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Guleng SR, Wu RH, Guo XB. Vancomycin-induced thrombocytopenia in endocarditis: A case report and review of literature. World J Clin Cases 2021; 9:1696-1704. [PMID: 33728314 PMCID: PMC7942037 DOI: 10.12998/wjcc.v9.i7.1696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/28/2020] [Accepted: 01/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Thrombocytopenia is a serious complication in the medical practice of numerous drugs. Vancomycin is frequently used for the prophylaxis and treatment of suspected or identified methicillin-resistant positive infections. Several cases with vancomycin-induced thrombocytopenia (VIT) have been reported. However, these have rarely been extensively reviewed. The present report describes a case of VIT in endocarditis, and reviews all VIT cases reported in the literature.
CASE SUMMARY A 26-year-old male diagnosed with infective endocarditis was admitted. The patient was treated with multiple drugs, including vancomycin, which was initially intravenously given at 1000 mg every 12 h and subsequently at 500 mg every 8 h on day 3. On day 11, the platelet count decreased to 51 × 109/L, vancomycin was switched to 500 mg every 12 h, and platelet transfusion was given. On day 17, the platelet count dropped to 27 × 109/L, and platelet transfusion was administered again. On day 23, vancomycin was adjusted to 500 mg every 8 h as the trough concentration dropped to the minimum effective concentration. On day 33, the platelet count declined to approximately 40 × 109/L. After platelet transfusion, the platelet count rebounded to 90 × 109/L on day 35 but dropped again to 42 × 109/L on day 43. Based on the time-to-platelet count curve and Naranjo’s Adverse Drug Reaction Probability Scale score, VIT was suspected. After vancomycin discontinuation and platelet transfusion, the platelet count gradually normalized.
CONCLUSION The diagnosis of VIT can be achieved through the time-to-platelet count curve and Naranjo’s Adverse Drug Reaction Probability Scale score. The platelet count cannot be normalized simply by platelet transfusion alone, and vancomycin discontinuation is essential.
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Affiliation(s)
- Si-Ri Guleng
- Department of Pharmacy, Inner Mongolia Autonomous Region People's Hospital, Hohhot 010010, Inner Mongolia Autonomous, China
| | - Ri-Han Wu
- Department of Pharmacy, Inner Mongolia Autonomous Region People's Hospital, Hohhot 010010, Inner Mongolia Autonomous, China
| | - Xiao-Bin Guo
- Department of Pharmacy, Inner Mongolia Autonomous Region People's Hospital, Hohhot 010010, Inner Mongolia Autonomous, China
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2
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Vayne C, Guéry EA, Rollin J, Baglo T, Petermann R, Gruel Y. Pathophysiology and Diagnosis of Drug-Induced Immune Thrombocytopenia. J Clin Med 2020; 9:jcm9072212. [PMID: 32668640 PMCID: PMC7408966 DOI: 10.3390/jcm9072212] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 12/12/2022] Open
Abstract
Drug-induced immune thrombocytopenia (DITP) is a life-threatening clinical syndrome that is under-recognized and difficult to diagnose. Many drugs can cause immune-mediated thrombocytopenia, but the most commonly implicated are abciximab, carbamazepine, ceftriaxone, eptifibatide, heparin, ibuprofen, mirtazapine, oxaliplatin, penicillin, quinine, quinidine, rifampicin, suramin, tirofiban, trimethoprim-sulfamethoxazole, and vancomycin. Several different mechanisms have been identified in typical DITP, which is most commonly characterized by severe thrombocytopenia due to clearance and/or destruction of platelets sensitized by a drug-dependent antibody. Patients with typical DITP usually bleed when symptomatic, and biological confirmation of the diagnosis is often difficult because detection of drug-dependent antibodies (DDabs) in the patient’s serum or plasma is frequently not possible. This is in contrast to heparin-induced thrombocytopenia (HIT), which is a particular DITP caused in most cases by heparin-dependent antibodies specific for platelet factor 4, which can strongly activate platelets in vitro and in vivo, explaining why affected patients usually have thrombotic complications but do not bleed. In addition, laboratory tests are readily available to diagnose HIT, unlike the methods used to detect DDabs associated with other DITP that are mostly reserved for laboratories specialized in platelet immunology.
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Affiliation(s)
- Caroline Vayne
- EA 7501-Groupe Innovation et Ciblage Cellulaire (GICC), Université François Rabelais, CEDEX 01, 37032 Tours, France; (C.V.); (J.R.)
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
| | - Eve-Anne Guéry
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
| | - Jérôme Rollin
- EA 7501-Groupe Innovation et Ciblage Cellulaire (GICC), Université François Rabelais, CEDEX 01, 37032 Tours, France; (C.V.); (J.R.)
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
| | - Tatiana Baglo
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
- Laboratoire d’Hématologie, CNHU de Cotonou, Cotonou 01 BP 386, Benin
| | - Rachel Petermann
- Département d’Immunologie plaquettaire, Institut National de la Transfusion Sanguine (INTS), 75015 Paris, France;
- Equipe ETRES (Ethics, Research, Translations), Centre de Recherche des Cordeliers, UMRS 1138, INSERM, Sorbonne Université, Université de Paris, 75006 Paris, France
| | - Yves Gruel
- EA 7501-Groupe Innovation et Ciblage Cellulaire (GICC), Université François Rabelais, CEDEX 01, 37032 Tours, France; (C.V.); (J.R.)
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
- Correspondence: ; Tel.: +33-2-4747-4672; Fax: +33-2-4747-5904
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3
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Abstract
Vancomycin-induced immune thrombocytopenia (ITP) is a rare, potentially life-threatening complication from an antibiotic frequently used in medical practice. We report a case of an 81-year-old male with recent removal of an infected right knee prosthesis and insertion of an articulating antibiotic spacer, presenting from rehabilitation for severe thrombocytopenia (1 X 103/µL). The patient’s thrombocytopenia was initially falsely attributed to rifampin-induced ITP, a much more common cause of drug-induced thrombocytopenia. Only later, after a second precipitous drop in platelet count, vancomycin was correctly identified as the culprit. The patient’s serum was tested for drug-dependent platelet antibodies with and without vancomycin. A positive reaction for IgG was detected by flow cytometry in the absence of vancomycin, which was potentiated in the presence of vancomycin. The result indicated the presence of vancomycin-dependent and nondrug-dependent platelet reactive antibodies and confirmed the diagnosis of vancomycin-induced ITP. In this case, the correct diagnosis was masked by the simultaneous administration of two drugs that cause drug-induced ITP and highlights the importance of early recognition of rare, vancomycin-induced ITP.
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Affiliation(s)
- Kira N MacDougall
- Internal Medicine, Staten Island University Hospital, Northwell Health, New York, USA
| | - Sara Parylo
- Hematology/Oncology, Staten Island University Hospital, New York, USA
| | - Alisa Sokoloff
- Hematology/Oncology, Staten Island University Hospital, Northwell Health, New York, USA
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4
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Ajit NE, Devarashetty SP, Master S. Vancomycin Induced Thrombocytopenia - Protracted Course in a Hemodialysis Patient. Case Rep Oncol 2019; 12:749-754. [PMID: 31762746 PMCID: PMC6873044 DOI: 10.1159/000503418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/17/2019] [Indexed: 12/14/2022] Open
Abstract
Vancomycin induced thrombocytopenia (VIT) is an uncommon side effect of vancomycin which can manifest from mild petechiae to life-threatening bleed. Decreased renal clearance of vancomycin results in prolonged thrombocytopenia by antibody-mediated platelet destruction in the presence of vancomycin. Improvement in thrombocytopenia is achieved with the elimination of vancomycin. We describe a patient with end stage renal disease who experienced a protracted course of thrombocytopenia from vancomycin. We illustrate the mechanism of thrombocytopenia and the treatment modalities used by us and those described in literature. VIT is an important differential in patients with thrombocytopenia admitted to the hospital.
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Affiliation(s)
- Nisha Elizabeth Ajit
- Hematology/Oncology Department, Ochsner Louisiana State University of Health Sciences, Shreveport, Louisiana, USA
| | - Sindhu Priya Devarashetty
- Department of Internal Medicine, Ochsner Louisiana State University of Health Sciences, Shreveport, Louisiana, USA
| | - Samip Master
- Hematology/Oncology Department, Ochsner Louisiana State University of Health Sciences, Shreveport, Louisiana, USA
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5
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Getz TM, Packer CD. Rapid-Onset Vancomycin-Induced Thrombocytopenia With Reexposure. Ann Pharmacother 2019; 53:1259-1261. [PMID: 31353923 DOI: 10.1177/1060028019867433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ted M Getz
- Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Clifford D Packer
- Case Western Reserve School of Medicine, Cleveland, OH, USA.,Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
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Chen QY, Wan J, Yang JH, Lin M, Chen Y. Vancomycin-induced severe thrombocytopenia in a young infant. Rev Soc Bras Med Trop 2019; 51:873-875. [PMID: 30517547 DOI: 10.1590/0037-8682-0150-2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/05/2018] [Indexed: 01/12/2023] Open
Abstract
Vancomycin is a first-line drug for treating methicillin-resistant Staphylococcus aureus. Thrombocytopenia is a rare adverse reaction to vancomycin treatment, and there are no reports of vancomycin-induced thrombocytopenia (VIT) in infants. We describe the case of a 3-month-old girl who was diagnosed with purulent meningitis. After 13 days of treatment with vancomycin, her platelet count reduced to 8 × 109/L. Vancomycin was discontinued, and intravenous methylprednisolone was administered. The platelet count returned to normal after 4 days. Patients, especially young children, receiving vancomycin for a long clinical course should undergo careful monitoring of laboratory indicators and blood tests.
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Affiliation(s)
- Quan-Yao Chen
- Department of Pharmacy, Xiamen Maternity and Child Care Hospital, Xiamen, Fujian, China
| | - Jun Wan
- Department of Pharmacy, Xiamen Maternity and Child Care Hospital, Xiamen, Fujian, China
| | - Jian-Hui Yang
- Department of Pharmacy, Xiamen Maternity and Child Care Hospital, Xiamen, Fujian, China
| | - Min Lin
- Department of Pharmacy, Xiamen Maternity and Child Care Hospital, Xiamen, Fujian, China
| | - Yao Chen
- Department of Pharmacy, Xiamen Maternity and Child Care Hospital, Xiamen, Fujian, China
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7
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Mohammadi M, Jahangard-Rafsanjani Z, Sarayani A, Hadjibabaei M, Taghizadeh-Ghehi M. Vancomycin-Induced Thrombocytopenia: A Narrative Review. Drug Saf 2017; 40:49-59. [PMID: 27848200 DOI: 10.1007/s40264-016-0469-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Thrombocytopenia has been reported as an adverse reaction of numerous drugs. Vancomycin is often overlooked as a culprit but has been associated with several cases of thrombocytopenia that were not well described in the literature. A literature search was conducted to find reports of thrombocytopenia induced by vancomycin. Biomedical databases including 'PubMed', 'Scopus', and 'Web of Science' were searched using terms 'vancomycin', 'platelet', 'pancytopenia', 'thrombocytopenia', and 'bleeding'. English language articles published before July 2015 were included. Thirty-nine papers including 29 case reports (30 cases), five observational studies, two clinical trials, two letters, and one case series remained for final analysis. The main route of administration was intravenous infusion. This adverse reaction seems to be duration dependent with the mean time to platelet nadir count of 8 days in reported cases. The interval may be significantly shorter in re-exposure to the drug. Platelet nadir counts ranged from 2000 to 100,000/mL in patients who experienced bleeding. Vancomycin-specific antibodies were detected in 13 of 17 patients who were tested in the case reports. Based on the Naranjo Adverse Drug Reaction Probability Scale, reaction was 'definite', 'probable', and 'possible' in 1, 15, and 14 patients, respectively. Among 30 cases, vancomycin was discontinued in 29 patients and platelets returned to normal counts within 5-6 days in 17 of them; in one patient, vancomycin was not discontinued, but platelet count recovered 11 days after the nadir time. Transfusion might be recommended if severe thrombocytopenia and bleeding occurs. Intravenous immunoglobulins, corticosteroids, rituximab, and plasma exchange should be reserved for patients with resistant thrombocytopenia and severe bleeding as mentioned in a number of reports.
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Affiliation(s)
- Mehdi Mohammadi
- Faculty of Pharmacy, Tehran University of Medical Sciences, Pour Sina St, District 6, Tehran, Iran
| | | | - Amir Sarayani
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, 4th Floor, No. 92, Karimkhan Zand Avenue, Hafte Tir Square, Tehran, Iran
| | - Molouk Hadjibabaei
- Faculty of Pharmacy, Tehran University of Medical Sciences, Pour Sina St, District 6, Tehran, Iran.,Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, 4th Floor, No. 92, Karimkhan Zand Avenue, Hafte Tir Square, Tehran, Iran
| | - Maryam Taghizadeh-Ghehi
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, 4th Floor, No. 92, Karimkhan Zand Avenue, Hafte Tir Square, Tehran, Iran.
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8
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Schueler SA, Shet NS, Stienstra N, Chen DC. A Masked Case of Vancomycin-induced Immune Thrombocytopenia. Am J Med Sci 2016; 351:636. [PMID: 27238931 DOI: 10.1016/j.amjms.2016.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/05/2016] [Accepted: 03/16/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Samuel A Schueler
- Department of Internal Medicine, Boston University Medical Center, Boston, Massachusetts.
| | - Nilima S Shet
- Department of Internal Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Nicholas Stienstra
- Department of Internal Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Daniel C Chen
- Department of Internal Medicine, Boston University Medical Center, Boston, Massachusetts
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9
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Towhid ST, Tolios A, Münzer P, Schmidt EM, Borst O, Gawaz M, Stegmann E, Lang F. Stimulation of platelet apoptosis by balhimycin. Biochem Biophys Res Commun 2013; 435:323-6. [PMID: 23399563 DOI: 10.1016/j.bbrc.2013.01.120] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 01/31/2013] [Indexed: 10/27/2022]
Abstract
Glycopeptides, such as vancomycin, are powerful antibiotics against methicillin-resistant Staphylococcus aureus. Balhimycin, a glycopeptide antibiotic isolated from Amycolatopsis balhimycina, is similarly effective as vancomycin. Side effects of vancomycin include triggering of platelet apoptosis, which is characterized by cell shrinkage and by cell membrane scrambling with phosphatidylserine exposure at the cell surface. Stimulation of apoptosis may involve increase of cytosolic Ca(2+) activity, ceramide formation, mitochondrial depolarization and/or caspase activation. An effect of balhimycin on apoptosis has, however, never been reported. The present study thus tested whether balhimycin triggers platelet apoptosis. Human blood platelets were treated with balhimycin and cell volume was estimated from forward scatter, phosphatidylserine exposure from annexin V-binding, cytosolic Ca(2+) activity from fluo-3AM fluorescence, ceramide formation utilizing antibodies, mitochondrial potential from DiOC6 fluorescence, and caspase-3 activity utilizing antibodies. As a result, a 30 min exposure to balhimycin significantly decreased cell volume (≥1 μg/ml), triggered annexin V binding (≥1 μg/ml), increased cytosolic Ca(2+) activity (≥1 μg/ml), stimulated ceramide formation (≥10 μg/ml), depolarized mitochondria (≥1 μg/ml) and activated caspase-3 (≥1 μg/ml). Cell membrane scrambling and caspase-3 activation were virtually abrogated by removal of extracellular Ca(2+). Cell membrane scrambling was not significantly blunted by pancaspase inhibition with zVAD-FMK (1μM). In conclusion, balhimycin triggers cell membrane scrambling of platelets, an effect dependent on Ca(2+), but not on activation of caspases.
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Affiliation(s)
- Syeda T Towhid
- Department of Physiology, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
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10
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Patel N, VanDeWall H, Tristani L, Rivera A, Woo B, Dihmess A, Li HK, Smith R, Lodise TP. A comparative evaluation of adverse platelet outcomes among Veterans' Affairs patients receiving linezolid or vancomycin. J Antimicrob Chemother 2011; 67:727-35. [PMID: 22174041 DOI: 10.1093/jac/dkr522] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES The primary objectives were to compare the incidences of severe thrombocytopenia, critical thrombocytopenia and a relative decline in platelets from baseline (≥50% decline) between patients receiving linezolid and those receiving vancomycin. The secondary objective was to assess the relationship between vancomycin trough concentration and adverse platelet outcomes. METHODS A matched cohort study was performed at the Upstate New York Veterans' Affairs Healthcare Network from January 2005 until February 2008. Eligibility criteria were: (i) receipt of linezolid or vancomycin therapy for ≥48 h; (ii) initiation of therapy as an inpatient; and (iii) baseline platelets available for evaluation. Patients who received linezolid were matched 1:1 to patients who received vancomycin. Cumulative incidences and times to event for (i) platelet count ≤50,000 cells/mm(3), (ii) platelet count ≤20,000 cells/mm(3) and (iii) ≥50% decline in platelets from baseline were evaluated. Multivariate analyses were performed. RESULTS The study included 502 patients (251 matched pairs). The occurrences of platelet counts ≤50,000 cells/mm(3) and ≤20,000 cells/mm(3) did not differ significantly between linezolid and vancomycin patients. A ≥50% decline in platelets from baseline was observed in 78 (31.1%) patients receiving vancomycin and 43 (17.1%) patients receiving linezolid (risk ratio 0.55; 95% CI 0.40-0.77). A clear exposure-response relationship was observed between vancomycin trough concentration and ≥50% decline in platelets from baseline. CONCLUSIONS The incidence of thrombocytopenia was low and did not differ significantly among vancomycin and linezolid patients.
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Affiliation(s)
- Nimish Patel
- Albany College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Albany, NY 12208, USA
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Ganly P, Downing J, Stiven P, Frizelle F, Badami K. Clinical and serological diagnoses of a patient with vancomycin-induced thrombocytopenia. Transfus Med 2010; 21:137-9. [PMID: 21083776 DOI: 10.1111/j.1365-3148.2010.01052.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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12
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Abstract
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.
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