Hypocoagulation induced by broad-spectrum antibiotics in extensive burn patients

Prophylactic Systemic Antibiotic and Systemic Glucocorticoid Therapy After Burn Inhalation Injury: A Report of Two Cases and Review of Literature

Burn inhalation injury is a significant risk factor for mortality in burn patients. Despite the considerable progress made in the treatment of burn inhalation injury, there remains no consensus on the appropriate course of treatment, leading to ongoing controversy regarding the use of prophylactic systemic antibiotics and systemic glucocorticoids. This study presents two cases of burn inhalation injury diagnosed by fiberoptic bronchoscopy and treated with systemic glucocorticoids and prophylactic systemic antibiotics. By conducting a literature review, this study aimed to discuss the application of systemic glucocorticoids and prophylactic systemic antibiotics in patients with burn inhalation injuries. The suitability of prophylactic systemic antibiotics and systemic glucocorticoids for treating burn inhalation injury patients necessitates a comprehensive assessment of the patient's condition and an accurate judgment of the course of their disease.

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

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

Signal Detection of Pediatric Drug–Induced Coagulopathy Using Routine Electronic Health Records

Background: Drug-induced coagulopathy (DIC) is a severe adverse reaction and has become a significantly increased clinical problem in children. It is crucial to the detection of the DIC safety signal for drug post-marketing scientific supervision purposes. Therefore, this study aimed to detect potential signals for DIC in children using the routine electronic medical record (EMR) data.

Methods: This study extracted EMR data from Beijing Children’s Hospital between 2009 and 2020. A two-stage modeling method was developed to detect the signal of DIC. We calculated the crude incidence by mining cases of coagulopathy to select the potential suspected drugs; then, propensity score-matched retrospective cohorts of specific screened drugs from the first stage were constructed and estimated the odds ratio (OR) and 95% confidence interval (CI) using conditional logistic regression models. The current literature evidence was used to assess the novelty of the signal.

Results:In the study, from a total of 340 drugs, 22 drugs were initially screened as potentially inducing coagulopathy. In total, we identified 19 positive DIC associations. Of these, potential DIC risk of omeprazole (OR: 2.23, 95% CI: 1.88–2.65), chlorpheniramine (OR:3.04, 95% CI:2.56–3.60), and salbutamol sulfate (OR:1.36, 95% CI:1.07–1.73) were three new DIC signals in both children and adults. Twelve associations between coagulopathy and drugs, meropenem (OR: 3.38, 95% CI: 2.72–4.20), cefoperazone sulbactam (OR: 2.80, 95% CI: 2.30–3.41), fluconazole (OR: 2.11, 95% CI: 1.71–2.59), voriconazole (OR: 2.82, 95% CI: 2.20–3.61), ambroxol hydrochloride (OR: 2.12, 95% CI: 1.74–2.58), furosemide (OR: 2.36, 95% CI: 2.08–2.67), iodixanol (OR: 2.21, 95% CI: 1.72–2.85), cefamandole (OR: 1.82, 95% CI: 1.56–2.13), ceftizoxime (OR: 1.95, 95% CI: 1.44–2.63), ceftriaxone (OR: 1.95, 95% CI: 1.44–2.63), latamoxef sodium (OR: 1.76, 95% CI: 1.49–2.07), and sulfamethoxazole (OR: 1.29, 95% CI: 1.01–1.64), were considered as new signals in children.

Conclusion: The two-stage algorithm developed in our study to detect safety signals of DIC found nineteen signals of DIC, including twelve new signals in a pediatric population. However, these safety signals of DIC need to be confirmed by further studies based on population study and mechanism research.

Hypercoagulation and Hypermetabolism of Fibrinogen in Severely Burned Adults

This study investigated changes in plasma fibrinogen metabolism and changes in coagulation in severely burned adults. Ten patients (27 ± 3 years; 91 ± 6 kg) with 51 ± 3% TBSA were consented and enrolled into an institutional review board-approved prospective study. On the study day, stable isotope infusion of 1-13C-phenylalanine and d5-phenylalanine was performed to quantify fibrinogen production and consumption. During the infusion, vital signs were recorded and blood samples were drawn every hour. Coagulation was measured by thromboelastograph (TEG). Ten normal healthy volunteers (37 ± 7 years; 74 ± 4 kg) were included as the control group. Burned adults had elevated heart rates (120 ± 2 vs 73 ± 5 [control] beats/minute), respiration rates (23 ± 2 vs 15 ± 1 breaths/minute), plasma glucose (127 ± 10 vs 89 ± 2 mg/dl), and fibrinogen levels (613 ± 35 vs 239 ± 17 mg/dl); and decreased albumin (1.3 ± 0.2 vs 3.7 ± 0.1 g/dl) and total protein (4.4 ± 0.2 vs 6.8 ± 0.1 g/dl, all P < .05). Fibrinogen breakdown was elevated in the burn group (2.3 ± 0.4 vs. 1.0 ± 0.3 µmol/kg/minute); and fibrinogen synthesis was further enhanced in the burn group (4.4 ± 0.7 vs 0.7 ± 0.2 µmol/kg/minute, both P < .05). Clotting speed (TEG-alpha) and clot strength (TEG-MA) were increased in the burn group (62 ± 4 vs 50 ± 4°, and 76 ± 2 vs 56 ± 2 mm, respectively, both P < .05). Fibrinolysis of TEG-LY60 was accelerated in the burn group (16 ± 6 vs 3 ± 1) and so was the increase in D-dimer level in the burn group (4.5 ± 0.4 vs 1.9 ± 0.3 mg/l, both P < .05). The hypercoagulable state postburn is in part a result of increased fibrinogen synthesis, over and above increased fibrinogen breakdown.