Novel approach towards antimicrobial chemotherapy optimization in lower respiratory tract infections in children: An observational study

The use of local antibiogram in guiding clinical decisions is an integral part of the antimicrobial stewardship program. Conventional antibiograms are not disease-specific, ignore the distribution of microorganisms, obscure the in-vitro efficacy interrelationships, and have limited use in polymicrobial infections.We aimed to develop an in-house empiric, disease-specific, antimicrobial prescription auxiliary for the treatment of hospitalized pediatric pneumonia patients and to present the methods which help to choose the first and the second line antimicrobial therapy, while accounting for cost and safety aspects.A retrospective single center observational study was conducted on bronchoscopy obtained sputum culture. Analysis of probabilities, variance minimization, Boolean network modeling, and dominance analysis were applied to analyze antibiogram data. The Kirby-Bauer disk diffusion method was used to test the susceptibility of all isolates. Final optimization analysis included local drug acquisition cost (standardized to price per DDD) and safety profile.Data of 145 pediatric patients hospitalized with pneumonia with 218 isolates over 5 years was collected. A combination of statistical methods such as probabilities of drug efficacy, variance minimization, Boolean network modeling, and dominance analysis can help to choose the optimal first-line and the second-line antimicrobial treatment and optimize patient care. This research reveals that ampicillin is the optimal choice as the first-line drug and piperacillin-tazobactam is the second-line antimicrobial drug if the first one is not effective, while accounting for cost and safety aspects.The paper proposes a new methodology to adapt empiric antimicrobial therapy recommendations based on real world data and accout for costs and risk of adverse events.

GYY4137 and Sodium Hydrogen Sulfide Relaxations Are Inhibited by L-Cysteine and KV7 Channel Blockers in Rat Small Mesenteric Arteries

Donors of H₂S may be beneficial in treating cardiovascular diseases where the plasma levels of H₂S are decreased. Therefore, we investigated the mechanisms involved in relaxation of small arteries induced by GYY4137 [(4-methoxyphenyl)-morpholin-4-yl-sulfanylidene-sulfido-λ5-phosphane;morpholin-4-ium], which is considered a slow-releasing H₂S donor. Sulfides were measured by use of 5,5′-dithiobis-(2-nitro benzoic acid), and small rat mesenteric arteries with internal diameters of 200–250 µm were mounted in microvascular myographs for isometric tension recordings. GYY4137 produced similar low levels of sulfides in the absence and the presence of arteries. In U46619-contracted small mesenteric arteries, GYY4137 (10⁻⁶–10^–3 M) induced concentration-dependent relaxations, while a synthetic, sulfur-free, GYY4137 did not change the vascular tone. L-cysteine (10⁻⁶–10^–3 M) induced only small relaxations reaching 24 ± 6% at 10^–3 M. Premixing L-cysteine (10^–3 M) with Na₂S and GYY4137 decreased Na₂S relaxation and abolished GYY4137 relaxation, an effect prevented by an nitric oxide (NO) synthase inhibitor, L-NAME (N^ω-nitro-L-arginine methyl ester). In arteries without endothelium or in the presence of L-NAME, relaxation curves for GYY4137 were rightward shifted. High extracellular K⁺ concentrations decreased Na₂S and abolished GYY4137 relaxation suggesting potassium channel-independent mechanisms are also involved Na₂S relaxation while potassium channel activation is pivotal for GYY4137 relaxation in small arteries. Blockers of large-conductance calcium-activated (BK_Ca) and voltage-gated type 7 (K_V7) potassium channels also inhibited GYY4137 relaxations. The present findings suggest that L-cysteine by reaction with Na₂S and GYY4137 and formation of sulfides, inhibits relaxations by these compounds. The low rate of release of H₂S species from GYY4137 is reflected by the different sensitivity of these relaxations towards high K⁺ concentration and potassium channel blockers compared with Na₂S. The perspective is that the rate of release of sulfides plays an important for the effects of H₂S salt vs. donors in small arteries, and hence for a beneficial effect of GYY4137 for treatment of cardiovascular disease.

The Glomerular Filtration Rate Estimators in the Pharmacokinetic Modelling in Acute Kidney Injury: An Observational Study

The glomerular filtration rate (GFR), according to which the drug dose for patients with chronic kidney disease (CKD) is adjusted, is computed with estimators (eGFR) that are developed specifically for CKD. These particular types of estimators are also used in population pharmacokinetic (pop PK) modelling in drug development. Similar approaches without scientific validation have been proposed for patients with acute kidney injury (AKI), yet it is uncertain which specific eGFR should be used for drug dosing or in pop PK models in patients with AKI. In our study, we included 34 patients with AKI and vancomycin (VCM) treatment, and we built both individual PK and pop PK (non-linear mixed-effects, one-compartment) models to see which eGFR estimator is the best covariate. In these models different eGFRs (Cockcroft-Gault, MDRD, CKD-EPI 2009, Jelliffe and Jelliffe, Chen et al., and Yashiro et al. 2013) were used. We included six additional patients to validate the final pop PK model. All eGFRs underrate the true renal clearance in the AKI, so we created pop PK models for VCM dosing in AKI with all eGFRs, to discover that the most accurate model was the one with the Cockcroft-Gault estimator. Since the eGFRs underestimate the true renal clearance in AKI, they are inaccurate for clinical drug dosing decisions, with the exception of the Cockcroft-Gault one, which is appropriate for the pop PK models intended for drug development purposes in AKI.

A case report and literature review: previously excluded tuberculosis masked by amiodarone induced lung injury

Background

Amiodarone is an antiarrhythmic drug which is used to treat and prevent several dysrhythmias. This includes ventricular tachycardia and fibrillation, wide complex tachycardia, as well as atrial fibrillation (AF) and paroxysmal supraventricular tachycardia. Amiodarone may prove to be the agent of choice where the patient is hemodynamically unstable and unsuitable for direct current (DC) cardioversion. Although, it is not recommended for long-term use. The physician might encounter issues when differentiating amiodarone-induced lung toxicity with suspicion of interstitial lung disease, cancer or vasculitis. Adverse drug reactions are difficult to confirm and it leads to serious problems of pharmacotherapy.

Case presentation

A 78-year-old Caucasian male pensioner complaining of fever, dyspnea, malaise, non-productive cough, fatigue, weight loss, diagnosed with acute respiratory failure with a 16-year long history of amiodarone use and histologically confirmed temporal arteritis with long-term glucocorticosteroid (GCC) therapy.

Patient was treated for temporal arteritis with GCC for ~ 1 year, then fever and dyspnea occurred, and the patient was hospitalized for treatment of bilateral pneumonia. Chest X-ray and chest high resolution computed tomography (HRCT) indicated several possible diagnoses: drug-induced interstitial lung disease, autoimmune interstitial lung disease, previously excluded pulmonary TB. Amiodarone was discontinued. Antibiotic therapy for bilateral pneumonia was started. Fiberoptic bronchoscopy with bronchial washings and brushings was performed. Acid fast bacilli (AFB) were found on Ziehl-Nielsen microscopy and tuberculosis (TB) was confirmed (later confirmed to be Mycobacterium tuberculosis in culture), initial treatment for TB was started. After a few months of treating for TB, patient was diagnosed with pneumonia and sepsis, empiric antibiotic therapy was prescribed.

After reevaluation and M. Tuberculosis identification, the patient was referred to the Tuberculosis hospital for further treatment. After 6 months of TB treatment, pneumonia occurred which was complicated by sepsis. Despite the treatment, multiple organ dysfunction syndrome evolved and patient died. Probable cause of death: pneumonia and sepsis.

Conclusions

The current clinical case emphasizes issues that a physician may encounter in the differential diagnostics of amiodarone-induced lung toxicity with other lung diseases.

Cisplatin-induced sudden cardiac death with hemodynamic collapse: a severe adverse drug reaction: Case report

RATIONALE

Cisplatin is responsible for a significant percentage of adverse drug reactions (ADRs) in oncology setting. A great proportion of cisplatin-induced severe adverse events are difficult to foresee, and giving premedication does not always prevent the occurrence of such events.

PATIENT CONCERNS

A 53-year-old woman with progressive T4 N0 M0 stage IV pleural mesothelioma experienced cardiac arrest with hemodynamic collapse after cisplatin and pemetrexed chemotherapy administration.

DIAGNOSES

Progressive pleural T4 N0 M0 stage IV mesothelioma of the right lung, primary arterial hypertension, and cardiac arrest with hemodynamic collapse.

INTERVENTIONS

The cisplatin and pemetrexed chemotherapy was administered intravenously for progressive pleural T4 N0 M0 stage IV mesothelioma of the right lung. During infusion of cisplatin the patient developed cardiac arrest, and cardiopulmonary resuscitation was initiated.

OUTCOMES

The patient was treated in intensive care unit and recovered successfully. Further chemotherapy with cisplatin and pemetrexed was withheld due to this severe adverse reaction to cisplatin.

LESSONS

Cisplatin therapy should be thoroughly monitored including electrolyte, especially magnesium levels. Absence of previous ADRs to cisplatin and premedication should not give false sense of security.

Methimazole-induced liver injury overshadowed by methylprednisolone pulse therapy: Case report

RATIONALE

Treatment choices are limited, when deciding how to manage thyrotoxicosis and moderate to severe Graves ophthalmopathy (GO) with suspected optic nerve damage in patients with elevated liver transaminase levels. The situation become even more complicated, if methimazole induced hepatotoxicity is suspected and intravenous methylprednisolone is co-administrated.

PATIENT CONCERNS

A 74-year-old woman presented with spontaneous retro-bulbar pain, eyelid swelling and inconstant diplopia.

DIAGNOSES

Thyrotoxicosis and severe GO with suspected optic nerve damage and drug induced liver injury (DILI).

INTERVENTIONS

Intravenous methylprednisolone pulse therapy was administered to treat GO and methimazole was continued for thyrotoxicosis. Dose of methimazole was reduced after exclusion of concurrent infection and active liver disease.

OUTCOMES

The GO symptoms (eyelid swelling, sight loss, proptosis, retro-bulbar pain, diplopia) markedly decreased after the treatment course. Liver transaminases spontaneously returned to normal ranges and remained normal during the next 12 months until the Graves' disease until the treatment was completed.

LESSONS

1. The interaction of methimazole and methylprednisolone may result in DILI. 2. In a patient without concomitant liver diseases MP can be continued if the methimazole dose is reduced if no other treatment options are available.

APPROACHES TO THE 26-36-YEAR-OLD LITHUANIAN MEN'S SEXUAL FUNCTION

Context

In the year 2003-2004 a circumstantial investigation of young men reproductive health parameters was performed in Nordic and Baltic countries, but sexuality remained undetermined.

Objective

To determine the suitability of the European Male Ageing Study - Sexual Function Questionnaire (EMAS - SFQ) for investigation of sexuality of 26-36 year aged general population and to investigate sexuality of Kaunas participants in the project "The reproductive function of Estonian, Latvian and Lithuanian Young men (2003-2004)" (KELLY), using EMAS - SFQ.

Design

Sixty one 26-36 year aged KELLY men were recaptured from the list of participants in a 2003-2004 study and completed EMAS - SFQ. Their anthropometric characteristics, scores of sexuality (22 parameters from EMAS - SFQ, 3 calculated parameters and 2 parameters consisting from answers to the only question - masturbation and erectile function-for each participant) were analysed, in conjunction with anthropometric, sperm quality and hormone levels of 2003-2004 18-25 year old general population.

Results

Overall sexual functioning and masturbation were higher as compared to all the published data for different age men and different testosterone concentration groups of EMAS study.

Conclusions

KELLY sexuality results, obtained using EMAS - SFQ, would be considered as referral values for young men in countries with generally good reproductive health.