Could nonsteroidal antiinflammatory drugs (NSAIDs) enhance the progression of bacterial infections to toxic shock syndrome?

Repurposing host-guest chemistry to sequester virulence and eradicate biofilms in multidrug resistant Pseudomonas aeruginosa and Acinetobacter baumannii

The limited diversity in targets of available antibiotic therapies has put tremendous pressure on the treatment of bacterial pathogens, where numerous resistance mechanisms that counteract their function are becoming increasingly prevalent. Here, we utilize an unconventional anti-virulence screen of host-guest interacting macrocycles, and identify a water-soluble synthetic macrocycle, Pillar[5]arene, that is non-bactericidal/bacteriostatic and has a mechanism of action that involves binding to both homoserine lactones and lipopolysaccharides, key virulence factors in Gram-negative pathogens. Pillar[5]arene is active against Top Priority carbapenem- and third/fourth-generation cephalosporin-resistant Pseudomonas aeruginosa and Acinetobacter baumannii, suppressing toxins and biofilms and increasing the penetration and efficacy of standard-of-care antibiotics in combined administrations. The binding of homoserine lactones and lipopolysaccharides also sequesters their direct effects as toxins on eukaryotic membranes, neutralizing key tools that promote bacterial colonization and impede immune defenses, both in vitro and in vivo. Pillar[5]arene evades both existing antibiotic resistance mechanisms, as well as the build-up of rapid tolerance/resistance. The versatility of macrocyclic host-guest chemistry provides ample strategies for tailored targeting of virulence in a wide range of Gram-negative infectious diseases.

Retrospective case series: Necrotising fasciitis in 23 dogs

BACKGROUND

Necrotising fasciitis (NF) is a rare, rapidly progressive subcutaneous bacterial infection. Few studies have characterised NF in dogs.

HYPOTHESIS/OBJECTIVES

To retrospectively describe clinical and laboratory findings, with treatments and outcomes, in dogs with NF.

ANIMALS

Twenty-three client-owned dogs treated at a veterinary teaching hospital between 1998 and 2021.

MATERIALS AND METHODS

Medical records and laboratory data from 23 dogs diagnosed with NF were reviewed.

RESULTS

Male dogs were significantly over-represented (p = 0.003). The most common presenting complaint was sudden lameness. Infection occurred in one or two limbs in 19 of 23 dogs, with right hindlimbs most often affected (13 of 23). Pitting oedema was evident in 14 of 23 dogs. Antibiotic and nonsteroidal anti-inflammatory drugs were administered before presentation in nine and 13 of 23 dogs, respectively. Common clinicopathological abnormalities included hypoalbuminemia, hyponatremia, elevated liver enzymes, elevated creatine kinase, increased bands and lymphopenia. Streptococcus canis was isolated from 18 of 23 dogs. Histopathological features included acute necrosis and severe neutrophilic inflammation. Fifteen dogs were euthanised or died, while surgical intervention led to survival in eight of 23 dogs.

CONCLUSIONS AND CLINICAL RELEVANCE

Dogs presenting for acute swelling of a limb with oedema should have the diagnosis of NF considered and early surgical intervention might increase survival.

Immunomodulatory effects of pharmaceutical opioids and antipyretic analgesics: Mechanisms and relevance to infection

Understanding how pharmaceutical opioids and antipyretic analgesics interact with the immune system potentially has major clinical implications for management of patients with infectious diseases and surgical and critical care patients. An electronic search was carried out on MEDLINE, EMBASE, PsycINFO, CENTRAL and the Cochrane library to identify reports describing the immunomodulatory effects of opioid analgesics and antipyretic analgesics, and their effects in infectious diseases. In adaptive immunity, nonsteroidal anti-inflammatory drugs have divergent effects: augmenting cell-mediated immunity but inhibiting humoral immunity. Nonsteroidal anti-inflammatory drugs have demonstrated a beneficial role in Mycobacterium tuberculosis infection and histoplasmosis in animals, and may be plausible adjuvants to antimicrobial agents in these diseases. There is a need to evaluate these findings rigorously in human clinical trials. There is preliminary evidence demonstrating antiviral effects of indomethacin in SARS CoV-2 in vitro; however, uncertainty regarding its clinical benefit in humans needs to be resolved in large clinical trials. Certain opioid analgesics are associated with immunosuppressive effects, with a developing understanding that fentanyl, morphine, methadone and buprenorphine suppress innate immunity, whilst having diverse effects on adaptive immunity. Morphine suppresses key cells of the innate immunity and is associated with greater risk of infection in the postsurgical setting. Efforts are needed to achieve adequate analgesia whilst avoiding suppression of the innate immunity in the immediate postoperative period caused by certain opioids, particularly in cancer surgery.

Ketorolac Administration After Colorectal Surgery Increases Anastomotic Leak Rate: A Meta-Analysis and Systematic Review

Objective

This meta-analysis aimed to evaluate whether ketorolac administration is associated with an increased anastomotic leak rate after colorectal surgery.

Methods

The literature was searched using the Web of Science, Embase, and PubMed databases, and the search ended on May 31, 2020. The Newcastle–Ottawa Scale was used to assess methodological quality. Statistical heterogeneity was assessed using the Chi-square Q test and I² statistics. Subgroup analysis was performed, and Egger's test was used to assess publication bias.

Results

This meta-analysis included seven studies with 400,822 patients. Our results demonstrated that ketorolac administration after surgery increases the risk of anastomotic leak [OR = 1.41, 95% CI: 0.81–2.49, Z = 1.21, P = 0.23]. Low heterogeneity was observed across these studies (I² = 0%, P = 0.51). The results of subgroup analysis showed that the use of ketorolac in case–control and retrospective cohort studies significantly increased the risk of anastomotic leak (P < 0.05). Furthermore, the subgroup analysis revealed that ketorolac use increased anastomotic leak rate in patients in the United States and Canada, and ketorolac plus morphine use did not increase anastomotic leak rate in Taiwanese patients (P < 0.05). No significant publication bias was observed (P = 0.126). Moreover, the analysis of risk factors related to anastomotic leak rate indicated that the total use of ketorolac did not increase the risk of anastomotic leak similar to the control group (P > 0.05).

Conclusion

The meta-analysis indicates that the use of ketorolac increases the risk of anastomotic leak after colorectal surgery.

Systematic Review Registration

PROSPERO, identifier CRD42020195724.

Necrotizing Bacterial Myositis as the Initial Presentation of Severe Aplastic Anaemia

Introduction

Necrotizing soft tissue infections are rapidly progressing infections associated with severe inflammation and cytokine release. Early recognition and surgical intervention are key factors to secure survival. The current case presents a patient with multifocal necrotizing soft tissue infection as the initial presentation of severe aplastic anaemia. Case Presentation. A man in his fifties was admitted with septic shock with multiorgan failure and severe pancytopenia, after two days of malaise with high fever and right flank pain. The diagnosis streptococcal necrotizing myositis was significantly delayed due to atypical clinical findings. After initial surgical exploration, the decision was made to defer from surgical debridement due to extensive involvement of several muscle groups, grave pancytopenia, and suspected dismal prognosis. Surprisingly, the patient stabilized after antibiotics and intensive care treatment. Based on severe pancytopenia and hypocellular bone marrow, with no evidence of other bone marrow disorders, the patient was diagnosed with aplastic anaemia. Treatment for aplastic anaemia with antithymocyte globulin, cyclosporine, and eltrombopaq was started, and 2 months later, a partial haematological recovery was observed. The patient could be discharged from hospital without antibiotic treatment.

Conclusions

This case illustrates the crucial role of a multidisciplinary approach on admission and further during the clinical course. Clinical improvement despite severe neutropenia and stabilization during immunosuppressive therapy suggest that immunological factors modulate clinical course in necrotizing soft tissue infections.

Anti-Inflammatory Therapy of Infections

Anti-inflammatory treatment of infections is challenging due to the heterogeneity of etiologic agents and complex immune interactions. Nevertheless, anti-inflammatory medications are commonly used in infections to reduce unpleasant symptoms and to modify host response. They may play a fundamental role in managing infection with over-inflammation by decreasing inflammatory organ damage, e.g., COVID-19. However, by its inherent inhibition of immune functions, they might also contribute to the development of serious bacterial infections. Moreover, reducing a patient's symptoms and signs may provide a false sense of security and delay diagnosing threatening infections.

Management of Infectious Emergencies for the Inpatient Dermatologist

Purpose of Review

There are various dermatologic emergencies stemming from bacterial, viral, and fungal etiologies that can present in the inpatient setting. This review summarizes the pathogenesis and diagnosis of infections with cutaneous involvement and highlights new therapies.

Recent Findings

Clindamycin inhibits toxin formation and can be used as an adjunct therapy for the staphylococcal scalded syndrome. Isavuconazole therapy for mucormycosis infection is a less toxic alternative to amphotericin B.

Summary

Diagnosis of these infections is primarily guided by high clinical suspicion and early recognition can prevent dangerous sequelae. Treatment mainstays have been well-established, but there are adjunctive therapies that may potentially benefit the patient.

Evaluation of ibuprofen contamination in local urban rivers and its effects on immune parameters of juvenile grass carp

Ibuprofen as a non-steroidal anti-inflammatory drug can be detected in the aquatic environments all over the world. This study evaluated the effects of ibuprofen on the immune parameters of juvenile grass carp at the concentration in real environments which were determined by detecting its concentrations in the surface water of local rivers. The concentration of ibuprofen ranged from 13.2 to 95.5 ng/L with a mean value of 47.9 ng/L in the surface water of local rivers detected by solid-phase extraction followed by LC-MS/MS analysis. Accordingly, juvenile grass carp were exposed to 4.8, 48.0 and 480.0 ng/L of ibuprofen for 14 days. The serum lysozyme activity of these fish decreased, while the serum creatinine levels were not affected after the exposure. Moreover, the mRNA expression of interleukin 6 in the skin and interleukin 1 beta and tumor necrosis factor alpha in the gills was enhanced by this exposure. These results collectively suggest that ibuprofen at environmentally relevant concentration can affect the immune parameters of juvenile grass carp, providing an insight into the possibility of this contaminant to modify the immunostatus of fish.

Fatal Necrotizing Fasciitis as a Consequence of Blunt Trauma: A Case Report

Necrotizing fasciitis is an uncommon lethal bacterial infection that involves the subcutaneous tissue and fascia. It can be mono or polymicrobial infection. The diagnosis is mainly dependent on clinical signs and symptoms. Trauma is the commonest cause for it. The early signs and symptoms may mimic cellulitis. We present a case of necrotizing fasciitis following an assault. The patient was received in a state of shock. Despite all measures, the patient could not be saved. Early debridement and antibiotic therapy have a key role in the prognosis of the disease. Medicolegal issues can arise when the disease develops post-assault because of the vague and unpredictable nature of the disease and its challenging prognosis.

Risk factors associated with necrotizing fasciitis of the lower limbs: A multicenter case-control study

OBJECTIVE

The aim of this case-control study was to identify risk factors associated with necrotizing fasciitis (NF) of the lower limbs.

PATIENTS AND METHODS

We conducted a prospective case-control study in hospital dermatology departments in 5 sub-Saharan African countries over a 2-year period (April 2017 to July 2019). The cases were patients with NF of the lower limbs and the controls were patients with leg erysipelas. Each case was matched with two controls for age (±5 years) and sex. We analyzed local and general factors.

RESULTS

During the study period, 159 cases (73 females, 86 males) were matched with 318 controls. The mean age was 48.5±15.8 years for cases and 46.5±16.2 years for controls (P=0.24). The main local signs of NF were cutaneous necrosis (83.7%), pain (75.5%) and induration (42.1%). Multivariate analysis showed the following to be independent risk factors associated with NF of the lower limbs: obesity (odds ratio [OR]=2.10; 95% confidence interval [CI]: 1.21-3.42), diabetes (OR=3.97; 95% CI: 1.95-6.13), nicotine addiction (OR=5.07; 95% CI: 2.20-11.70), use of non-steroidal anti-inflammatory drugs (NSAIDs) (OR=7.85; 95% CI 4.60-14.21) and voluntary cosmetic depigmentation (OR=2.29; 95% CI: 1.19-3.73).

CONCLUSION

Our study documents the role of NSAID use at the onset of symptoms as a risk factor for NF of the lower limbs. However, the originality of our study consists in the identification of voluntary cosmetic depigmentation as a risk factor for NF of the lower limbs in sub-Saharan Africa patients. Our results also identified typical overarching factors such as diabetes, obesity and nicotine addiction. Knowing these factors and taking them into account will enable optimization of management strategies for these conditions.

Serious infectious events and ibuprofen administration in pediatrics: a narrative review in the era of COVID-19 pandemic

Purpose of review

Despite its recognized efficacy and tolerability profile, during the last decade a rise of adverse events following ibuprofen administration in children has been reported, including a possible role in worsening the clinical course of infections. Our aim was to critically evaluate the safety of ibuprofen during the course of pediatric infectious disease in order to promote its appropriate use in children.

Recent findings

Ibuprofen is associated with severe necrotizing soft tissue infections (NSTI) during chickenpox course. Pre-hospital use of ibuprofen seems to increase the risk of complicated pneumonia in children. Conflicting data have been published in septic children, while ibuprofen in the setting of Cystic Fibrosis (CF) exacerbations is safe and efficacious. No data is yet available for ibuprofen use during COVID-19 course.

Summary

Ibuprofen should not be recommended for chickenpox management. Due to possible higher risks of complicated pneumonia, we suggest caution on its use in children with respiratory symptoms. While it remains unclear whether ibuprofen may have harmful effects during systemic bacterial infection, its administration is recommended in CF course. Despite the lack of data, it is seems cautious to prefer the use of paracetamol during COVID-19 acute respiratory distress syndrome in children.

Does anti-inflammatory drugs modify the severe odontogenic infection prognosis? A 10-year's experience

Background

Numerous biochemical datas support the noxious role of anti-inflammatory drugs on immune response. Those observations are often put forward for unfavorable evolution of odontogenic infection but has never been really proven in clinic. The aim of this study is to try to clarify this role based on the collection of the clinical course of odontogenic infections over a 10-year analysis period.

Material and Methods

The investigators implemented a prospective observational study. The sample was composed of patients managed between January 2004 and December 2014 for severe odontogenic infection based on three criteria: hospital admission, intravenous antibiotic therapy, tooth extraction and collections drainage under general anesthesia. Clinical and pharmacological data were collected at admission, during hospitalization until discharged home. The population was first separated into two groups patients with or without anti-inflammatory drugs on admission, then on four groups (non-steroidal anti-inflammatory drugs, corticosteroids drugs, both and none on admission). Analysis were performed each time by univariate analysis, multivariate analysis and propensity score matching.

Results

Six hundred and fifty-three patients were included in the study, 329 (50%) patients report orally anti-inflammatory treatment before presenting to hospital, 50 (7.6%) received corticosteroids, 242 (37%) received NSAIDs and 37 (5.6%) both. Evolution is worsening for patients under anti-inflammatory drugs in term of hospitalization in ICU (p=0.016), number of surgeries (p=0.003), risk of tracheotomy (p=0.036), duration of hospitalization (p=0.005) and spaces involved by the infection (p<0.001). When separating patients into 4 groups, dysphonia and odynophagia are more frequent for patients under corticosteroid and NSAID (35.14%, p<0.001), mediastinal erythema is more frequent for patients under corticosteroid (16%, p=0.004), fever is more frequent for patients under NSAID (35.5%, p=0.032), pain is higher for patients under corticosteroids (p=0.024). But, in order to reduce bias, linked to factors of gravity, a regression weighted by propensity scores was performed and any group of patients is different from the others.

Conclusions

Patients under anti-inflammatory drugs have more severe dental infection on admission and their complex evolution seems to be linked to the severity of infection on admission.

Key words:Severe odontogenic infection, anti-inflammatory drugs, corticosteroids.

Spontaneous Necrotizing Fasciitis

Necrotizing soft tissue infections typically begin with direct inoculation of bacteria into the subcutaneous tissues. Here, we present a case with no such exposure, but with severe necrotizing fasciitis. We present a middle-aged man presented to the emergency department for a presumed allergic reaction after having initially sought care twice at an urgent care facility. The patient had swelling, but no tenderness of his right lateral chest and flank. Subsequent imaging showed extensive fluid in the fascial planes of the right chest wall requiring surgical debridement. Necrotizing fasciitis that is not treated with surgical debridement carries a mortality rate approaching 100%. This case highlights a potential atypical presentation as well as highlights the fact that the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score lacks sensitivity to rule out a necrotizing soft tissue infection, requiring surgical debridement for diagnosis.

Medico-legal importance of necrotizing fasciitis

Despite the rarity of necrotizing fasciitis (NF), it is a relatively common cause of death in many lawsuits. Families seek financial compensation or legal charges against those they believe to be involved in the death, usually physicians who did not identify the infection soon enough. This paper explores six cases in forensic pathology practice where NF posed a unique medico-legal dilemma.

Non-steroidal anti-inflammatory drugs, pharmacology, and COVID-19 infection

Non-steroidal anti-inflammatory drugs (NSAIDs) have an optional prescription status that has resulted in frequent use, in particular for the symptomatic treatment of fever and non-rheumatic pain. In 2019, a multi-source analysis of complementary pharmacological data showed that using NSAIDs in these indications (potentially indicative of an underlying infection) increases the risk of a severe bacterial complication, in particular in the case of lung infections. First, the clinical observations of the French Pharmacovigilance Network showed that severe bacterial infections can occur even after a short NSAID treatment, and even if the NSAID is associated with an antibiotic. Second, pharmacoepidemiological studies, some of which minimized the protopathic bias, all converged and confirmed the risk. Third, experimental in vitro and in vivo animal studies suggest several biological mechanisms, which strengthens a causal link beyond the well-known risk of delaying the care of the infection (immunomodulatory effects, effects on S. pyogenes infections, and reduced antibiotics efficacy). Therefore, in case of infection, symptomatic treatment with NSAIDs for non-severe symptoms (fever, pain, or myalgia) is not to be recommended, given a range of clinical and scientific arguments supporting an increased risk of severe bacterial complication. Besides, the existence of a safer drug alternative, with paracetamol at recommended doses, makes this recommendation of precaution and common sense even more legitimate. In 2020, such recommendation is more topical than ever with the emergence of COVID-19, especially since it results in fever, headaches, muscular pain, and cough, and is further complicated with pneumopathy, and given experimental data suggesting a link between ibuprofen and the level of expression of angiotensin-converting enzyme 2.

Ibuprofen Safety at the Golden Anniversary: Are all NSAIDs the Same? A Narrative Review

Ibuprofen first came to market about 50 years ago and rapidly moved to over-the-counter (OTC) sales. In April 2019, the National Agency for the Safety of Medicines and Health Products (ANSM) of France issued a warning for NSAID uses by patients with infectious diseases based on an analysis of 20 years of real-world safety data on ibuprofen and ketoprofen. Nevertheless, ibuprofen remains a mainstay in the analgesic armamentarium and with numerous randomized clinical trials, head-to-head studies, and decades of clinical experience. The authors offer a review of the safety of ibuprofen and how it may differ from other NSAIDs. Ibuprofen is associated with certain well-known gastrointestinal adverse effects that are related to dose and patient population. Among nonsteroidal anti-inflammatory drugs (NSAIDs), ibuprofen has a comparatively low risk of cardiovascular adverse effects. It has been associated with renal and hepatic adverse effects, which appear to depend on dose, concomitant medications, and patient population. The association of ibuprofen with infections is more complex in that it confers risk in some situations but benefits in others, the latter in cystic fibrosis. Emerging interest in the literature is providing evidence of the role of ibuprofen as a possible endocrine disrupter as well as its potential antiproliferative effects for cancer cells. Taken altogether, ibuprofen has a favorable safety profile and is an effective analgesic for many acute and chronic pain conditions, although it-like other NSAIDs-is not without risk. After 50 years, evidence is still emerging about ibuprofen and its unique safety profile among NSAIDs. FUNDING: The Rapid Service Fee was funded by Abbott Established Pharmaceuticals Division (EPD).

Nonsteroidal Anti-Inflammatory Drugs Impact on the Outcomes of Hospitalized Patients with Clostridium difficile Infection

Purpose

Mouse model experiments have demonstrated an increased Clostridium difficile infection (CDI) severity with Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) use. We aim to evaluate the impact of NSAIDs in humans after a diagnosis of CDI on primary outcomes defined as I) all-cause mortality and II) toxic mega-colon attributable to CDI.

Patients and methods

All hospitalized patients with a diagnosis of CDI were divided into two groups; those with NSAIDs administered up to 10 days after onset of CDI versus no NSAIDs use. The primary outcomes were analyzed between the groups, while controlling for severity of CDI. A logistic regression analysis was performed to identify the predictors of worse outcomes.

Results

NSAIDs were administered in 14% (n=80) of the 568 hospitalized visits for an average of 2.5 days after the CDI diagnosis. All-cause mortality was high in patients who did not receive NSAIDs as compared to those who did receive NSAIDs (16.6% vs 12.5%, p 0.354). Patients who were prescribed NSAIDs were more likely to have toxic mega-colon as compared to those who were not prescribed NSAIDs (2.5% vs 0.6%, p 0.094). Results were not statistically significant, even after controlling for CDI severity. Logistic regression analysis did not identify NSAIDs administration as a significant factor for all-cause mortality in CDI patients.

Conclusion

This retrospective study results, contrary to mouse model, did not show association between NSAID use and CDI related mortality and toxic mega-colon. Shorter duration of NSAIDs use, younger people in study group, and timely CDI treatment may have resulted in contrasting results.

Ibuprofen as risk-factor for complications of acute anterior sinusitis in children

IMPORTANCE

Non-steroidal anti-inflammatory drugs (NSAIDs) are known to inhibit chemotaxis, oxidative burst and phagocytosis, bacterial killing in granulocytes as well as inhibiting neutrophil aggregation or degranulation, thereby interfering with the function of lymphocytes. On the other hand, ibuprofen is widely prescribed in pediatrics for its powerful analgesic and antipyretic effects. To our knowledge, no previous publication outlines the relationship between Ibuprofen therapy and an increased risk of intracranial and/or orbital complications of acute fronto-ethmoidal sinusitis in childhood.

OBJECTIVE

To look for a relationship between ibuprofen and occurrence of intra-cranial and/or orbital complications of acute fronto-ethmoidal sinusitis in pediatrics.

SETTING AND METHODS

The medical charts of patients younger than 18 years admitted into the E.N.T. departments of 4 academic care centers during 2 consecutive years for fronto ethmoidal sinusitis were reviewed retrospectively. The history of ibuprofen intake, the occurrence of complication (orbital or intracranial) as well as the usual demographic data were noted. A statistical analysis was performed in order to ascertain whether a relationship between taking NSAIDs and the onset of an intracranial and/or orbital complication exists.

RESULTS

Intake of ibuprofen appeared to be a risk-factor of intracranial complications or associated orbital and intracranial complications of acute fronto-ethmoidal sinusitis in children. Neither gender nor age nor initial pain intensity were statistically related to the onset of complications.

CONCLUSION AND RELEVANCE

This retrospective multicenter cohort study appears to suggest that ibuprofen increases the risk of orbital and/or intracranial complications of acute fronto-ethmoidal sinusitis in childhood. Therefore, we recommend not prescribing ibuprofen if one suspects an acute sinusitis in a child or adolescent.

Combined Biological Effects of N-Bromotaurine Analogs and Ibuprofen. Part I: Influence on Inflammatory Properties of Macrophages

Taurine haloamines (N-chlorotaurine, N-bromotaurine) due to their strong antiseptic and anti-inflammatory properties are good candidates for topical application in treatment of skin inflammatory/infectious disorders. Recently, we have demonstrated that more stable N-bromotaurine analogs (N-dibromo-dimethyl taurine, N-monobromo-dimethyl taurine) and bromamine T show strong microbicidal and anti-inflammatory properties at concentrations well tolerated by human cells and tissue. Non-steroidal anti-inflammatory drugs (NSAIDs) with cyclooxygenase (COX) inhibitory activity are commonly used in various inflammatory diseases. However, systemic administration of NSAIDs may result in adverse side effects. For example, the use of ibuprofen in children with varicella is associated with enhanced serum levels of TNF-α and with increased risk of necrotizing soft tissue infections and secondary skin infections caused by invasive streptococci. The aim of this study was to examine combined immunomodulatory effects of bromamines and ibuprofen on J774.A1 macrophages. We have shown that the primary activity of ibuprofen, the inhibition of PGE2 production by activated macrophages was intensified in the presence of bromamines. Most importantly, the stimulatory effect of ibuprofen on production of inflammatory cytokines (TNF-α, IL-6) was inhibited by all tested bromamines. These observations indicate that bromamines may neutralize massive production of TNF-α at sites of inflammation, a side effect of ibuprofen. Therefore, we suggest that systemic administration of ibuprofen (NSAIDs) in treatment of inflammatory/infectious skin diseases should be supported by topical application of bromamines as an adjunctive therapy.

Combined Biological Effects of N-Bromotaurine Analogs and Ibuprofen. Part II: Influence on a Local Defense System

The stable N-bromotaurine analogs (N-dibromo-dimethyl taurine, N-monobromo-dimethyl taurine), and bromamine T (BAT) show anti-inflammatory and microbicidal properties. These bromamines are good candidates for a treatment of skin infectious/inflammatory diseases as local antiseptics. Ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), is commonly used in various infectious/inflammatory diseases due to its analgesic and antipyretic therapeutic effects. However, systemic administration of ibuprofen may also result in adverse side effects. It has been reported that ibuprofen enhances serum levels of TNF-α and worsens secondary skin infections caused by invasive streptococci (S. pyogenes). Recently we have demonstrated that bromamines inhibit the stimulatory effect of ibuprofen on the production of inflammatory cytokines (TNF-α, IL-6). The aim of this study was to examine the combined antibacterial actions of ibuprofen and bromamines against S. pyogenes and their joint effect on the generation of reactive oxygen species (ROS) by activated neutrophils and macrophages. We have shown that the microbicidal activity of bromamines against S. pyogenes was not altered by ibuprofen. On the other hand, co-administration of ibuprofen and bromamines markedly decreased the generation of ROS by activated neutrophils and macrophages. Finally, we discuss how the antioxidant combined effect of bromamines and ibuprofen may affect a local defense system.

Predicting Complicated Parapneumonic Effusion in Community Acquired Pneumonia: Hospital Based Case-Control Study

OBJECTIVE

To identify predictors of complicated parapneumonic effusion (CPE)/empyema in patients of community acquired pneumonia (CAP) by using clinical and simple laboratory variables like hemoglobin (Hb), serum C-reactive protein (CRP), serum albumin (SA) levels and total leukocyte counts (TLC).

METHODS

This prospective case-control study was conducted after institutional ethical approval. Subjects between ages of 2-59 mo with World Health Organization (WHO) defined CAP with written, informed parental consent were included. Cases had CAP with CPE/empyema diagnosed by pleurocentesis. Controls had severe CAP without significant pleural collection on chest X-ray (CXR). Patients with congenital and chronic diseases/infections and possible immune deficiency were excluded. Variables with univariate association with case-control status were considered as potential predictors. Final prediction model was developed by Forward Stepwise Logistic Regression (FSLR). Adjusted odd's ratios (Adj OR) were smoothened into nearest whole numbers to develop KGMU-CPE score.

RESULTS

From 2016 to 17, 30 cases (66.6% males, age 38.7 + 14.9 mo) and 118 controls (78% males, age 17.8 + 16.9 mo) were included. In FSLR, predictors of CPE/empyema were ibuprofen intake (adj OR 6.8; 95%CI: 1.07-43.6), infective focus elsewhere (adj OR 28.2; 95%CI: 1.4-563.1), hypoalbuminemia <3.1 g/dL (adj OR 6.9; 95%CI: 1.22-39.3), serum CRP >20 mg/dL (adj OR 59; 95%CI: 1.86-1874.7), Hb <10 g/dL (adj OR 21.1; 95%CI: 2.8-158.1) and TLC >10,000 (adj OR 37; 95%CI: 5.7-239.8) and these six variables formed KGMU-CPE Score with a minimum score of 0 and maximum of 25. KGMU-CPE score area under the ROC curve was 0.97 and cut- off 15.55 had sensitivity of 80% and specificity of 94% for predicting CPE/empyema.

CONCLUSIONS

Using simple clinical and laboratory parameters it is possible to predict CAP with CPE/empyema. Use of ibuprofen is to be avoided in CAP as it associated with CPE. KGMU-CPE score had good diagnostic accuracy and needs external validation.

Streptococcal toxic shock syndrome in the intensive care unit

The streptococcal toxic shock syndrome is a severe complication associated with invasive infections by group A streptococci. In spite of medical progresses in the care of patients with septic shock during the last decades, this condition has remained associated with a high mortality. Early recognition and multidisciplinary management are key to the care of patients with streptococcal toxic shock syndrome, with intensive and appropriate intensive support of failing organs, rapid diagnosis of infectious source(s), and surgical management. The epidemiology and risk factors for streptococcal toxic shock syndrome remain to be better studied, including the possible causal role of exposure to nonsteroidal anti-inflammatory drugs. In this review article, the authors review the current knowledge of streptococcal toxic shock syndrome and discuss the pathophysiology as well as its supportive and specific treatment.

The role of nonsteroidal anti-inflammatory drugs intramuscular injection in the development and severity of deep soft tissue infection in mice

The aim of this study was to determine the role of nonsteroidal anti-inflammatory drugs (NSAID) injection on the severity of local infection and the effect on the progression of soft tissue infection (STI).The mouse model of STI with Group A streptococcus (GAS) was developed and treated with diclofenac sodium (DS) intramuscularly. Mice were divided into five groups: administered DS for 48 h before GAS (Group 1), GAS-DS and maintained DS for 48 h (Group 2), DS for 48 h (Group 3), GAS on zero time (Group 4), and control (Group 5). In vitro, a high concentration (40 mg/L) of DS inhibited GAS growth, whereas a lower concentration (0.4 mg/L) was not effective. Sepsis was observed in animals with DS and GAS inoculation (group 1 and 2). Group 4 had statistically significant higher bacterial load than groups 1 and 2. All groups had a higher inflammation rate than the control group. The median of TNF-alpha and mean IL-6 in the groups 1, 2, and 4 was significantly higher than those in the control group. Even if the animals that were treated with DS injection prior to the GAS inoculation had similar inflammation score, similar cytokine levels and low bacterial load in the tissue, they had a rather high rate of sepsis. In conclusion, DS injection prior to bacterial inoculation might predispose to bacteremia and sepsis.

Bacterial infections and NSAIDs exposure? Seek septic complications

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely consumed. Some authors suggested a relationship between more severe infections and NSAIDs exposure, especially skin and soft tissue infections (SSTI). However, their impact during bacterial infections remains unclear. The aim of the study was to report the severity features of patients having bacterial infection who were exposed to NSAIDs prior to their hospitalisation. Cases of infected patients with these characteristics declared to the pharmacovigilance department of a French university hospital from 1 January 2011 to 31 December 2013 were retrospectively reviewed. Forty-one patients were included, mainly male (61%). Median age was 37years. No underlying disease was noted for 68% of cases. Ibuprofen was the most frequent drug (63%). Self-medication concerned 61% of cases. Respiratory tract, osteoarticular and SSTI were the most frequent infected sites. Patients suffered septic complications: dissemination of infection to more than one site (51%), suppuration (59%), and requirement for invasive procedures (32%). Eleven patients (27%) had severity criteria as usually defined (10 severe sepsis and 1 septic shock) and 30 did not. There was no significant difference regarding the rate of septic complications between the severe and non-severe group. Septic complications frequently occurred in patients with NSAIDs exposure, whether or not there was severe sepsis or shock. Further studies investigating the impact of NSAIDs in bacterial infections should consider the septic complications depicted here as clinically relevant endpoints. Moreover, clinicians should seek those complications in case of bacterial infections and NSAIDs use.

Management and Novel Adjuncts of Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections (NSTI) have been recognized for millennia and continue to impose considerable burden on both patient and society in terms of morbidity, death, and the allocation of resources. With improvements in the delivery of critical care, outcomes have improved, although disease-specific therapies are lacking. The basic principles of early diagnosis, of prompt and broad antimicrobial therapy, and of aggressive debridement have remained unchanged. Clearly novel and new therapeutics are needed to combat this persistently lethal disease. This review emphasizes the pillars of NSTI management and then summarizes the contemporary evidence supporting the incorporation of novel adjuncts to the pharmacologic and operative foundations of managing this disease.

Prehospital NSAIDs use prolong hospitalization in patients with pleuro-pulmonary infection

OBJECTIVE

Nonsteroidal anti-inflammatory drug (NSAID) pre-hospitalization consumption might affect the course of pneumonia. We opted to assess the potential effects of pre-hospitalization use of NSAIDs in patients with pleuropulmonary infection in the context of the duration of hospitalization.

METHODS

A prospective observational study of 57 consecutive patients with a diagnosis of pneumonia and parapneumonic pleural effusion was conducted. The exact medication history the previous fifteen days was recorded.

RESULTS

Prehospital use of NSAIDs >6 days was positively associated with prolonged hospitalization extending out for approximately 10 days. Immunosuppression was an independent risk factor for prolonged hospitalization of more than 5 days. This group of patients also had more complicated pleural effusions and difficult to treat management. In the immunocompetent group of patients, there was a negative inverse correlation of duration of NSAIDs use with pleural fluid pH and glucose. The longer medication with NSAIDs correlated with lower values of C-reactive protein, and erythrocyte sedimentation rate. Importantly, the early prehospital antibiotic use significantly prevented the development of empyema.

CONCLUSION

Our findings highlight the potential complications involved with prehospital use of NSAIDs and especially that prolonged NSAID use which may lead to longer hospitalization duration and more complicated pleural effusions.

Topical Prostaglandin E Analog Restores Defective Dendritic Cell-Mediated Th17 Host Defense Against Methicillin-Resistant Staphylococcus Aureus in the Skin of Diabetic Mice

People with diabetes are more prone to Staphylococcus aureus skin infection than healthy individuals. Control of S. aureus infection depends on dendritic cell (DC)-induced T-helper 17 (Th17)-mediated neutrophil recruitment and bacterial clearance. DC ingestion of infected apoptotic cells (IACs) drive prostaglandin E₂ (PGE₂) secretion to generate Th17 cells. We speculated that hyperglycemia inhibits skin DC migration to the lymph nodes and impairs the Th17 differentiation that accounts for poor skin host defense in diabetic mice. Diabetic mice showed increased skin lesion size and bacterial load and decreased PGE₂ secretion and Th17 cells compared with nondiabetic mice after methicillin-resistant S. aureus (MRSA) infection. Bone marrow-derived DCs (BMDCs) cultured in high glucose (25 mmol/L) exhibited decreased Ptges mRNA expression, PGE₂ production, lower CCR7-dependent DC migration, and diminished maturation after recognition of MRSA-IACs than BMDCs cultured in low glucose (5 mmol/L). Similar events were observed in DCs from diabetic mice infected with MRSA. Topical treatment of diabetic mice with the PGE analog misoprostol improved host defense against MRSA skin infection by restoring DC migration to draining lymph nodes, Th17 differentiation, and increased antimicrobial peptide expression. These findings identify a novel mechanism involved in poor skin host defense in diabetes and propose a targeted strategy to restore skin host defense in diabetes.

Nonsteroidal Anti-Inflammatory Drug without Antibiotics for Acute Viral Infection Increases the Empyema Risk in Children: A Matched Case-Control Study

OBJECTIVE

To investigate the risk factors of empyema after acute viral infection and to clarify the hypothesized association(s) between empyema and some viruses and/or the use of nonsteroidal anti-inflammatory drugs (NSAIDs).

STUDY DESIGN

A case-control study was conducted in 15 centers. Cases and controls were enrolled for a source population of children 3-15 years of age with acute viral infections between 2006 and 2009.

RESULTS

Among 215 empyemas, 83 cases (children with empyema and acute viral infection within the 15 preceding days) were included, and 83 controls (children with acute viral infection) were matched to cases. Considering the intake of any drug within 72 hours after acute viral infection onset and at least 6 consecutive days of antibiotic use and at least 1 day of NSAIDs exposure, the multivariable analysis retained an increased risk of empyema associated with NSAIDs exposure (aOR 2.79, 95% CI 1.4-5.58, P = .004), and a decreased risk associated with antibiotic use (aOR 0.32, 95% CI 0.11-0.97, P = .04). The risk of empyema associated with NSAIDs exposure was greater for children not prescribed an antibiotic and antibiotic intake diminished that risk for children given NSAIDs.

CONCLUSIONS

NSAIDs use during acute viral infection is associated with an increased risk of empyema in children, and antibiotics are associated with a decreased risk. The presence of antibiotic-NSAIDs interaction with this risk is suggested. These findings suggest that NSAIDs should not be recommended as a first-line antipyretic treatment during acute viral infections in children.

NSAIDs in paediatrics: caution with varicella!

Anti-inflammatory drugs have been suspected on several occasions to have promoted development of bacterial infection among varicella patients. Some countries have not implemented childhood varicella vaccination. Three cases in our hospital suggested the predisposing role of NSAIDs in varicella patient deterioration. Open access to these drugs widely increases their use and patient information should be continually provided in the medical offices and at dispensing pharmacy counters. Taking account of the benefit/risk balance and applying the simple precautionary principle, it would be appropriate to be cautious about the use of NSAIDs in the paediatric population.

Ketorolac Use and Postoperative Complications in Gastrointestinal Surgery

OBJECTIVE

To study the association between ketorolac use and postoperative complications.

BACKGROUND

Nonsteroidal anti-inflammatory drugs may impair wound healing and increase the risk of anastomotic leak in colon surgery. Studies to date have been limited by sample size, inability to identify confounding, and a focus limited to colon surgery.

METHODS

Ketorolac use, reinterventions, emergency department (ED) visits, and readmissions in adults (≥ 18 years) undergoing gastrointestinal (GI) operations was assessed in a nationwide cohort using the MarketScan Database (2008-2012).

RESULTS

Among 398,752 patients (median age 52, 45% male), 55% underwent colorectal surgery, whereas 45% had noncolorectal GI surgery. Five percent of patients received ketorolac. Adjusting for demographic characteristics, comorbidities, surgery type/indication, and preoperative medications, patients receiving ketorolac had higher odds of reintervention (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.08-1.32), ED visit (OR 1.44, 95% CI 1.37-1.51), and readmission within 30 days (OR 1.11, 95% CI 1.05-1.18) compared to those who did not receive ketorolac. Ketorolac use was associated with readmissions related to anastomotic complications (OR 1.20, 95% CI 1.06-1.36). Evaluating only admissions with ≤ 3 days duration to exclude cases where ketorolac might have been used for complication-related pain relief, the odds of complications associated with ketorolac were even greater.

CONCLUSIONS

Use of intravenous ketorolac was associated with greater odds of reintervention, ED visit, and readmission in both colorectal and noncolorectal GI surgery. Given this confirmatory evaluation of other reports of a negative association and the large size of this cohort, clinicians should exercise caution when using ketorolac in patients undergoing GI surgery.

Prostaglandin E₂ constrains systemic inflammation through an innate lymphoid cell-IL-22 axis

Systemic inflammation, which results from the massive release of proinflammatory molecules into the circulatory system, is a major risk factor for severe illness, but the precise mechanisms underlying its control are not fully understood. We observed that prostaglandin E2 (PGE2), through its receptor EP4, is down-regulated in human systemic inflammatory disease. Mice with reduced PGE2 synthesis develop systemic inflammation, associated with translocation of gut bacteria, which can be prevented by treatment with EP4 agonists. Mechanistically, we demonstrate that PGE2-EP4 signaling acts directly on type 3 innate lymphoid cells (ILCs), promoting their homeostasis and driving them to produce interleukin-22 (IL-22). Disruption of the ILC-IL-22 axis impairs PGE2-mediated inhibition of systemic inflammation. Hence, the ILC-IL-22 axis is essential in protecting against gut barrier dysfunction, enabling PGE2-EP4 signaling to impede systemic inflammation.

The roles of injury and nonsteroidal anti-inflammatory drugs in the development and outcomes of severe group A streptococcal soft tissue infections

PURPOSE OF REVIEW

This review summarizes clinical and basic science evidence linking trauma and nonsteroidal anti-inflammatory drug (NSAID) use to initiation and progression of severe group A streptococcal (GAS) soft tissue infection.

RECENT FINDINGS

New evidence includes recent clinical series and controlled studies that lend support to an NSAID/GAS association, basic science studies that demonstrate unique roles for nonpenetrating injury and NSAID administration in initiation of cryptogenic GAS infection and experimental studies showing that nonselective NSAIDs accelerate disease progression and limit antibiotic efficacy in established GAS soft tissue infections. Potential mechanisms for these processes are discussed.

SUMMARY

NSAIDs are important anti-inflammatory and analgesic drugs; however, new experimental data suggest that nonselective NSAIDs do more than simply mask the signs and symptoms of developing GAS infection. A more thorough understanding of the triadic interplay of injury-triggered immune signaling, GAS soft tissue infection and NSAIDs is of significant clinical importance and could shift the current paradigm of pain management to avert the consequences of such devastating infections.

[Necrotizing Soft Tissue Infection Caused by Serratia marcescens in a Patient Treated with Tocilizumab]

We report herein on a case of community-acquired necrotizing soft tissue infection caused by Serratia marcescens. The patient had been treated with prednisolone, tocilizumab and tacrolimus for rheumatoid arthritis. Since Gram staining of the tissue revealed Gram negative rod bacteria, ceftriaxone and clindamycin were administered as empiric therapy. Tissue culture revealed S. marcescens. Ceftriaxone was continued according to the antibiotic sensitivity. She underwent debridement of necrotic tissue and continued ceftriaxone for 17 days. She recovered and was discharged after skin grafting.

Nonsteroidal anti-inflammatory drugs and the risk for anastomotic failure: a report from Washington State's Surgical Care and Outcomes Assessment Program (SCOAP)

IMPORTANCE

Nonsteroidal anti-inflammatory drugs (NSAIDs) have many physiologic effects and are being used more commonly to treat postoperative pain, but recent small studies have suggested that NSAIDs may impair anastomotic healing in the gastrointestinal tract.

OBJECTIVE

To evaluate the relationship between postoperative NSAID administration and anastomotic complications.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of 13,082 patients undergoing bariatric or colorectal surgery at 47 hospitals in Washington State from January 1, 2006, through December 31, 2010, using data from the Surgical Care and Outcomes Assessment Program linked to the Washington State Comprehensive Abstract Reporting System.

EXPOSURE

NSAID administration beginning within 24 hours after surgery.

MAIN OUTCOMES AND MEASURES

We used multivariate logistic regression modeling to assess the risk for anastomotic complications (reoperation, rescue stoma, revision of an anastomosis, and percutaneous drainage of an abscess) through 90 days after bariatric and colorectal surgery involving anastomoses.

RESULTS

Of the 13,082 patients (mean [SD] age, 58.1 [15.8] years; 60.7% women), 3158 (24.1%) received NSAIDs. The overall 90-day rate of anastomotic leaks was 4.3% for all patients (151 patients [4.8%] in the NSAID group and 417 patients [4.2%] in the non-NSAID group; P=.16). After risk adjustment, NSAIDs were associated with a 24% increased risk for anastomotic leak (odds ratio, 1.24 [95% CI, 1.01-1.56]; P=.04). This association was isolated to nonelective colorectal surgery, for which the leak rate was 12.3% in the NSAID group and 8.3% in the non-NSAID group (odds ratio, 1.70 [95% CI, 1.11-2.68]; P=.01).

CONCLUSIONS AND RELEVANCE

Postoperative NSAIDs were associated with a significantly increased risk for anastomotic complications among patients undergoing nonelective colorectal resection. To determine the role of NSAIDs in colorectal surgery, future evaluations should consider specific formulations, the dose effect, mechanism, and other relevant outcome domains, including pain control, cardiac complications, and overall recovery.

Effects of selective and nonselective nonsteroidal anti-inflammatory drugs on antibiotic efficacy of experimental group A streptococcal myonecrosis

BACKGROUND

 Epidemiologic evidence suggests that nonsteroidal anti-inflammatory drugs (NSAIDs) contribute to more severe group A streptococcal (GAS) infections, yet a beneficial role for NSAIDs has been demonstrated in other experimental bacterial infections.

METHODS

 Nonselective (ketorolac tromethamine, ibuprofen, indomethacin), COX-1-selective (SC-560), or COX-2-selective (SC-236) NSAIDs ± antibiotics (penicillin, clindamycin) were given to mice challenged intramuscularly with M-type 3 GAS and disease course was followed for 14 days. RESULTS. All nonselective NSAIDs significantly accelerated mortality and reduced antibiotic efficacy; COX-selective NSAIDs had no significant effects.

CONCLUSIONS

 Use of nonselective NSAIDs, either alone or as adjuncts to antibiotic therapy, for GAS soft tissue infection may contribute to worse outcomes.

Resolution of inflammation as a novel chemopreventive strategy

Acute inflammation, a physiologic response to protect cells from microbial infection and other noxious stimuli, is automatically terminated by endogenous anti-inflammatory and pro-resolving mediators to restore homeostatic conditions. However, if timely resolution of inflammation is failed, inflammation persists and can progress to a chronic inflammation which has long been thought as a predisposing factor to carcinogenesis. Excessive and pathologic inflammation causes DNA damage, genomic instability, epigenetic dysregulation, and alteration of intracellular signaling, all of which are involved in neoplastic transformation. To prevent chronic inflammation and resulting inflammation-promoted cancer development, understanding the process that resolves inflammation is essential. Resolution of inflammation is an active coordinated process regulated by distinct anti-inflammatory and pro-resolving endogenous lipid mediators, such as resolvins and lipoxins. The role of pro-inflammatory signaling in carcinogenesis has become more and more evident and well characterized, but the potential role of pro-resolving mediators in cancer prevention remains still elusive. In searching for an efficacious way to prevent chronic inflammation-associated cancer, the pro-resolving signal transduction pathways and their regulators should be unraveled.

[Necrotizing soft tissue infection of the upper limb]

Necrotizing soft tissue infections and necrotizing fasciitis are life-threatening infections affecting the hypodermis, muscular fascia, and dermis secondarily. Mortality is high, with an average of 30%. The early diagnosis of necrotizing soft tissue infection is challenging, but is key to successful management of these patients. The mainstay of therapy includes early and wide surgical debridement, antibiotics and supportive care. Adjunctive therapies may have a role, but their effectiveness remains unproven. A review of the literature allows us to highlight this multidisciplinary management.