Tissue necrosis and necrotizing fasciitis after intramuscular administration of diclofenac

A case of necrotizing fasciitis following intra-articular injections - Iatrogenic or spontaneous?

Here, we report a case of necrotizing fasciitis following intra-articular injection of hyaluronic acid. A 73-year-old female received intra-articular injections of hyaluronic acid due to arthralgia at the left shoulder and knee, and was found dead in her living room at one day. At the forensic autopsy, injection marks with bullae and erythema were found at the left shoulder and knee and liquefactive necrosis of muscle tissues was observed in the left but not right extremities. Histopathological examinations of the left upper arm and thigh revealed severe rhabdomyolysis with lots of bacterial clusters. Bacteriological examinations detected group A Streptococcus from intracardiac blood and affected muscle tissues. Postmortem biochemical analysis of blood showed escalated blood urea nitrogen (133.8 mg/dL), creatinine (4.57 mg/dL) and C-reactive protein (45.0 mg/dL). The cause of her death was diagnosed as streptococcal toxic shock syndrome (STSS). Moreover, it was suggested that the injection was inappropriately conducted and served as a portal of bacterial entry.

Clinical Decision Support Reduces Unnecessary Tetanus Vaccinations in the Emergency Department

STUDY OBJECTIVE

Tetanus is the most common vaccination given in the emergency department; yet, administrations of tetanus vaccine boosters in the ED may not comply with the US Centers for Disease Control and Prevention's recommended vaccination schedule. We implemented a clinical decision support alert in the electronic health record that warned providers when ordering a tetanus vaccine if a prior one had been given within 10 years and studied its efficacy to reduce potentially unnecessary vaccines in the ED.

METHODS

This was a retrospective, quasi-experimental, 1-group, pretest-posttest study in 3 hospital EDs in Boston, MA. We studied adult patients for whom tetanus vaccines were ordered despite a history of vaccination within the prior 10 years. We compared the number of potentially unnecessary tetanus vaccine administrations in a baseline phase (when the clinical decision support alert was not visible) versus an intervention phase.

RESULTS

Of eligible patients, 22.1% (95% confidence interval [CI] 21.8% to 22.4%) had prior tetanus vaccines within 5 years, 12.8% (95% CI 12.5% to 13.0%) within 5 to 10 years, 3.8% (95% CI 3.6% to 3.9%) more than 10 years ago, and 61.3% (95% CI 60.9% to 61.7%) had no prior tetanus vaccination documentation. Of 60,983 encounters, 337 met the inclusion criteria. A tetanus vaccination was administered in 91% (95% CI 87% to 96%) of encounters in the baseline phase, compared to 55% (95% CI 47% to 62%) during the intervention. The absolute risk reduction was 36.7% (95% CI 28.0% to 45.4%), and the number of encounters needed to alert to avoid 1 potentially unnecessary tetanus vaccine (number needed to treat) was 2.7 (95% CI 2.2% to 3.6%). For patients with tetanus vaccines within the prior 5 years, the absolute risk reduction was 47.9% (95% CI 35.5 % to 60.3%) and the number needed to treat was 2.1 (95% CI 1.7% to 2.8%).

CONCLUSION

A clinical decision support alert that warns ED clinicians that a patient may have an up-to-date tetanus vaccination status reduces potentially unnecessary vaccinations.

A Prospective, Randomised Clinical Trial Comparing Oral Diclofenac Potassium and Intramuscular Diclofenac Sodium in Acute Pain Relief

Objectives

To compare the efficacy of oral (PO) diclofenac potassium (Cataflam®) and intramuscular (IM) diclofenac sodium (Voltaren®) in acute pain relief, with a hypothesis of equivalence between the two.

Patients and methods

In this prospective randomised single center clinical study, adult Chinese patients attending the emergency department and suffering from renal colic, acute musculoskeletal injury or arthritis were enrolled. They were randomly assigned either 75 mg of IM Voltaren® or 75 mg of PO Cataflam®. Pain was assessed by the Visual Analogue Scale (VAS) and evaluations were performed at baseline, 30 minutes, 1 hour and 2 hours after treatment. Blood pressure, pulse rate and respiratory rate were also recorded at similar time intervals.

Results

We recruited 46 cases in the Voltaren® group and 45 cases in the Cataflam® group. Both treatment groups showed statistically highly significant reduction (P<0.0001) in pain VAS, systolic blood pressure and pulse rate compared with the baseline. Voltaren® was statistically more effective in pain relief at 30 minutes (P=0.012) and 1 hour (P=0.010) but not at 2 hours (P=0.311) compared with Cataflam®. The changes in blood pressure, pulse rate and respiratory rate were not statistically significant between the two treatment groups at all time points.

Conclusion

IM Voltaren® was more effective in acute pain relief compared with PO Cataflam®.

The use of Injectable Nonsteroidal Anti-Inflammatory Drugs in Local Accident & Emergency Practice

Objective

To review the utilization of injectable NSAID in local A&E practice.

Materials and Methods

NSAID utilization data, in relation to type and specialty, were retrieved through the hospital and central pharmacy computer systems of the Hospital Authority.

Results

A&E departments were the main users of injectable NSAID. Their expenditure exceeded other forms of NSAID and narcotic analgesics.

Conclusion

It seems that the use of injectable NSAID in local A&E practice may be excessive. The oral route should be the first consideration, as fast acting oral preparations are now available. As there are risks of severe local complications, stringent justifications should be confirmed before intramuscular administration.

Necrotizing Fasciitis Associated with Nonsteroidal Antiinflammatory Drug Use

Objective:

To describe a case of necrotizing fasciitis (NF) that occurred following minor clean surgery in a seemingly otherwise healthy man who was taking over-the-counter (OTC) ibuprofen 200 mg and aspirin 325 mg before surgery.

Case Summary:

A 71-year-old white man underwent an uncomplicated laparoscopic cholecystectomy. His only medical disorder prior to surgery was osteoarthritis, for which he took OTC-strength ibuprofen; his only other regular medication was one aspirin 325-mg tablet daily for prevention of cardiac disease. Within 48 hours of the surgery, the onset of NF was apparent, and extensive tissue excision and debridement was required 1 week after the operation. All nonsteroidal antiinflammatory drugs (NSAIDs) were withheld. The patient survived a complicated clinical course over the next month.

Discussion:

A review of proposed risk factors for the development of NF in the patient indicated surgery and NSAID use. Analysis of the probability of NSAID use as a causative factor for the adverse reaction of NF suggests a possible role. This case suggests that NSAID use in lower OTC dosages may contribute to the onset or course of NF. The case report adds to existing literature suggesting an association between NSAID use and the development or course of NF.

Conclusions:

NSAIDs are widely used drugs, and any association as a causative or provocative factor for NF is a rare finding. However, practitioners should be aware of the proposed association.

Necrotising pyomyositis complicating intramuscular antipsychotic administration

A 26-year-old woman with paranoid schizophrenia was admitted to the medical intensive care unit with septic shock requiring intubation and mechanical ventilation. The source of septic shock was not identified despite obtaining CT of the chest/abdomen/pelvis, bronchoalveolar lavage and microbiological results for tracheal secretions, blood, urine and cervix. An indium-111 tagged white cell count scan was subsequently performed, revealing increased right anterior deltoid uptake. Owing to serial increases (up to 1310 U/L) in serum creatine kinase and a history of local intramuscular paliperidone injections for management of schizophrenia, surgical exploration was performed and identified necrotising skeletal muscle inflammation and extensive fat necrosis with an organising abscess, consistent with pyomyositis. A gram stain of purulent fluid revealed gram-positive cocci, but no organisms grew in culture. The patient recovered after 10 days of daptomycin and 7 weeks of wound care. Paliperidone injections were discontinued and oral risperidone was initiated.

Sepsis requiring intensive care following intramuscular injections: two case reports

Introduction

Intramuscular injections can rarely result in serious infectious complications such as abscesses which may progress to bacteraemia and generalized sepsis. These complications are rare, but can be life threatening, as they can lead to multi-organ failure associated with high morbidity and mortality.

Case presentation

In this report we present two patients who developed life-threatening infections after intramuscular injections. They were admitted to the hospital, had prompt surgical drainage, required ICU admission for severe sepsis, were treated with an early goal-directed therapy protocol and had a good outcome.

Conclusion

Sepsis is a rare, potentially life-threatening complication after intramuscular injections. Timely surgical drainage followed by appropriate ICU care and early goal directed therapy is crucial and may contribute to a good outcome in these rare cases.

Clarification of terminology in medication errors: definitions and classification

We have previously described and analysed some terms that are used in drug safety and have proposed definitions. Here we discuss and define terms that are used in the field of medication errors, particularly terms that are sometimes misunderstood or misused. We also discuss the classification of medication errors. A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Errors can be classified according to whether they are mistakes, slips, or lapses. Mistakes are errors in the planning of an action. They can be knowledge based or rule based. Slips and lapses are errors in carrying out an action - a slip through an erroneous performance and a lapse through an erroneous memory. Classification of medication errors is important because the probabilities of errors of different classes are different, as are the potential remedies.

Livedoid dermatitis and severe necrosis (Nicolau's syndrome) after intramuscular hydroxyzine injection

Nicolau's syndrome, also called embolica cutis medicamentosa, is characterized by well- circumscribed livedoid dermatitis with aseptic necrosis after intramuscular injection. We report the case of a 45-year-old woman with severe necrosis of the thigh several days after a routine intramuscular injection of hydroxyzine who was transferred to and treated at our Regional Burn Center. Although there has been one case report and numerous voluntarily reported instances of intramuscular hydroxyzine-induced necrosis to the Food and Drug Administration Spontaneous Reporting System, this phenomenon is rare.

Streptococcal infection and necrotizing fasciitis—implications for rehabilitation: a report of 5 cases and review of the literature

Five cases are presented of patients who were diagnosed with necrotizing fasciitis secondary to (1) hip disarticulation (in a paraplegic patient); (2) tooth abscess with extensive neck dissection, complicated by sepsis and hypotension with resultant dysphagia and ischemic encephalopathy; (3) below-knee amputation, anoxia, and severe debility; (4) emergent above-knee amputation; and (5) percutaneous endoscopic gastrostomy placement. The latter patient developed abdominal and chest wall necrotizing fasciitis that required skin grafting. Four patients were treated in an acute rehabilitation setting and returned home, and the fifth was rehabilitated in a subacute facility. This report emphasizes the importance of carefully monitoring rehabilitation patients, especially those with impaired sensation.

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.

Medication use in athletes selected for doping control at the Sydney Olympics (2000)

During the Olympic Games held in Sydney in September, 2000 Doping Control was undertaken as specified in the International Olympic Code. During this process information about the medications taken by athletes was collected as a routine and formed part of the paperwork associated with a urine test. In their Post Games Report the World Anti-Doping Agency (WADA) recommended that the information about medications be collated with a view to assessing their use by athletes. Mandatory doping control for winners of events as well as random selection of athletes both during competition and out of competition allowed data to be collected about medications and supplements used by athletes. At the Doping Control Stations all competitors selected for a test, after providing a urine sample for analysis, were asked the same question: "what medications have you taken in the past three days?" The answer was to include all prescription drugs, over-the-counter medications, any other substances taken by mouth, injection, inhalation, ointment or by suppository, as well as vitamins, minerals, and all other supplements. This paper reviews the data from the 2758 Declaration Forms obtained at doping control. The prevalence of use of medications, the number used by an individual, and the pattern of use by these elite sports people were examined. The trends seen in this survey point to a dangerous overuse of nonsteroidal anti-inflammatory agents and an unnecessary overuse of vitamins in this population, while pointing out the increased prevalence of asthma and the dangers of drug interactions.

OBJECTIVE

The main objective here is to review some of the medications used by athletes in the Olympic Games in Sydney 2000.

DATA SOURCES

During these Games Doping Control was undertaken as specified by the International Olympic Committee. As well as a urine test, information about medications routinely taken was collected. Mandatory doping control for winners of events as well as random selection of athletes both during competition and out of competition required data to be collected about medications and supplements used by athletes as part of the sample collection protocol. At the Doping Control Stations all competitors selected for a test, after providing a urine sample for analysis, were asked the same question: "what medications have you taken in the past three days?" The answer was to include all prescription drugs, over-the-counter medications, any other substances taken by mouth, injection, inhalation, ointment or by suppository, as well as vitamins, minerals, and all other supplements.

DATA SELECTION

In this article we review the data from the laboratory copy of the 2758 Declaration Forms obtained at doping control. The cut down version of the Declaration Form submitted to the laboratory had all information identifying the athlete removed. Thus all information used in this article is completely anonymous. The prevalence of use of medications, the number used by an individual, and the pattern of use by these elite sports people were examined at the request of the IOC.

CONCLUSIONS

In their Post-Games Report, the World Anti-Doping Agency (WADA) acting as independent observers of the anti-doping process recommended to the IOC that the information obtained in the Athlete Declaration Forms concerning medications be collated with a view to assessing their use by athletes. The trends in their use seen in this survey point to an overuse of supplements as well as a dangerous overuse of drugs such as nonsteroidal anti-inflammatory agents together with multiple drug use emphasising the dangers of drug interactions and points out the increased prevalence of asthma in this population.

A case of fatal necrotizing fasciitis after intramuscular administration of diclofenac

Necrotizing fasciitis is a rapidly progressive soft tissue infection that involves subcutaneous fat and spreads along the fascial planes. This disease has a potentially fatal outcome if not recognized in early. Several cases have been reported of a possible association between the use of non-steroidal anti-inflammatory drugs (NSAIDs) and the development or aggravation of necrotizing fasciitis. This association is still a subject of controversy. In this article we present a case of fatal necrotizing fasciitis occurring in association with intramuscular injections of diclofenac in a patient who was admitted for the symptoms of a urinary stone. Our opinion is that the intramuscular injections caused a locally aseptic necrosis, which was secondarily invaded by. Since this incident, our policy is to avoid the use of intramuscular injections of diclofenac and other NSAIDs in cases of potentially infectious diseases.

Tissue tolerance of diclofenac sodium encapsulated in liposomes after intramuscular administration

In this work the effect of the encapsulation of diclofenac sodium within liposomes on the reduction of the myotoxicity after intramuscular administration in rats was studied. Diclofenac sodium was encapsulated in small unilamellar liposomes obtained from phosphatidylcholine, cholesterol, and alpha-tocopherol (40:10:0.04 mM), and administered by intramuscular injection in the quadriceps femoral muscle of male Wistar rats. After a single dose of 0.2 mg diclofenac formulations the local tissue damage was assessed by plasma creatine kinase (CPK) activity and histological analysis. It was demonstrated that formulations containing free diclofenac produced a higher increase in CPK activity, while those encapsulated in liposomes exhibited CPK activity similar to the control groups. Histopathological analysis of local muscle tissue performed on the third and seventh days following the injection showed intense cellular damage when free drug solution was used, while encapsulation in liposome protected the tissue against the local tissue inflammation.

Parenteral ketoprofen for pain management after adenoidectomy: comparison of intravenous and intramuscular routes of administration

BACKGROUND

Different parenteral routes of administration of NSAIDs such as ketoprofen have not been properly compared in children. This study was designed to compare the analgesic efficacy of intravenous and intramuscular ketoprofen for pain management in children after day-case adenoidectomy.

METHODS

A total of 120 children, aged 1-9 years, who were scheduled to undergo adenoidectomy, were randomized to receive ketoprofen 2 mg/kg either intravenously with intramuscular placebo (n = 40) or ketoprofen 2 mg/kg intramuscularly with intravenous placebo (n = 40), or both intravenous and intramuscular placebo (n = 40) at induction of anesthesia. The study design was prospective and double-blind with parallel groups. Pain was assessed at rest and during swallowing using the Maunuksela pain scale during 3 h after surgery, and fentanyl i.v. was given for rescue analgesia.

RESULTS

Children in the Placebo group needed significantly more doses of fentanyl (72 doses) than either children in the intravenous group (47 doses) or children in the intramuscular group (51 doses) (P = 0.021). In addition, a higher proportion of children in the Placebo group than in the two ketoprofen groups (P = 0.03) demanded rescue analgesic. No difference in the need for rescue analgesia or in pain scores was found between the two ketoprofen groups. Children in the intravenous group had less pain than children in the Placebo group. The difference was significant during swallowing at 1 h after surgery (P = 0.046) and for the worst pain observed during swallowing for 3 h after surgery (P = 0.022). There were no differences between the three groups with respect to operation times, amount of perioperative bleeding, or rate or extent of adverse events.

CONCLUSION

The efficacy of intravenous and intramuscular ketoprofen was similar, and they both differed from placebo.

Skin necrosis following injection of non-steroidal anti-inflammatory drug

We report two patients who developed skin necrosis following an intramuscular injection of non-steroidal anti-inflammatory drug into the anteriolateral area of their thigh. Both patients required further multiple operations and one developed life threatening septicaemia. They were left with disfiguring scars. Skin necrosis, although rare, is a recognized adverse reaction to intramuscular non-steroidal anti-inflammatory injections. It is likely that the injections were, unwittingly, administered subcutaneously. It is important to ensure intra-muscular administration, with an appropriate needle length.

Necrotizing fasciitis due to Streptococcus pneumoniae after intramuscular injection of nonsteroidal anti-inflammatory drugs: report of 2 cases and review

Two cases of pneumococcal necrotizing fasciitis (NF) occurred after intramuscular injections of nonsteroidal anti-inflammatory drugs; another 5 cases reported in the literature fulfilled the criteria for NF involving Streptococcus pneumoniae. Conditions associated with alterations of immune function could be identified in 6 of the 7 cases; 2 patients died despite surgical and antimicrobial treatment.

[Intramuscular administration of drugs: skills of pharmacy personnel]

Complications from the incorrect administration of intramuscular injections can cause serious organic damages, infections and increase the patient's permanence in health institution or to harm the functions in the work. The previous study detected several cases of patients with local complications after administration of diclofenac in pharmacies and it concluded that the lack of knowledge of this technique can be the causes of these complications. This current study objectives to identify and evaluate the level of knowledge of the professional that administer medications in pharmacies of Ribeirão Preto--SP. The study constituted in a survey, from a questionnaire with 20 open and closed questions, applied to a population constituted for occupational working in pharmacies, selected through the method of the sampling, resulting in a total of 41 pharmacies. It was concluded that the population is receiving medications from occupationals, without a specific formation and with deficit of knowledge regarding the technique. The subjects referred not to receive training to exercise that procedure, learning it with other employee or observing somebody that accomplishes it. It results knowledge gaps that can cause complications in the population that uses the services of those institutions.

Current perspectives on pain upon injection of drugs

A limitation in the administration of parenteral products is the pain caused upon injection. Injection site pain has been predominately associated with intravenous, intramuscular, and subcutaneous administration. It becomes important for the formulation scientist to have a basic understanding of the physiology underlying the pain process, as well as the pharmaceutical factors associated with injection site pain. Initially, this review will provide the reader with a primer on the mediation of pain in the periphery and a compilation of those drugs that have been associated with pain on injection. In addition, this review will present important considerations and general formulation approaches or methods that have been used to overcome pain on injection. Finally, a brief overview of the various experimental systems used to investigate injection site pain is discussed.

Necrotizing soft tissue infections reported with nonsteroidal antiinflammatory drugs

BACKGROUND

Recent reports of necrotizing fasciitis in children with varicella who received a nonsteroidal antiinflammatory drug (NSAID) recall earlier concerns regarding the possibility of relationships between infections and NSAIDs. We searched the Food and Drug Administration's Spontaneous Reporting System (SRS) for necrotizing soft tissue infections reported in conjunction with the use of NSAIDs, to identify common features.

METHODS

A computer search of NSAID listings in the adverse event database recovered reports with codes for selected infection and necrosis-related diagnostic categories. From review of individual reports classified under these codes, cases were selected if the terms "necrotizing fasciitis," "necrotic," or "gangrenous" appeared in the adverse drug reaction description. Demographic, drug use, and disease course information were gathered.

FINDINGS

Thirty-three cases were identified, of which 10 were fatal. Over two-thirds of the patients were younger than 40 years. Thirty (91%) had a possible portal of entry for infection. Most received NSAIDs for acute conditions including varicella, trauma, and postoperative or postpartum pain; 7 received an NSAID by intramuscular injection. Specific NSAIDs accounting for most reports were also among those likely to be most heavily used in the relevant populations.

INTERPRETATION

Common features of these rare case reports of necrotizing soft tissue infections with NSAID use include characteristics such as age, portal of infection entry, indication for NSAID use, route of administration, and individual NSAIDs. The total number of SRS cases does not suggest that necrotizing infection is frequent with NSAIDs or likely without other risk factors. Controlled observational studies would help to define any causal contribution of these factors to the evolution of severe infection.