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Shahbazi F, Shojaei L, Farvadi F, Kadivarian S. Antimicrobial safety considerations in critically ill patients: part II: focused on anti-microbial toxicities. Expert Rev Clin Pharmacol 2022; 15:563-573. [PMID: 35734938 DOI: 10.1080/17512433.2022.2093716] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics. AREAS COVERED In the current article we searched PubMed, Scopus and Google Scholar for neurotoxicities, hematologic toxicity and fluid stewardship in intensive care units. EXPERT OPINION Critically ill patients who receive antimicrobial agents should be monitored for neurological, hematologic toxicities especially seizure, thrombocytopenia, and clostridioides infections. Other toxicities including QTc prolongation, electrolyte disturbances, liver enzyme elevation, and infusion-related reactions were being considered. Other changes, including fluid overload, hypoalbuminemia, augmented renal clearance, increased cardiac outputs in septic shock, and acute kidney injury, may influence treatment efficiency and patient outcome.
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Affiliation(s)
- Foroud Shahbazi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Lida Shojaei
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Fakhrossadat Farvadi
- Center for nanotechnology in drug delivery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Kadivarian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Jonsson AB, Rygård SL, Hildebrandt T, Perner A, Møller MH, Russell L. Thrombocytopenia in intensive care unit patients: A scoping review. Acta Anaesthesiol Scand 2021; 65:2-14. [PMID: 32916017 DOI: 10.1111/aas.13699] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/17/2020] [Accepted: 08/22/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Thrombocytopenia is frequent in intensive care unit (ICU) patients and may be associated with adverse outcomes. We aimed to assess the incidence, risk factors, and outcomes associated with thrombocytopenia in adult ICU patients. METHODS We conducted a scoping review in accordance with the Preferred Reporting Items for Systematic Review and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We included study reports on adult ICU patients with thrombocytopenia and assessed patient-important outcomes, including mortality and health-related quality-of-life. RESULTS We included a total of 70 studies comprising a total of 215 098 patients; 57 were cohort studies. The incidence of thrombocytopenia varied from 8 to 56 per 100 admissions (very low quality of evidence). We identified several risk factors including age, sepsis, and higher disease severity (low quality of evidence). Thrombocytopenia was associated with bleeding, use of life support, length of stay in the ICU, and increased mortality (low/very low quality of evidence). Data on platelet transfusion before invasive procedures and transfusion thresholds were limited. No studies assessed the benefits and harms of thromboprophylaxis in ICU patients with thrombocytopenia. CONCLUSIONS Thrombocytopenia is common and associated with increased morbidity and mortality in adult ICU patients. Several risk factors for thrombocytopenia exists, but the evidence-base on management strategies, including transfusion thresholds and thromboprophylaxis in ICU patients is very limited.
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Affiliation(s)
- Andreas Bender Jonsson
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Sofie Louise Rygård
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | | | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Lene Russell
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Copenhagen Academy for Medical Education and Simulation Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
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Zhang MK, Xu TQ, Zhang XJ, Rao ZG, He XX, Wu MQ, Li ZP, Liu Y, Yang JC, Gong YF, Tang M, Xue XY. Thrombocytopenia in 737 adult intensive care unit patients: A real-world study of associated factors, drugs, platelet transfusion, and clinical outcome. SAGE Open Med 2020; 8:2050312120958908. [PMID: 33110602 PMCID: PMC7564627 DOI: 10.1177/2050312120958908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 08/25/2020] [Indexed: 12/28/2022] Open
Abstract
Objective: We aimed to identify and represent factors associated with thrombocytopenia
in intensive care unit, especially the pathogens and drugs related to severe
and extremely thrombocytopenia. Then, we aim to compare the mortality of
platelet transfusion and non-transfusion in patients with different degrees
of thrombocytopenia. Methods: We identified all thrombocytopenic patients in intensive care unit by using
platelet-specific values and then extracted electronic health records from
our Hospital Information System. Data were statistically analyzed with t
test, chi-square test, and logistic regression. Results: We found that infections (32.7%) were the most frequent cause associated with
thrombocytopenia, followed by sepsis shock (3.93%) and blood loss (2.99%).
Meanwhile, antifungals (p = 0.002) and bacterial infection
(p = 0.037) were associated with severe and extremely
severe thrombocytopenia. Finally, we found that the mortality of platelet
transfusion and non-transfusion in patients was statistically significant
for patients with platelet counts between 30 and 49/nL
(χ2 = 9.719, p = 0.002). Conclusion: Infection and sepsis emerged as two primary factors associated with
thrombocytopenia in intensive care unit. Meanwhile, antifungals and
bacterial infection were associated with platelet counts less than 49/nL.
Finally, platelet transfusion may be associated with reduced mortality in
patients with platelet counts between 30 and 49/nL.
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Affiliation(s)
- Man-Ka Zhang
- Intensive Care Unit, Aerospace Central Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Tian-Qi Xu
- Intensive Care Unit, Aerospace Central Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Xiao-Jing Zhang
- Intensive Care Unit, Aerospace Central Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Zhi-Guo Rao
- Intensive Care Unit, Aerospace Central Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Xiao-Xu He
- Intensive Care Unit, Aerospace Central Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Mei-Qing Wu
- Intensive Care Unit, Aerospace Central Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Zhou-Ping Li
- Intensive Care Unit, Aerospace Central Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Yin Liu
- Intensive Care Unit, Aerospace Central Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Jing-Cheng Yang
- Intensive Care Unit, Aerospace Central Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Yi-Fan Gong
- Intensive Care Unit, Aerospace Central Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Ming Tang
- Intensive Care Unit, Aerospace Central Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Xiao-Yan Xue
- Intensive Care Unit, Aerospace Central Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
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Abstract
Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.
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Stoll F, Gödde M, Leo A, Katus HA, Müller OJ. Characterization of hospitalized cardiovascular patients with suspected heparin-induced thrombocytopenia. Clin Cardiol 2018; 41:1521-1526. [PMID: 30144122 DOI: 10.1002/clc.23061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 08/21/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Little is known about heparin-induced thrombocytopenia (HIT), a pro-thrombotic, potentially life-threatening immune-mediated reaction to heparin exposure, in conservative and interventional cardiovascular medicine. HYPOTHESIS The 4T score, validated for prediction of HIT in surgical patients before, is also suitable for assessing HIT probability in cardiovascular patients with unclear thrombocytopenia. METHODS A total of 403 consecutive patients from our Department of Cardiology, Angiology and Pneumology in whom a HIT screening test was performed between 2009 and 2016 were identified. All 72 patients with a positive screening test were subjected to a functional confirmation test (heparin-induced platelet activation test, HIPA), resulting in 23 patients with serologically confirmed HIT (positive screening test, positive HIPA) and 49 patients with nonconfirmed HIT (positive screening test, negative HIPA). RESULTS The 4TScore had a sensitivity of 82.6% and a specificity of 28.6% in our patients, suggesting that it might not sufficiently predict the clinical probability of HIT in cardiovascular patients. In both confirmed and nonconfirmed HIT, intrahospital mortality was high without a significant difference (30% in confirmed HIT vs 43% in nonconfirmed HIT). Bacteremia was more often found in patients with nonconfirmed HIT, suggesting infection as a frequent differential diagnosis of thrombocytopenia in these patients (49% vs 17%, P = 0.0185). CONCLUSION HIT screening should be initiated in cardiovascular patients with unclear thrombocytopenia despite a low 4Tscore in order to distinguish patients requiring alternative anticoagulants from those with other causes such as infections. Further research is needed to specify the risk profile for HIT in cardiovascular patients.
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Affiliation(s)
- Felicitas Stoll
- Heidelberg University Hospital, Internal Medicine III, DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Miriel Gödde
- Heidelberg University Hospital, Internal Medicine III, DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Albrecht Leo
- Institute for Clinical Transfusion Medicine and Cell Therapy Heidelberg gGmbH, Heidelberg, Germany
| | - Hugo A Katus
- Heidelberg University Hospital, Internal Medicine III, DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Oliver J Müller
- Heidelberg University Hospital, Internal Medicine III, DZHK (German Center for Cardiovascular Research), Mannheim, Germany.,Department of Internal Medicine III, University of Kiel, Germany
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Sim DW, Yu JE, Jeong J, Koh YI. Ciprofloxacin-induced immune-mediated thrombocytopenia: No cross-reactivity with gemifloxacin. J Clin Pharm Ther 2017; 43:134-136. [PMID: 28791716 DOI: 10.1111/jcpt.12596] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/26/2017] [Indexed: 01/22/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Fluoroquinolone-induced immune-mediated thrombocytopenia is uncommon, and no reports of cross-reactivity among fluoroquinolones exist. Here, we describe a case of ciprofloxacin-induced immune thrombocytopenia with no cross-reactivity with gemifloxacin. CASE DESCRIPTION A 77-year-old woman showed profound thrombocytopenia immediately after two ciprofloxacin injections for pneumonia. Platelet counts recovered rapidly after ciprofloxacin discontinuation. She had experienced thrombocytopenia after ciprofloxacin administration 4 years earlier, which was assumed to be ciprofloxacin-induced immune-related. Interestingly, no thrombocytopenia occurred following the subsequent exposure to another fluoroquinolone, gemifloxacin. WHAT IS NEW AND CONCLUSION No cross-reactivity occurred between ciprofloxacin and gemifloxacin in this fluoroquinolone-induced immune thrombocytopenia case.
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Affiliation(s)
- D W Sim
- Division of Allergy, Asthma and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - J E Yu
- Division of Allergy, Asthma and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - J Jeong
- Division of Allergy, Asthma and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Y-I Koh
- Division of Allergy, Asthma and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Brent J, Burkhart K, Dargan P, Hatten B, Megarbane B, Palmer R, White J. Adverse Drug Reactions in the Intensive Care Unit. CRITICAL CARE TOXICOLOGY 2017. [PMCID: PMC7153447 DOI: 10.1007/978-3-319-17900-1_33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.
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Affiliation(s)
- Jeffrey Brent
- Department of Medicine, Division of Clinical Pharmacology and Toxicology, University of Colorado, School of Medicine, Aurora, Colorado USA
| | - Keith Burkhart
- FDA, Office of New Drugs/Immediate Office, Center for Drug Evaluation and Research, Silver Spring, Maryland USA
| | - Paul Dargan
- Clinical Toxicology, St Thomas’ Hospital, Silver Spring, Maryland USA
| | - Benjamin Hatten
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Bruno Megarbane
- Medical Toxicological Intensive Care Unit, Lariboisiere Hospital, Paris-Diderot University, Paris, France
| | - Robert Palmer
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Julian White
- Toxinology Department, Women’s and Children’s Hospital, North Adelaide, South Australia Australia
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