destruction is largely immune-mediated and results in a precipitous drop in the platelet count over a short period of time. Most cases of VITP are drug-dependent, as discontinuation of the offending agent frequently results in a timely return to baseline to pre-exposure platelet levels. Here, we present a case of severe vancomycin-induced thrombocytopenia in a 35-year-old female with a history of multiple comorbidities who presented with pneumonia. She was undergoing treatment with vancomycin and piperacillin-tazobactam and developed thrombocytopenia within 24 hours of hospitalization. The patient was on a loading dose of 1250 mg intravenous vancomycin every 24 hours and piperacillin-tazobactam 3.375 g intravenously every six hours for presumed community-acquired pneumonia. Her other medications included ondansetron, bupropion, sertraline, tamsulosin, pantoprazole, ergocalciferol, and insulin glargine. Additionally, the patient was placed on a prophylactic dose of enoxaparin while in-patient. The patient's thrombocytopenia resolved with discontinuation of vancomycin. Clinicians should be well-informed about which medications can trigger thrombocytopenia whenever starting a medication in such cases.

Immune Thrombocytopenia: A Rare Adverse Event of Vancomycin Therapy

Vancomycin, a glycopeptide antibiotic, is widely used for Gram-positive cocci or bacilli bacteria-induced serious infections. Although considered safe and effective, it still causes adverse events. Vancomycin-induced immune thrombocytopenia is a rarely reported adverse event, manifesting from asymptomatic thrombocytopenia to life-threatening bleeding. We underline a case of a 56-year-old male with a diabetic foot with an infected exudating purulent ulcer. He experienced a significant drop in platelet count after commencing vancomycin, and discontinuing vancomycin resulted in improved platelet count with positive vancomycin-induced anti-platelet antibodies. After ruling out other possible causes of thrombocytopenia, a presumptive diagnosis of vancomycin-induced thrombocytopenia was made.

A meta-analysis of risk factors associated with platelet transfusion refractoriness

BACKGROUND

Platelet transfusion refractoriness (PTR) remains an intractable issue in clinical practice, and is common in hematological patients. At present, it is believed that both immune and non-immune factors play a role. We conducted a meta-analysis of various risk factors which may contribute to PTR.

METHODS

PubMed, Embase, Cochrane library, and Web of Science were selected as research database platforms. Citations included were further assessed for quality and bias using the Newcastle-Ottawa Scale. All analyses were performed using Review Manager Version 5.4 and STATA 16.0.

RESULTS

The preliminary search revealed 1069 publications, and 17 (5929 patients in total) were ultimately included in the quantitative analysis. The following variables were associated with the occurrence of PTR: fever (OR = 2.26, 95%CI 2.00-2.55, p < 0.00001), bleeding (OR = 2.10, 95%CI 1.36-3.24, p = 0.0008), female sex (OR = 2.06, 95%CI 1.13-3.75, p = 0.02), antibiotic use (OR = 2.94, 95%CI 1.54-5.59, p = 0.001), and infection (OR = 2.19, 95%CI 1.20-4.03, p = 0.01). Antibodies involved in immune activation were a higher risk factor (OR = 4.17, 95%CI 2.36-7.36, p < 0.00001), and splenomegaly was nearly significant (OR = 1.73, 95%CI 0.97-3.07, p = 0.06).

CONCLUSIONS

We identified some important risk factors for PTR, but further research is needed to identify the many other possible elements that may contribute to or mediate PTR.

Native and Prosthetic Simultaneously Double Valve Infective Endocarditis with Enterococcus faecalis-Case-Based Review

Infective endocarditis is a severe infective heart disease, commonly involving native or prosthetic valves. It frequently presents with univalvular involvement and simultaneous double valve or multivalvular involvement is rarely described. The third leading cause of infective endocarditis worldwide is Enterococcus faecalis, which is associated with high mortality rates despite important advances in antimicrobial therapy. It develops secondary to enterococcal bacteremia, with its origin from the gastrointestinal or genitourinary tract and predominantly affecting the elderly population with multiple comorbidities. Clinical presentation is usually less typical, and the treatment is challenging. It can be marked by antibiotic resistance, side effects, and subsequent complications. Surgical treatment can be considered if deemed appropriate. To the best of our knowledge, we present the first case-based narrative review of Enterococcus faecalis double valve endocarditis involving both the aortic native and prosthetic mitral valve, highlighting the clinical characteristics, treatment, and complications of this condition.

Severe Thrombocytopenia Caused by Vancomycin in the Intensive Care Unit: A Case Report

Thrombocytopenia can cause substantial morbidity and mortality in critically ill patients. There are multiple etiology factors and various mechanisms associated with thrombocytopenia, of which drug-induced thrombocytopenia (DITP) deserves attention. Herein, we describe a case of severe thrombocytopenia during intensive care unit (ICU) hospitalization that was likely to be associated with vancomycin. By revealing the process of identifying this case of DITP and reviewing relevant clinical studies, a risk alert of vancomycin-related severe hematotoxicity should be considered.

Linezolid vs Vancomycin in Induced Thrombocytopenia

INTRODUCTION

Linezolid and vancomycin have an important place among therapeutic antimicrobial options for multidrug-resistant gram-positive infections. Thrombocytopenia is an adverse effect reported with both and can lead to treatment interruption. Our objective was to compare the incidence of thrombocytopenia in patients receiving linezolid or vancomycin and to identify risk factors associated with thrombocytopenia.

METHODS

This was a retrospective observational cohort study that involved patients who received linezolid (intravenously or orally) or vancomycin (intravenously) at a tertiary care hospital, between January 2016 and October 2019, for a minimum of 5 days and in whom platelet values were measured during treatment. Data on platelet count were collected during therapy in each group to identify the incidence of thrombocytopenia.

RESULTS

A total of 453 patients fulfilled the study criteria; 241 patients received linezolid and 212 patients vancomycin. The main logistic regression analysis revealed that patients in the linezolid group had approximately a four times higher incidence of thrombocytopenia (OR 4.39; 95% CI 2.38-8.08) compared to vancomycin. An increased incidence of thrombocytopenia was associated with advanced age, baseline platelet count and vasopressor use.

CONCLUSION

Clinicians considering vancomycin or linezolid for a susceptible infection should weigh the higher risk of thrombocytopenia that may be observed with linezolid vs. vancomycin in their decision.

Anesthesia Considerations in Infective Endocarditis

The management of infective endocarditis is complex and inherently requires multidisciplinary cooperation. About half of all patients diagnosed with infective endocarditis will meet the criteria to undergo cardiac surgery, which regularly takes place in urgent or emergency settings. The pathophysiology and clinical presentation of infective endocarditis make it a unique disorder within cardiac surgery that warrants a thorough understanding of specific characteristics in the perioperative period. This includes, among others, echocardiography, coagulation, bleeding management, or treatment of organ dysfunction. In this narrative review article, the authors summarize the current knowledge on infective endocarditis relevant for the clinical anesthesiologist in perioperative management of respective patients. Furthermore, the authors advocate for the anesthesiologist to become a structural member of the endocarditis team.

Re-exposure causing rapid onset of vancomycin induced thrombocytopenia

Vancomycin is used for the treatment of gram-positive infections. The increasing prevalence of methicillin-resistant Staphylococcus aureus since the 1980 s has led to a significant increase in the clinical utility of vancomycin in the United States. The diagnosis of vancomycin induced thrombocytopenia (VIT) poses a challenge since it requires the exclusion of other etiologies of thrombocytopenia, such as infectious or immunologic diseases and alternative drugs. Physicians should be aware that VIT is a rare but important complication of IV vancomycin therapy and failure to recognize this diagnosis may lead to a delay in discontinuation of vancomycin and serious complications

Intraperitoneal vancomycin-induced immune thrombocytopenia

Vancomycin is one of the drugs used in the peritonitis treatment regimen of peritoneal dialysis patients. Intraperitoneal route is generally preferred to provide rapid elimination of infective agents. Systemic toxicities of certain drugs after intraperitoneal administration are not very clear. The same also applies to vancomycin, although it has a considerable amount of systemic absorption after intraperitoneal administration. We herein report a case of severe thrombocytopenia, which was seen during the treatment of a peritonitis attack in a peritoneal dialysis patient. Culture studies revealed methicillin resistant staphylococci as the causative agent and the patient received intraperitoneal vancomycin per sensitivity analysis. Thrombocyte levels dropped abruptly to 3,900/μl after 10 days of vancomycin treatment. Clinical criteria pointed out to vancomycin-related immune thrombocytopenia. Platelet levels did not recover with initial dexamethasone treatment and platelet transfusions. In the meantime, the clinical course was also complicated with intracranial bleeding. Intravenous immunoglobulin treatment was applied and dexamethasone was switched to high-dose methylprednisolone. This latter treatment generated a response and platelet levels gradually increased to normal levels. The patient could be discharged without any sequelae. There have been two previous intraperitoneal vancomycin-related immune thrombocytopenia cases in the literature. Previous cases were reviewed, and the present case was given in comparison with the previous cases.

Severe vancomycin-induced thrombocytopenia in a patient with meningitis

Vancomycin is a widely used antibiotic and rarely can cause drug-induced thrombocytopenia. A patient with hospital-acquired meningitis after neurosurgery was treated with systemic and intrathecal vancomycin. On 9th day of antibiotic treatment, the patient's platelets dropped to 0.68×109/L. Multiple platelet transfusions had minimal influence on platelet count. After cessation of vancomycin therapy, platelets returned to normal values without any additional interventions. Diagnosis of vancomycin-induced thrombocytopenia was confirmed by detection of drug-dependent antiplatelet IgG antibodies.

Rapid onset vancomycin-induced thrombocytopenia confirmed by vancomycin antibody test

We report a case of vancomycin-induced thrombocytopenia (VIT) with rapid onset after re-exposure to vancomycin. A 58-year-old man with cellulitis was initiated on vancomycin. Approximately 1 hour into the vancomycin infusion, the patient developed an infusion-related reaction. Vancomycin infusion was stopped. A complete blood count obtained 4 hours after discontinuation of the vancomycin infusion revealed a platelet count of 31 ×10-⁹/L. Investigations ruled out likely causes of thrombocytopenia. VIT was diagnosed based on clinical symptoms and confirmed with drug-dependent platelet antibody testing. Without complications, platelet counts recovered within 7 days after discontinuation of vancomycin. No correlation between vancomycin level and VIT was observed.

Research Advances in the Subtype of Sepsis-Associated Thrombocytopenia

The incidence and mortality of sepsis in the intensive care unit (ICU) are extremely high. Thrombocytopenia, one of the most common laboratory abnormalities, is correlated with prognosis in sepsis. The pathophysiology of sepsis-associated thrombocytopenia (SAT) remains unclear and may be associated with several factors such as platelet activation due to vascular injury and pathogen, suppression of bone marrow, platelet-targeted antibodies and desialylation. This review summarized all these possible mechanisms in the 3 subtypes of SAT: increased platelet consumption, reduced platelet production and increased platelet destruction. Based on the clinically available platelet parameters, the evidence for identifying SAT subtypes and the recent progress in treatments according to these subtypes are proposed to provide new prospects for the management of SAT.

Vancomycin-induced thrombocytopenia in endocarditis: A case report and review of literature

BACKGROUND

Thrombocytopenia is a serious complication in the medical practice of numerous drugs. Vancomycin is frequently used for the prophylaxis and treatment of suspected or identified methicillin-resistant positive infections. Several cases with vancomycin-induced thrombocytopenia (VIT) have been reported. However, these have rarely been extensively reviewed. The present report describes a case of VIT in endocarditis, and reviews all VIT cases reported in the literature.

CASE SUMMARY

A 26-year-old male diagnosed with infective endocarditis was admitted. The patient was treated with multiple drugs, including vancomycin, which was initially intravenously given at 1000 mg every 12 h and subsequently at 500 mg every 8 h on day 3. On day 11, the platelet count decreased to 51 × 10⁹/L, vancomycin was switched to 500 mg every 12 h, and platelet transfusion was given. On day 17, the platelet count dropped to 27 × 10⁹/L, and platelet transfusion was administered again. On day 23, vancomycin was adjusted to 500 mg every 8 h as the trough concentration dropped to the minimum effective concentration. On day 33, the platelet count declined to approximately 40 × 10⁹/L. After platelet transfusion, the platelet count rebounded to 90 × 10⁹/L on day 35 but dropped again to 42 × 10⁹/L on day 43. Based on the time-to-platelet count curve and Naranjo’s Adverse Drug Reaction Probability Scale score, VIT was suspected. After vancomycin discontinuation and platelet transfusion, the platelet count gradually normalized.

CONCLUSION

The diagnosis of VIT can be achieved through the time-to-platelet count curve and Naranjo’s Adverse Drug Reaction Probability Scale score. The platelet count cannot be normalized simply by platelet transfusion alone, and vancomycin discontinuation is essential.

Thrombocytopenia Secondary to Herpes Simplex Virus-2 Infection Successfully Treated by Acyclovir

Thrombocytopenia is a common clinical condition associated with a wide variety of clinical conditions including infections, malignancy, medications, liver disorder, and autoimmune conditions, etc. The association between thrombocytopenia and herpes simplex virus (HSV) is reported only once in a case report dating back to 1978. We report a case of a 66-year-old female with generalized weakness, mechanical fall, genital ulcerations, and breast fold and genital area skin redness, warmth, and mild tenderness. Initial labs showed mild leukocytosis, normal platelet count, mild lactic acidosis, and urine analysis suggestive of urinary tract infection. The patient was started on broad-spectrum antibiotics. During the course of hospitalization, the patient developed severe thrombocytopenia with platelet counts dropping less than 40000/μL (normal range: 150,000-450,000/μL), and genital pain and ulceration worsened. The genital swab was sent which came back positive for the HSV-2 virus. Soon after the start of acyclovir for HSV-2 infection, the genital pain and ulceration improved and platelet counts gradually increased to 157,000/μL. Other causes of thrombocytopenia such as sepsis, heparin-induced thrombocytopenia, consumptive coagulopathy, medication-induced thrombocytopenia, immune thrombocytopenia, and thrombotic thrombocytopenic purpura were ruled out.

Vancomycin in ICU Patients with Gram-Positive Infections: Initial Trough Levels and Mortality

Background

Vancomycin is one of the most common therapeutic agents for treating gram-positive infections, particularly in critically ill patients. The aim of this study was to identify factors associated with initial therapeutic vancomycin trough levels and mortality in a tertiary-care intensive care unit (ICU).

Methods

This retrospective study evaluated 301 adult ICU patients admitted to King Abdulaziz Medical City in Riyadh between October 1, 2017 and December 31, 2018 with confirmed gram-positive infections and received intravenous vancomycin. Vancomycin trough levels of 15–20 mg/L for severe infections and 10–15 mg/L for less severe infections were considered therapeutic.

Results

The patients were relatively older with a mean age of 60 (SD ±20) years. Initial vancomycin trough levels were therapeutic in 168 (55.8%). Factors associated with initial therapeutic vancomycin trough levels were female gender (adjusted odds ratio [aOR]=2.575), older age (aOR=1.024), receiving a loading dose (aOR=2.445), having bacteremia (aOR=2.061), and high platelet count (aOR=1.003). On the other hand, the increase of estimated glomerular filtration rate (eGFR) (aOR=0.993) and albumin levels (aOR=0.944) were associated with lower odds of initial therapeutic vancomycin trough levels. Factors associated with higher mortality were female gender (adjusted hazard ratio [aHR]=2.630), increased body weight (aHR=1.021), cancer (aHR=3.451), and high APACHE II score (aHR=1.068).

Conclusion

The study identified several factors associated with achieving initial therapeutic vancomycin trough levels (i.e. older age, female gender, receiving a loading dose, bacteremia, high platelets count, low eGFR and albumin level). These factors should be considered in the dosing of vancomycin in critically ill patients with gram-positive infections.

Life-Threatening Intrapulmonary Hemorrhage due to Vancomycin-Induced Thrombocytopenia: A Case Report

Thrombocytopenia is a rare and sometimes life-threatening complication of Vancomycin. A 52-year-old male patient with acute kidney injury was treated with Vancomycin for ventilator-associated pneumonia. Three days later, his platelets decreased from 172 × 10⁹/L to 3 × 10⁹/L over a 36-hour period. The patient developed significant intrapulmonary bleeding leading to profound hypoxemia. Workup was negative for thrombotic thrombocytopenic purpura, disseminated intravascular coagulopathy, atypical hemolytic uremic syndrome, heparin-induced thrombocytopenia, and autoimmune diseases. All recently started medications were discontinued, and the patient was started empirically on methylprednisolone and intravenous immunoglobulin. The patient's platelets increased, and his airway bleeding stopped within 48 hours; his platelet count returned to normal by 18 days. Vancomycin-dependent anti-platelet antibodies were identified in the patient's serum by flow cytometry. Thrombocytopenia is an underrecognized complication of Vancomycin that can lead to life-threating bleeding. Stopping Vancomycin may be sufficient to reverse the thrombocytopenia in patients with normal renal function, but more aggressive measures such as steroids, IVIG, and dialysis may be required to stop bleeding and reverse thrombocytopenia in patients with underlying kidney injury who cannot effectively excrete Vancomycin.

Drug-Induced Thrombocytopenia Secondary to Commonly Used Antibiotics in Total Joint Arthroplasty

Drug-induced thrombocytopenia secondary to antibiotic exposure is a rare complication more commonly associated with other medications. In this review, we present a case of antibiotic-induced thrombocytopenia and discuss the clinical picture and approach to identifying the complication. With increasing use of antibiotics that may be associated with drug-induced thrombocytopenia in perioperative prophylaxis protocols, surgeons need to be cognizant of this cause of thrombocytopenia in the postoperative patient. A delay in recognition and discontinuation of the offending agent can result in significant complications secondary to bleeding and superfluous testing.

Glycopeptide Hypersensitivity and Adverse Reactions

Glycopeptides, such as vancomycin and teicoplanin, are primarily used in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections, such as cellulitis, endocarditis, meningitis, pneumonia, and septicemia, and are some of the most commonly prescribed parenteral antimicrobials. Parenteral glycopeptides are first-line therapy for severe MRSA infections; however, oral vancomycin is used as a first-line treatment of Clostridioides difficile infections. Also, we currently have the longer-acting lipoglycopeptides, such as dalbavancin, oritavancin, and telavancin to our armamentarium for the treatment of MRSA infections. Lastly, vancomycin is often used as an alternative treatment for patients with β-lactam hypersensitivity. Common adverse effects associated with glycopeptide use include nephrotoxicity, ototoxicity, and Redman Syndrome (RMS). The RMS is often mistaken for a true allergy; however, it is a histamine-related infusion reaction rather than a true immunoglobulin E (IgE)-mediated allergic reaction. Although hypersensitivity to glycopeptides is rare, both immune-mediated and delayed reactions have been reported in the literature. We describe the various types of glycopeptide hypersensitivity reactions associated with glycopeptides and lipoglycopeptides, including IgE-mediated reactions, RMS, and linear immunoglobulin A bullous dermatosis, as well as describe cross-reactivity with other glycopeptides.

A Machine-Learning Approach for Dynamic Prediction of Sepsis-Induced Coagulopathy in Critically Ill Patients With Sepsis

Background: Sepsis-induced coagulopathy (SIC) denotes an increased mortality rate and poorer prognosis in septic patients. Objectives: Our study aimed to develop and validate machine-learning models to dynamically predict the risk of SIC in critically ill patients with sepsis. Methods: Machine-learning models were developed and validated based on two public databases named Medical Information Mart for Intensive Care (MIMIC)-IV and the eICU Collaborative Research Database (eICU-CRD). Dynamic prediction of SIC involved an evaluation of the risk of SIC each day after the diagnosis of sepsis using 15 predictive models. The best model was selected based on its accuracy and area under the receiver operating characteristic curve (AUC), followed by fine-grained hyperparameter adjustment using the Bayesian Optimization Algorithm. A compact model was developed, based on 15 features selected according to their importance and clinical availability. These two models were compared with Logistic Regression and SIC scores in terms of SIC prediction. Results: Of 11,362 patients in MIMIC-IV included in the final cohort, a total of 6,744 (59%) patients developed SIC during sepsis. The model named Categorical Boosting (CatBoost) had the greatest AUC in our study (0.869; 95% CI: 0.850-0.886). Coagulation profile and renal function indicators were the most important features for predicting SIC. A compact model was developed with an AUC of 0.854 (95% CI: 0.832-0.872), while the AUCs of Logistic Regression and SIC scores were 0.746 (95% CI: 0.735-0.755) and 0.709 (95% CI: 0.687-0.733), respectively. A cohort of 35,252 septic patients in eICU-CRD was analyzed. The AUCs of the full and the compact models in the external validation were 0.842 (95% CI: 0.837-0.846) and 0.803 (95% CI: 0.798-0.809), respectively, which were still larger than those of Logistic Regression (0.660; 95% CI: 0.653-0.667) and SIC scores (0.752; 95% CI: 0.747-0.757). Prediction results were illustrated by SHapley Additive exPlanations (SHAP) values, which made our models clinically interpretable. Conclusions: We developed two models which were able to dynamically predict the risk of SIC in septic patients better than conventional Logistic Regression and SIC scores.

Cefepime challenge after piperacillin/tazobactam-induced thrombocytopenia

Drug-induced thrombocytopenia (DITP) has been described as a sudden and severe hematologic complication of piperacillin/tazobactam. The proposed mechanism by which piperacillin/tazobactam causes DITP involves the formation of a covalent bond to platelet membrane protein thereby inducing a humoral immune response. Given the immunogenic nature of this adverse event and the structural similarities across beta-lactam antibiotics, the potential for cross-reactivity between agents within the class should be considered. However, the structural moiety of piperacillin/tazobactam responsible for this immunogenic response has not been identified-the relationship between structure and activity for this phenomenon remains unknown. Data on the safety and cross-reactivity of other beta-lactam agents in this setting is lacking. We report the first case of piperacillin/tazobactam DITP successfully challenged by the use of cefepime for the treatment of aspiration pneumonia. Further studies are needed to determine the structural moiety of piperacillin/tazobactam responsible for this immunogenic response and evaluate the safety of other beta-lactam antibiotics in this clinical setting.

Vancomycin Induced Thrombocytopenia - Protracted Course in a Hemodialysis Patient

Vancomycin induced thrombocytopenia (VIT) is an uncommon side effect of vancomycin which can manifest from mild petechiae to life-threatening bleed. Decreased renal clearance of vancomycin results in prolonged thrombocytopenia by antibody-mediated platelet destruction in the presence of vancomycin. Improvement in thrombocytopenia is achieved with the elimination of vancomycin. We describe a patient with end stage renal disease who experienced a protracted course of thrombocytopenia from vancomycin. We illustrate the mechanism of thrombocytopenia and the treatment modalities used by us and those described in literature. VIT is an important differential in patients with thrombocytopenia admitted to the hospital.

Documented vancomycin-induced severe immune-mediated thrombocytopaenia

A 69-year-old man developed Propionibacterium acnes left knee hardware infection after suffering from an infected ingrown toenail. The hardware was removed and he was treated with intravenous vancomycin. Ten days after initiation of vancomycin, he developed severe thrombocytopaenia, epistaxis and petechiae. Vancomycin was discontinued, and platelets rapidly recovered. Serum vancomycin IgG were positive. Patient completed a 6-week course of ceftriaxone with no further complications.