Nonsteroidal anti-inflammatory drugs and streptococcal toxic shock syndrome

Immune Modulatory Effects of Nonsteroidal Anti-inflammatory Drugs in the Perioperative Period and Their Consequence on Postoperative Outcome

Nonsteroidal anti-inflammatory drugs are among the most commonly administered drugs in the perioperative period due to their prominent role in pain management. However, they potentially have perioperative consequences due to immune-modulating effects through the inhibition of prostanoid synthesis, thereby affecting the levels of various cytokines. These effects may have a direct impact on the postoperative outcome of patients since the immune system aims to restore homeostasis and plays an indispensable role in regeneration and repair. By affecting the immune response, consequences can be expected on various organ systems. This narrative review aims to highlight these potential immune system-related consequences, which include systemic inflammatory response syndrome, acute respiratory distress syndrome, immediate and persistent postoperative pain, effects on oncological and neurologic outcome, and wound, anastomotic, and bone healing.

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.

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.

Ibuprofen worsens Streptococcus pyogenes soft tissue infections in mice

BACKGROUND

Group A streptococcus (GAS) is a common cause of soft tissue infection. Nonsteroidal anti-inflammatory drugs have been reported to worsen GAS soft tissue infections.

METHODS

A mouse model of GAS soft tissue infection was developed. The extent of cutaneous lesions, tissue damage, release of inflammatory cytokines, and survival rates were compared between mice with and without ibuprofen administration after GAS soft tissue infection.

RESULTS

All twelve mice without ibuprofen administration survived for at least 10 days. In contrast, mortality rate of 14 mice with ibuprofen therapy was 72.5%. Ibuprofen-treated mice exhibited more evident macrophage infiltration and tissue damage in the GAS-infected soft tissues. In GAS-infected mice, tissue levels of interleukin 6 and tumor necrosis factor alpha were significantly higher in ibuprofen-treated mice than those in the control group.

CONCLUSIONS

The results supported the concept that ibuprofen use in GAS soft tissue infections might induce the development of severe necrotizing infections and increase mortality rate.

A multicentre case-control study of nonsteroidal anti-inflammatory drugs as a risk factor for severe sepsis and septic shock

INTRODUCTION

We aimed to establish whether the use of nonsteroidal anti-inflammatory drugs (NSAIDs) during evolving bacterial community-acquired infection in adults is associated with severe sepsis or septic shock.

METHODS

We conducted a multicentre case-control study in eight intensive care units. Cases were all adult patients admitted for severe sepsis or septic shock due to a bacterial community-acquired infection. Control individuals were patients hospitalized with a mild community-acquired infection. Each case was matched to one control for age, presence of diabetes and site of infection.

RESULTS

The main outcome measures were the proportions of cases and controls exposed to NSAIDs or aspirin during the period of observation. In all, 152 matched pairs were analyzed. The use of NSAIDs or aspirin during the observation period did not differ between cases and controls (27% versus 28; odds ratio = 0.93, 95% confidence interval [CI] = 0.52 to 1.64). If aspirin was not considered or if a distinction was made between acute and chronic drug treatment, there remained no difference between groups. However, the median time to prescription of effective antibiotic therapy was longer for NSAID users (6 days, 95% CI = 3 to 7 days) than for nonusers (3 days, 95% CI = 2 to 3 days; P = 0.02).

CONCLUSIONS

In this study, the use of NSAIDs or aspirin during evolving bacterial infection was frequent and occurred in one-quarter of the patients with such infection. Although the use of NSAIDs by patients with severe sepsis or septic shock did not differ from their use by those with mild infection at the same infected site, we observed a longer median time to prescription of effective antibiotic therapy in NSAID users.

Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus

Group A streptococcal (GAS) necrotizing fasciitis is a rapidly progressive soft tissue infection. Elderly and chronically ill individuals are at greatest risk, particularly when skin breakdown is present. Reports suggest that nonsteroidal antiinflammatory drugs (NSAIDs) increase the risk of developing GAS necrotizing fasciitis, impede its timely recognition and management, and accelerate the course of infection. We present a literature review conducted to examine these hypotheses and present a case of GAS necrotizing fasciitis associated with rofecoxib use. Initial symptoms of fasciitis may be nondescript, mimicking more benign conditions such as cellulitis, arthritis, or musculoskeletal pain. Case reports and retrospective studies suggest that the application of NSAIDs to relieve these nonspecific symptoms can delay diagnosis and treatment of GAS necrotizing fasciitis. However, prospective studies do not support a risk of developing GAS necrotizing fasciitis as a result of NSAID therapy, or a worsening of established streptococcal infection. To avoid the application of NSAIDs in lieu of aggressive medical and surgical management of streptococcal fasciitis, clinicians must understand the early symptoms of GAS necrotizing fasciitis that precede visible soft tissue necrosis. A rational approach to patients presenting with localized soft tissue pain will enhance detection and therapy of this rapidly progressive, life-threatening disease.