Should we stop the effective antibiotics immediately when treating severe sepsis patients with antibiotic-related thrombocytopenia?

Incidence, Risk Factors, and Outcomes of Thrombocytopenia in Older Medical Inpatients: A Prospective Cohort Study

BACKGROUND

Thrombocytopenia, defined as a platelet count of less than 150 × 109/L, is a frequent condition among hospitalized patients and presents unique challenges in diagnosis and management. Despite its commonality, data on incidence and related risk factors in medical inpatients remain limited, especially in older people.

METHODS

A 2-year prospective cohort study with a 3-year follow-up was conducted on inpatients aged ≥65 years admitted to a medical ward. Clinical data were collected, including demographics, comorbidities, laboratory results, and outcomes. Multivariate logistic regression analysis assessed risk factors associated with non-resolution of thrombocytopenia and mortality.

RESULTS

The study included 961 older inpatients with a mean age of 82 years. Thrombocytopenia occurred in 22.6% of the study population. The most common causes were infections (57.4%) and drug-induced thrombocytopenia (25.3%). The non-resolution of thrombocytopenia was noted in 59% of patients. In-hospital and 3-year mortality was significantly higher in this subgroup compared to the rest (24.5% vs. 12.7%, p = 0.015) and (72.4% vs. 59.8%, p = 0.04, respectively). In multivariate analysis, nadir platelet count and hematologic disease were independent factors associated with the non-resolution of thrombocytopenia. Furthermore, in individuals with thrombocytopenia, the administration of norepinephrine (p < 0.001) and a higher clinical frailty score (p < 0.001) were observed as independent mortality predictors.

CONCLUSIONS

Thrombocytopenia in older medical inpatients is associated with poor prognosis, particularly in those with non-resolution thrombocytopenia. Early identification and targeted management may improve outcomes.

Drug-Induced Thrombocytopenia in the Critically Ill

Background:Drugs are suspected when obvious causes of intensive care unit (ICU)-acquired thrombocytopenia have been excluded. It has been estimated that 10% to 25% of cases may be drug induced. Objectives: The objectives of this study were to evaluate the risk of thrombocytopenia associated with drug classes commonly used in the ICU. Methods: Data concerning patients admitted for more than 48 hours between 1997 and 2011 were extracted from a research-purpose database. Patients with thrombocytopenia within the first 72 hours of admission and with diagnoses or interventions considered strongly associated with thrombocytopenia were excluded. Drug exposures were compared and adjusted for confounders using conditional logistic regression. Results: A total of 238 cases were identified after exclusions. Each case was matched according to sex, age, admission year, and admission unit with 1 control. In univariate analysis, quinolones (odds ratio [OR] = 1.56; 95% CI = 1.01-2.40) and extended spectrum β-lactams (OR = 1.71; 95% CI = 1.00-2.93) were significantly associated with an increased risk of thrombocytopenia. After adjusting for confounders, exposure to quinolones was the only drug class with a statistically significant increase in risk of thrombocytopenia (OR = 1.697; 95% CI = 1.002-2.873; P = 0.049). Conclusion: In this study of ICU-acquired thrombocytopenia, we found no association between the exposures to several antibiotic classes, anticonvulsants, antiplatelet agents, nonsteroidal anti-inflammatory agents, and heparins and thrombocytopenia. As linezolid was not studied, no conclusions can be drawn concerning this agent. The statistically significant association between quinolones and thrombocytopenia warrants further investigation.

Drug-induced thrombocytopenia in critically ill patients

Thrombocytopenia occurs in 15% to 58% of intensive care unit patients. The incidence varies based upon patient population, timing and frequency of platelet monitoring, and definition of thrombocytopenia. Up to 25% of acutely ill patients develop drug-induced thrombocytopenia. When drug-induced thrombocytopenia is suspected, nondrug related causes must be evaluated and excluded. Establishing the diagnosis of drug-induced thrombocytopenia is challenging, as hundreds of medications have been implicated. Medications commonly associated with drug-induced thrombocytopenia include glycoprotein IIb/IIIa inhibitors, cinchona alkaloids, antibiotics, anticonvulsants, and heparin. Once the diagnosis is suspected, clinicians should identify the start date of medications to assess the timeline of development. The likelihood of each medication causing thrombocytopenia must be evaluated. The risk vs. benefit of discontinuing the suspected medication and availability of alternative medications must be assessed. The role of corticosteroids, immune globulin, and plasmapheresis is uncertain. Once the offending agent has been discontinued, the overall prognosis is excellent. In the case of suspected or confirmed heparin-induced thrombocytopenia, an alternative anticoagulant should be initiated. Drug-induced thrombocytopenia should be documented in the medical record and reported according to institutional and national standards. This review focuses on immune-mediated drug-induced thrombocytopenia from medications commonly utilized in the critically ill patient.