Tigecycline-Associated Acute Pancreatitis

Prolonged course of eravacycline leading to acute pancreatitis

Eravacycline is the newest member of the broad-spectrum class of tetracycline antimicrobials. Pancreatitis has been previously associated with the tetracycline class of antibiotics, but, to our knowledge, we believe that this is the first reported case of eravacycline-induced pancreatitis. We describe a 46-year-old male who received eravacycline for treatment of a perirectal abscess. While the patient had slightly elevated lipase levels at baseline post-cardiopulmonary arrest, he developed abdominal pain and a further increase in lipase levels following 10 days of eravacycline, consistent with pancreatitis. Based on the Naranjo adverse drug reaction probability scale, eravacycline was the probable etiology of acute pancreatitis given improvement immediately after discontinuation. Clinicians should be aware of this potential adverse effect of eravacycline and should not initiate eravacycline in those with risk factors for acute pancreatic injury. However, acute pancreatitis should be suspected in all patients complaining of symptoms followed by immediate discontinuation of eravacycline.

Safety and effectiveness of tigecycline combination therapy in renal transplant patients with infection due to carbapenem-resistant gram-negative bacteria

Background

Carbapenem-resistant gram-negative bacterial (CRGNB) infections are increasing among kidney transplant recipients, and effective therapeutic options are limited. This study aimed to investigate the efficacy and adverse events associated with combination therapy tigecycline in renal transplant patients with CRGNB infections.

Methods

This study retrospectively analyzed 40 Chinese patients with confirmed or suspected CRGNB infections who received tigecycline therapy. The patients' case features and clinical and microbiological data were analyzed.

Results

A total of 40 renal transplant recipients received tigecycline therapy for a median duration of 9 (range, 3-25) days. CRGNB isolates were obtained from the organ preservation solution of the donor kidney in 28 patients, with confirmed transmission in 4 patients. Infections were detected in the bloodstream, urinary tract, sputum, and wound. The most prevalent isolates were Klebsiella pneumoniae (75%, 30/40), Acinetobacter baumannii (15%, 6/40), and Escherichia coli (10%, 4/40). A clinical response was observed in 32 (80%) patients. The 28-day all-cause mortality rate was 7.5% (3/40), while the one-year all-cause mortality rate was 2.5% (1/40). While one patient died owing to severe pancreatitis, no serious adverse events related to tigecycline therapy were reported. However, multiple indices of liver function and pancreatitis precursors increased after treatment with tigecycline compared to before treatment.

Conclusion

Tigecycline therapy appears to be well tolerated in renal transplant recipients with multidrug-resistant bacterial infections. Nevertheless, attention should be paid to adverse reactions related to tigecycline therapy, especially gastrointestinal reactions, and the related laboratory tests should be closely monitored.

Tigecycline Tango: A Case of Antibiotic-Induced Pancreatitis

Acute pancreatitis is a frequent cause of hospitalization, with the most common triggers being alcohol consumption and gallstones. Although the incidence of drug-induced pancreatitis remains low, it is steadily increasing due to the advent of newly discovered broad-spectrum antibiotics targeting multi-drug resistant organisms. Tigecycline, a broad-spectrum intravenous antibiotic derived from the tetracycline class, was approved by the FDA in 2005 for the treatment of complicated skin and skin structure infections, complicated intra-abdominal infections, and community-acquired pneumonia. It has activity against vancomycin-resistant Enterococcus, Methicillin-resistant Staphylococcus aureus, multi-drug-resistant Acinetobacter baumannii, multi-drug-resistant Stenotrophomonas maltophilia, and Extended Spectrum Beta-lactamase (ESBL) producing Enterobacter species. However, it was later discovered that tigecycline can cause acute pancreatitis. We present a case of a 27-year-old female patient who was admitted to the emergency department with abdominal pain and was subsequently diagnosed with tigecycline-induced pancreatitis based on the clinical resolution after withdrawal of the drug.

The Spectrum of Tigecycline-Induced Pancreatitis in Clinical Characteristics, Diagnosis, and Management

Introduction

Tigecycline-induced acute pancreatitis (AP) has been frequently increasingly reported in solid organ transplant patients. This review aimed to summarize the characteristics, possible mechanisms, and management of tigecycline-induced AP.

Methods

Case reports of tigecycline-induced AP published in Chinese or English were collected until February 2023 for retrospective analysis.

Results

Thirty-four patients from 29 articles were included. Fifteen patients (46.9%) had solid organ transplantation, and 4 patients (12.5%) had malignant tumors. Twenty-five patients (89.3%) received a recommended maintenance dose of tigecycline (50 mg q12 h). The median age was 50 years (range 9-87). Compared to the nontransplant patients, the median age of the transplant patients was significantly younger, 44 years (range 12.5-61) versus 57.5 years (range 9-87) (P=0.03). The median time of symptom onset was 7 days (range 2-29), and 91.2% (31/34) were less than 14 days. Typical initial symptoms included abdominal pain (90.6%), nausea (46.9%), vomiting (43.8%), and abdominal distention (21.9%). Most cases were accompanied by elevated levels of pancreatic enzymes. The main radiological features included edematous infiltrate and acute pancreatitis on computed tomography (CT) scan and abdominal ultrasound. Except for one patient who continued tigecycline treatment, all patients discontinued treatment and received symptomatic support such as fasting, acid suppression, and enzyme suppression. The median time to recover pancreatic enzymes to the normal range was 5 days (range 1-43), and the median time to relieve symptoms was 4 days (range 1-12). Four patients died, of whom two died of severe pancreatitis complications and two of cardiogenic shock and septicemia.

Conclusion

Tigecycline-induced AP was a rare and serious complication that occurred mainly within two weeks of the medication. This serious side effect should be kept in mind while treating severe infections especially in transplant recipients.

Analysis of the clinical characteristics of tigecycline-induced hypofibrinogenemia

Knowledge regarding the association between hypofibrinogenemia and tigecycline is based mainly on case reports. However, the clinical features of tigecycline-induced hypofibrinogenemia are unclear. We collected 20 patients (16 males and 4 females) with tigecycline-induced hypofibrinogenemia by searching the Chinese and English databases from June 2005 to May 2021, with a median age of 63.5 years (range 39∼90 years). Hypofibrinogenemia developed at a median of 9 days (range 2∼35 days). Most patients had no typical clinical manifestations, and only a few patients had bleeding and ecchymosis. Fibrinogen levels gradually decreased from 3.98 ± 2.05 g/L to 0.87 ± 0.45 g/L (P = 0.000), and the activated partial thromboplastin time (APTT) increased from 38.26 ± 8.80 s to 83.43 ± 47.23 s (P = 0.002). Fibrinogen levels in all patients recovered to the normal range within a median of 4 days (range 1∼12 days) after tigecycline cessation. Our results suggest that fibrinogen levels should be closely monitored in patients treated with tigecycline, specifically patients who may have renal insufficiency or patients with long-term use.

Acute pancreatitis caused by tigecycline: A case report and literature review

RATIONALE

There is evidence that tigecycline has broad-spectrum antibiotic activity against a variety of complicated infections. However, adverse effects are inevitable, including gastrointestinal side effects such as nausea, vomiting, and diarrhea; in 2006, acute pancreatitis was also brought into the side-effect list after postmarketing surveillance. Here, we present a case of tigecycline-induced acute pancreatitis.

PATIENT CONCERNS

An 87-year-old female patient with urinary tract infection received an intravenous drip of tigecycline for 6 days, after which she developed abdominal distension, vomiting, abdominal pain, and abdominal rigidity.

DIAGNOSIS

The patient was suspected to have tigecycline-induced acute pancreatitis.

INTERVENTIONS

Tigecycline was discontinued immediately, and the patient received a series of immediate treatments including an indwelling gastric tube for continuous gastrointestinal decompression and inhibition of gastric acid and pancreatic enzyme secretion.

OUTCOMES

Following initial interventions, we observed that the patient's symptoms improved significantly, and abdominal distension, vomiting, abdominal pain, and abdominal rigidity were slightly relieved. After 5 days of follow-up, blood lipase and amylase levels decreased to normal levels. Unfortunately, the patient developed convulsions during the use of multiple antibiotics after 1 week and then died of septic shock and acute liver failure.

LESSONS

Acute pancreatitis caused by tigecycline is rare. However, in the application of antibiotics, the possibility of adverse effects must be considered, and antibiotics should be used reasonably. If the patient has relevant symptoms, it is necessary to stop using tigecycline immediately, carry out symptomatic treatment, and change to other types of antibiotics for antibacterial treatment.

A case report of tigecycline induced acute pancreatitis in a renal transplant patient and review of the literature: Should we avoid tigecycline in patients on calcineurin inhibitors?

Tigecycline has been approved by the US (United States) Food and Drug Administration in a variety of complicated infections due to its broad-spectrum antibiotic activity. Following phase III trials, the product label was revised and acute pancreatitis was listed as an adverse effect. Its safety profile in special groups such as renal transplant patients is not exactly known. We report the first case of unintentional rechallenge of tigecycline induced pancreatitis in a renal transplant patient. Ten days following the renal transplantation, a 35-year-old patient presented to the clinic with acute rejection. He received anti-thymocyte globulin (ATG) and pulse steroid treatments for rejection. Following the treatment, he developed perianal cellulitis and tigecycline was started. Nine days following initiation of tigecycline he received thrombectomy for his incidental cardiac thrombus. One day after thrombectomy, he developed acute pancreatitis (AP). Thrombectomy was suspected to be the cause of AP. During hospitalization for transplant rejection, tigecycline was re-started for a newly developed complicated abdominal infection. On the third day of the tigecycline re-treatment, he developed a second episode of AP. Following tigecycline withdrawal, his symptoms resolved and serum pancreatic enzymes returned to normal, thus AP was ultimately attributed to tigecycline. This lethal side effect should be kept in mind while treating severe infections in renal transplant recipients.

Successful Treatment of Early Post-Transplant Bloodstream and Pulmonary Infection Caused by Carbapenem-Resistant Klebsiella pneumoniae With a Combination of Ceftazidime-Avibactam and Carbapenem: A Case Report

Bloodstream infection with carbapenem-resistant Klebsiella pneumoniae (CRKP) is a severe and challenging complication in the early post-transplantation period. Pulmonary infection secondary to sepsis caused by CRKP has been reported only rarely in kidney transplant recipients. Here we report an interesting and complicated case in which CRKP was initially isolated in a culture of renal graft preservation solution, yet was not detected in the daily cultures from collection of surgical drainage. Prophylactic tigecycline was terminated at post-transplantation day 10 because of the occurrence of acute pancreatitis. Five days later, the patient suddenly developed a multisite infection with CRKP involving the bloodstream, urinary tract, and lungs, indicating probable transmission from the donor. Fortunately, the infection was controlled quickly and effectively with a combination therapy consisting of ceftazidime-avibactam (CZA) and carbapenem, which was suggested by the results of disc diffusion susceptibility testing. However, the CRKP infection reappeared in the bloodstream and urinary tract soon after the treatment of acute rejection. The combination regimen was continued for another 15 days, and the patient ultimately recovered. During the following 15 months of observation, the patient's renal graft function remained stable, without recurrence of the CRKP infection. In conclusion, the combined use of CZA and carbapenem was safe and produced an optimal therapeutic effect on the severe multisite infection caused by CRKP in a renal transplant recipient, thus providing a reference case for treating such patients.