Tigecycline-induced acute pancreatitis in a renal transplant patient: a case report and literature review

Clinical characteristics and risk factors of tigecycline-induced acute pancreatitis in kidney transplant recipients: a retrospective study

OBJECTIVE

Acute pancreatitis (AP) is a severe but insufficiently recognized adverse effect of tigecycline in kidney transplant (KT) recipients. This study aimed to identify the clinical characteristics and risk factors associated with tigecycline-induced AP in this population.

METHODS

A single-center retrospective study was conducted in KT recipients treated with tigecycline. The clinical characteristics of patients who developed AP were analyzed, and risk factors for tigecycline-induced AP were assessed using univariate analysis and multivariate logistic regression.

RESULTS

80 KT recipients were enrolled, of whom nine developed AP (incidence: 11.25%), and four died. The mean time from tigecycline administration to AP onset was 7.00 days, to symptomatic relief after discontinuation was 4.87 days, and to normalisation of pancreatic enzymes after discontinuation was 8.75 days. The analysis revealed that tacrolimus trough concentration (C0 Tac) and post-transplant acute kidney injury (AKI) were independent risk factors for tigecycline-induced AP in KT recipients. Logistic regression analysis produced a combined predictive expression: Ycombined = AKI + 0.064C0 Tac-2.789. Receiver operating characteristic curve analysis determined that the C0  Tac cut-off was 13.9 ng/mL. The area under the curve for C0  Tac and combined predictor were 0.802 and 0.853, respectively.

CONCLUSION

The incidence of AP following tigecycline treatment was significantly higher in KT recipients than in non-transplant patients. Post-transplant AKI and elevated C0 Tac concentrations were identified as independent risk factors for the development of AP. Close monitoring of renal function and ensuring therapeutic monitoring of C0 Tac levels may help prevent AP.

Management of multidrug-resistant gram-negative bacilli infections in adult solid organ transplant recipients: GESITRA-IC/SEIMC, CIBERINFEC, and SET recommendations update

Multidrug-resistant (MDR) Gram-negative bacilli (GNB) infections in solid organ transplant (SOT) recipients continue to pose a significant threat despite advances in diagnostics and treatments. The last international consensus guidelines of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) on the management of MDR GNB in adult solid organ transplant (SOT) recipients were published in 2018, underscoring the need for an update to incorporate recent advances, particularly the availability of new drugs that may improve the current standard of care. A working group consisting of members from the Study Group of Infection in Transplantation and Immunocompromised Hosts (GESITRA-IC) of SEIMC, the Center for Biomedical Research Network in Infectious Diseases (CIBERINFEC) and the Spanish Society of Transplantation (SET) developed consensus-based recommendations for managing MDR GNB infections during the transplant procedure. Recommendations were categorized based on evidence quality and strength, utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The final recommendations were endorsed through a consensus meeting and approved by the expert panel.

Minocycline-Induced Acute Pancreatitis With Cyst Formation in a Young Man

An 18-year-old male, diagnosed with urethritis and treated with minocycline for six days, presented to our hospital complaining of abdominal pain and nausea. Blood tests and contrast-enhanced computed tomography (CT) showed severe acute pancreatitis. Based on his medical history, blood tests, and imaging studies, common etiologies of acute pancreatitis were excluded, including alcohol intake, anatomical abnormalities of the pancreas and biliary tract, stones, malignancy, autoimmune diseases, and lipid abnormalities. The patient was diagnosed with drug-induced acute pancreatitis due to minocycline. Upon admission, minocycline was discontinued, and the patient was treated symptomatically. His symptoms improved steadily, and he was discharged on day 14 of hospitalization. A follow-up CT scan on day 8 of hospitalization revealed a 4-cm cyst at the pancreatic tail; however, since the patient was asymptomatic, he was monitored with imaging studies. The cyst gradually shrank and was no longer visible on a CT scan 12 weeks after discharge. Most cases of drug-induced acute pancreatitis caused by tetracycline have been reported as mild to moderate, and there are no documented cases of severe pancreatitis with cyst formation in the literature. This case illustrates that minocycline-induced acute pancreatitis can lead to severe pancreatitis and cyst formation, warranting careful use.

Possible omadacycline induce acute pancreatitis: a case report and literature review

BACKGROUND

Omadacycline is a new generation of tetracycline antibiotics, and its clinical application is increasing. We report the first case of acute pancreatitis possibly induced by omadacycline.

CASE PRESENTATION

The patient was admitted to the emergency intensive care unit due to community-acquired pneumonia. The initial treatment consisted of meropenem combined with levofloxacin, and the regimen was subsequently switched to omadacycline combined with cefoperazone/sulbactam due to sputum culture showing carbapenem-resistant Acinetobacter baumannii. Seven days after the administration of omadacycline, abdominal tenderness occurred, and CT scan revealed an enlarged gallbladder with exudation from the pancreatic head. The patient was diagnosed with acute pancreatitis and improved after dis-continuing omadacycline.

CONCLUSIONS

Omadacycline, like other tetracycline antibiotics, may cause pancreatitis. Combination medications can be an important factor in this adverse reaction.

Risk factors for drug-related acute pancreatitis: an analysis of the FDA adverse event reporting system (FAERS)

Objective: While several drugs have been linked to acute pancreatitis (AP), the AP-related risk of most drugs remains unclear. This study investigated the risk factors for drug-induced AP by analyzing a large dataset from the FDA Adverse Event Reporting System (FAERS). Methods: The reporting odds ratios (ROR) were used to assess the reports of drug-induced AP from the first quarter of 2004 to the second quarter of 2022. Single-factor, LASSO, and multi-factor regression analysis were performed to explore drug-related AP-related risk factors. Bonferroni correction was applied for the multiple comparisons performed. Results: A total of 264 drugs associated with AP, including antineoplastic drugs (35/264), antidiabetic drugs (28/264), antibacterial drugs (24/264), immunomodulatory drugs (11/264), antipsychotic drugs (6/264), and other drugs (160/264) were retrieved. Multi-factor analysis showed that males, age 41-54 years old, and 36 drugs, including Tigecycline, were risk factors for drug-related AP. The median time to drug-related AP onset was 31 days (interquartile range [IQR] 7-102 days) and about 75% of adverse events occurred within 100 days. Conclusion: These findings may help clinicians to identify drug-related AP at the early stage and can be used to inform future studies of drug-related AP pathogenesis.

Safety and effectiveness of tigecycline combination therapy in renal transplant patients with infection due to carbapenem-resistant gram-negative bacteria

Background

Carbapenem-resistant gram-negative bacterial (CRGNB) infections are increasing among kidney transplant recipients, and effective therapeutic options are limited. This study aimed to investigate the efficacy and adverse events associated with combination therapy tigecycline in renal transplant patients with CRGNB infections.

Methods

This study retrospectively analyzed 40 Chinese patients with confirmed or suspected CRGNB infections who received tigecycline therapy. The patients' case features and clinical and microbiological data were analyzed.

Results

A total of 40 renal transplant recipients received tigecycline therapy for a median duration of 9 (range, 3-25) days. CRGNB isolates were obtained from the organ preservation solution of the donor kidney in 28 patients, with confirmed transmission in 4 patients. Infections were detected in the bloodstream, urinary tract, sputum, and wound. The most prevalent isolates were Klebsiella pneumoniae (75%, 30/40), Acinetobacter baumannii (15%, 6/40), and Escherichia coli (10%, 4/40). A clinical response was observed in 32 (80%) patients. The 28-day all-cause mortality rate was 7.5% (3/40), while the one-year all-cause mortality rate was 2.5% (1/40). While one patient died owing to severe pancreatitis, no serious adverse events related to tigecycline therapy were reported. However, multiple indices of liver function and pancreatitis precursors increased after treatment with tigecycline compared to before treatment.

Conclusion

Tigecycline therapy appears to be well tolerated in renal transplant recipients with multidrug-resistant bacterial infections. Nevertheless, attention should be paid to adverse reactions related to tigecycline therapy, especially gastrointestinal reactions, and the related laboratory tests should be closely monitored.

Drug-Induced Acute Pancreatitis in Adults: Focus on Antimicrobial and Antiviral Drugs, a Narrative Review

Acute pancreatitis (AP) is an acute inflammation of the pancreas caused by the activation of digestive enzymes in the pancreatic tissue. The main causes of AP are cholelithiasis and alcohol abuse; less commonly, it can be caused by drugs, with a prevalence of up to 5%. Causal associations between drugs and pancreatitis are largely based on case reports or case series with limited evidence. We reviewed the available data on drug-induced AP, focusing on antimicrobial drugs and antivirals, and discussed the current evidence in relation to the classification systems available in the literature. We found 51 suspected associations between antimicrobial and antiviral drugs and AP. The drugs with the most evidence of correlation are didanosine, protease inhibitors, and metronidazole. In addition, other drugs have been described in case reports demonstrating positive rechallenge. However, there are major differences between the various classifications available, where the same drug being assigned to different probability classes. It is likely that the presence in multiple case reports of an association between acute pancreatitis and a drug should serve as a basis for conducting prospective randomized controlled trials to improve the quality of the evidence.

Tigecycline Tango: A Case of Antibiotic-Induced Pancreatitis

Acute pancreatitis is a frequent cause of hospitalization, with the most common triggers being alcohol consumption and gallstones. Although the incidence of drug-induced pancreatitis remains low, it is steadily increasing due to the advent of newly discovered broad-spectrum antibiotics targeting multi-drug resistant organisms. Tigecycline, a broad-spectrum intravenous antibiotic derived from the tetracycline class, was approved by the FDA in 2005 for the treatment of complicated skin and skin structure infections, complicated intra-abdominal infections, and community-acquired pneumonia. It has activity against vancomycin-resistant Enterococcus, Methicillin-resistant Staphylococcus aureus, multi-drug-resistant Acinetobacter baumannii, multi-drug-resistant Stenotrophomonas maltophilia, and Extended Spectrum Beta-lactamase (ESBL) producing Enterobacter species. However, it was later discovered that tigecycline can cause acute pancreatitis. We present a case of a 27-year-old female patient who was admitted to the emergency department with abdominal pain and was subsequently diagnosed with tigecycline-induced pancreatitis based on the clinical resolution after withdrawal of the drug.

The Spectrum of Tigecycline-Induced Pancreatitis in Clinical Characteristics, Diagnosis, and Management

Introduction

Tigecycline-induced acute pancreatitis (AP) has been frequently increasingly reported in solid organ transplant patients. This review aimed to summarize the characteristics, possible mechanisms, and management of tigecycline-induced AP.

Methods

Case reports of tigecycline-induced AP published in Chinese or English were collected until February 2023 for retrospective analysis.

Results

Thirty-four patients from 29 articles were included. Fifteen patients (46.9%) had solid organ transplantation, and 4 patients (12.5%) had malignant tumors. Twenty-five patients (89.3%) received a recommended maintenance dose of tigecycline (50 mg q12 h). The median age was 50 years (range 9-87). Compared to the nontransplant patients, the median age of the transplant patients was significantly younger, 44 years (range 12.5-61) versus 57.5 years (range 9-87) (P=0.03). The median time of symptom onset was 7 days (range 2-29), and 91.2% (31/34) were less than 14 days. Typical initial symptoms included abdominal pain (90.6%), nausea (46.9%), vomiting (43.8%), and abdominal distention (21.9%). Most cases were accompanied by elevated levels of pancreatic enzymes. The main radiological features included edematous infiltrate and acute pancreatitis on computed tomography (CT) scan and abdominal ultrasound. Except for one patient who continued tigecycline treatment, all patients discontinued treatment and received symptomatic support such as fasting, acid suppression, and enzyme suppression. The median time to recover pancreatic enzymes to the normal range was 5 days (range 1-43), and the median time to relieve symptoms was 4 days (range 1-12). Four patients died, of whom two died of severe pancreatitis complications and two of cardiogenic shock and septicemia.

Conclusion

Tigecycline-induced AP was a rare and serious complication that occurred mainly within two weeks of the medication. This serious side effect should be kept in mind while treating severe infections especially in transplant recipients.

Wide-spectrum antibiotic prophylaxis guarantees optimal outcomes in drowned donor kidney transplantation

BACKGROUND

Drowned victims possibly obtain various pathogens from drowning sites. Using drowned renal donors to expand the donor pool still lacks consensus due to the potential risk of disease transmission.

RESEARCH DESIGN AND METHODS

This retrospective study enrolled 38 drowned donor renal recipients in a large clinical center from August 2012 to February 2021. A 1:2 matched cohort was generated with donor demographics, including age, gender, BMI, and ICU durations. Donor microbiological results, recipient perioperative infections, and early post-transplant and first-year clinical outcomes were analyzed.

RESULTS

Compared to the control group, drowned donors had significantly increased positive fungal cultures (36.84% vs.13.15%, p = 0.039). Recipients in the drowned group had significantly higher rates of gram-negative bacteria (GNB) and multidrug-resistant GNB infections (23.68% vs.5.26%, 18.42% vs. 3.95%, both p < 0.05). Other colonization and infections were also numerically more frequent in the drowned group. Drowned donor recipients receiving inadequate antibiotic prophylaxis had more perioperative bloodstream infections, higher DGF incidences, and more first-year respiratory tract infections and recipient loss than those receiving adequate prophylaxis (all p < 0.05). Clinical outcomes were similar between the adequate group and the control group.

CONCLUSIONS

Drowned donors could be suitable options under wide-spectrum and adequate antimicrobial prophylaxis.

Tigecycline and Gentamicin-Combined Treatment Enhances Renal Damage: Oxidative Stress, Inflammatory Reaction, and Apoptosis Interplay

Although the combination of antibiotics is generally well-tolerated, they may have nephrotoxic effects. This study investigated whether tigecycline (TG) and gentamicin (GM) co-administration could accelerate renal damage. Male Wistar rats were randomly divided into six experimental groups: the control, TG7 (tigecycline, 7 mg/kg), TG14 (tigecycline, 14 mg/kg), GM (gentamicin, 80 mg/kg), TG7+GM, and TG14+GM groups. The combination of TG and GM evoked renal damage seen by the disruption of kidney function tests. The perturbation of renal tissue was mainly confounded to the TG and GM-induced oxidative damage, which was exhibited by marked increases in renal MDA (malondialdehyde) along with a drastic reduction in GSH (reduced-glutathione) content and CAT (catalase) activity compared to their individual treatments. More obvious apoptotic events and inflammation were also revealed by elevating the annexin-V and interleukin-6 (IL-6) levels, aside from the upregulation of renal PCNA (proliferating cell nuclear antigen) expression in the TG and GM concurrent treatment. The principal component analysis indicated that creatinine, urea, annexin-V, IL-6, and MDA all played a role in discriminating the TG and GM combined toxicity. Oxidative stress, inflammatory response, and apoptosis were the key mechanisms involved in this potentiated toxicity.

Acute pancreatitis caused by tigecycline: A case report and literature review

RATIONALE

There is evidence that tigecycline has broad-spectrum antibiotic activity against a variety of complicated infections. However, adverse effects are inevitable, including gastrointestinal side effects such as nausea, vomiting, and diarrhea; in 2006, acute pancreatitis was also brought into the side-effect list after postmarketing surveillance. Here, we present a case of tigecycline-induced acute pancreatitis.

PATIENT CONCERNS

An 87-year-old female patient with urinary tract infection received an intravenous drip of tigecycline for 6 days, after which she developed abdominal distension, vomiting, abdominal pain, and abdominal rigidity.

DIAGNOSIS

The patient was suspected to have tigecycline-induced acute pancreatitis.

INTERVENTIONS

Tigecycline was discontinued immediately, and the patient received a series of immediate treatments including an indwelling gastric tube for continuous gastrointestinal decompression and inhibition of gastric acid and pancreatic enzyme secretion.

OUTCOMES

Following initial interventions, we observed that the patient's symptoms improved significantly, and abdominal distension, vomiting, abdominal pain, and abdominal rigidity were slightly relieved. After 5 days of follow-up, blood lipase and amylase levels decreased to normal levels. Unfortunately, the patient developed convulsions during the use of multiple antibiotics after 1 week and then died of septic shock and acute liver failure.

LESSONS

Acute pancreatitis caused by tigecycline is rare. However, in the application of antibiotics, the possibility of adverse effects must be considered, and antibiotics should be used reasonably. If the patient has relevant symptoms, it is necessary to stop using tigecycline immediately, carry out symptomatic treatment, and change to other types of antibiotics for antibacterial treatment.

A case report of tigecycline induced acute pancreatitis in a renal transplant patient and review of the literature: Should we avoid tigecycline in patients on calcineurin inhibitors?

Tigecycline has been approved by the US (United States) Food and Drug Administration in a variety of complicated infections due to its broad-spectrum antibiotic activity. Following phase III trials, the product label was revised and acute pancreatitis was listed as an adverse effect. Its safety profile in special groups such as renal transplant patients is not exactly known. We report the first case of unintentional rechallenge of tigecycline induced pancreatitis in a renal transplant patient. Ten days following the renal transplantation, a 35-year-old patient presented to the clinic with acute rejection. He received anti-thymocyte globulin (ATG) and pulse steroid treatments for rejection. Following the treatment, he developed perianal cellulitis and tigecycline was started. Nine days following initiation of tigecycline he received thrombectomy for his incidental cardiac thrombus. One day after thrombectomy, he developed acute pancreatitis (AP). Thrombectomy was suspected to be the cause of AP. During hospitalization for transplant rejection, tigecycline was re-started for a newly developed complicated abdominal infection. On the third day of the tigecycline re-treatment, he developed a second episode of AP. Following tigecycline withdrawal, his symptoms resolved and serum pancreatic enzymes returned to normal, thus AP was ultimately attributed to tigecycline. This lethal side effect should be kept in mind while treating severe infections in renal transplant recipients.

Tigecycline antibacterial activity, clinical effectiveness, and mechanisms and epidemiology of resistance: narrative review

Tigecycline is unique glycylcycline class of semisynthetic antimicrobial agents developed for the treatment of polymicrobial infections caused by multidrug-resistant Gram-positive and Gram-negative pathogens. Tigecycline evades the main tetracycline resistance genetic mechanisms, such as tetracycline-specific efflux pump acquisition and ribosomal protection, via the addition of a glycyclamide moiety to the 9-position of minocycline. The use of the parenteral form of tigecycline is approved for complicated skin and skin structure infections (excluding diabetes foot infection), complicated intra-abdominal infections, and community-acquired bacterial pneumonia in adults. New evidence also suggests the effectiveness of tigecycline for the treatment of severe Clostridioides difficile infections. Tigecycline showed in vitro susceptibility to Coxiella spp., Rickettsia spp., and multidrug-resistant Neisseria gonnorrhoeae strains which indicate the possible use of tigecycline in the treatment of infections caused by these pathogens. Except for intrinsic, or often reported resistance in some Gram-negatives, tigecycline is effective against a wide range of multidrug-resistant nosocomial pathogens. Herein, we summarize the currently available data on tigecycline pharmacokinetics and pharmacodynamics, its mechanism of action, the epidemiology of tigecycline resistance, and its clinical effectiveness.

Updates in drug-induced acute pancreatitis

Background

Being infrequent, drug-induced acute pancreatitis (DIP) is an overlooked clinical entity that can be serious with significant morbidity and mortality.

Main body

A renovative review of drugs incriminated in acute pancreatitis had been presented with all relevant data and case presentations. Antibiotics, antidiabetics, antihypertensive agents, H2 blockers (H2B) and proton pump inhibitors (PPIs), anticancer therapies, and the new direct-acting antiviral therapies (DAAs) of hepatitis C virus (HCV) were discussed pertinently to DIP.

Conclusions

DIP should be suspected as a potential adverse event to every newly emerged drug. Herein, an updated review of drugs recently alleged to be implicated in DIP.

Acute pancreatitis due to tacrolimus in kidney transplant and review of the literature

WHAT IS KNOWN AND OBJECTIVE

The purpose of this case report is to increase the awareness of tacrolimus-induced acute pancreatitis in renal transplantation patients.

CASE SUMMARY

We present a case of tacrolimus-induced acute pancreatitis with positive rechallenge. The 24-year-old male patient underwent kidney transplant and received immunosuppressive therapy with tacrolimus. On day 10 post-transplant, he presented with abdominal pain. A laboratory analysis showed elevated serum amylase and serum lipase levels. An abdominal computed tomography scan showed large-volume ascites and pelvic cavity effusion. These findings led to a diagnosis of acute pancreatitis. After tacrolimus was temporarily stopped and altered with cyclosporine, his symptoms decreased and he was restarted with tacrolimus. On day 61, laboratory tests again revealed significant elevations of serum amylase and serum lipase. A computed tomography scan of the abdomen showed increased pancreatic tail fluid collections. We excluded other possible causes and concluded that tacrolimus was the definite inducer of pancreatitis. The patient was switched from tacrolimus to cyclosporine again. Serum amylase and serum lipase were gradually decreased to normal, and he was discharged home with no relapse.

WHAT IS NEW AND CONCLUSION

With the consideration of the wide use of tacrolimus, it is important that healthcare providers are aware of tacrolimus-induced acute pancreatitis. Future studies are needed to confirm and quantify the risk of tacrolimus-induced acute pancreatitis.

Successful Treatment of Early Post-Transplant Bloodstream and Pulmonary Infection Caused by Carbapenem-Resistant Klebsiella pneumoniae With a Combination of Ceftazidime-Avibactam and Carbapenem: A Case Report

Bloodstream infection with carbapenem-resistant Klebsiella pneumoniae (CRKP) is a severe and challenging complication in the early post-transplantation period. Pulmonary infection secondary to sepsis caused by CRKP has been reported only rarely in kidney transplant recipients. Here we report an interesting and complicated case in which CRKP was initially isolated in a culture of renal graft preservation solution, yet was not detected in the daily cultures from collection of surgical drainage. Prophylactic tigecycline was terminated at post-transplantation day 10 because of the occurrence of acute pancreatitis. Five days later, the patient suddenly developed a multisite infection with CRKP involving the bloodstream, urinary tract, and lungs, indicating probable transmission from the donor. Fortunately, the infection was controlled quickly and effectively with a combination therapy consisting of ceftazidime-avibactam (CZA) and carbapenem, which was suggested by the results of disc diffusion susceptibility testing. However, the CRKP infection reappeared in the bloodstream and urinary tract soon after the treatment of acute rejection. The combination regimen was continued for another 15 days, and the patient ultimately recovered. During the following 15 months of observation, the patient's renal graft function remained stable, without recurrence of the CRKP infection. In conclusion, the combined use of CZA and carbapenem was safe and produced an optimal therapeutic effect on the severe multisite infection caused by CRKP in a renal transplant recipient, thus providing a reference case for treating such patients.

Analysis of clinical characteristics of tigecycline-induced acute pancreatitis

WHAT IS KNOWN AND OBJECTIVE

The purpose of this study is to explore the clinical characteristics of tigecycline-induced acute pancreatitis.

METHODS

We searched the PubMed/Medline, Web of Knowledge, OVID, Elsevier, Springer Link, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Data, and Chinese VIP databases from 2005 and identified 19 studies of tigecycline-induced acute pancreatitis involving a total of 22 patients for inclusion in a retrospective analysis.

RESULTS AND DISCUSSION

The median (range) age of 22 patients with acute pancreatitis was 58 years (range 9-83). Overall, the median (range) time of symptom onset was 6.5 days (range 2-28), or 6 days (range 2-14) and 6 days (range 3-28) in patients with or without a loading dose of tigecycline, respectively. Symptoms included nausea, vomiting and abdominal distension (73%) and abdominal pain (73%); 90% (18/20) of patients developed mild acute pancreatitis (MAP), and 10% (2/20) developed severe acute pancreatitis (SAP). Computed tomography (CT) scans showed oedematous infiltrate in 56% (10/18) of cases and acute pancreatitis in 28% (5/18) of cases. The median (range) level of lipase and amylase was 936U/L (range 382-4089) and 588U/L (range 312-1166), respectively. The median (range) time to recovery of symptoms was 4 days (range 1-10), and the time for recovery of pancreatic enzymes to the normal range was 5 days (range 1-30) after the withdrawal of tigecycline in all patients.

WHAT IS NEW AND CONCLUSION

Clinicians should be particularly mindful of clinical signs and symptoms, the level of serum pancreatic enzymes and abdominal CT images in order to monitor the development of pancreatitis when using tigecycline.

Drug induced pancreatitis: A systematic review of case reports to determine potential drug associations

OBJECTIVE

A current assessment of case reports of possible drug-induced pancreatitis is needed. We systematically reviewed the case report literature to identify drugs with potential associations with acute pancreatitis and the burden of evidence supporting these associations.

METHODS

A protocol was developed a priori (PROSPERO CRD42017060473). We searched MEDLINE, Embase, the Cochrane Library, and additional sources to identify cases of drug-induced pancreatitis that met accepted diagnostic criteria of acute pancreatitis. Cases caused by multiple drugs or combination therapy were excluded. Established systematic review methods were used for screening and data extraction. A classification system for associated drugs was developed a priori based upon the number of cases, re-challenge, exclusion of non-drug causes of acute pancreatitis, and consistency of latency.

RESULTS

Seven-hundred and thirteen cases of potential drug-induced pancreatitis were identified, implicating 213 unique drugs. The evidence base was poor: exclusion of non-drug causes of acute pancreatitis was incomplete or poorly reported in all cases, 47% had at least one underlying condition predisposing to acute pancreatitis, and causality assessment was not conducted in 81%. Forty-five drugs (21%) were classified as having the highest level of evidence regarding their association with acute pancreatitis; causality was deemed to be probable or definite for 19 of these drugs (42%). Fifty-seven drugs (27%) had the lowest level of evidence regarding an association with acute pancreatitis, being implicated in single case reports, without exclusion of other causes of acute pancreatitis.

DISCUSSION

Much of the case report evidence upon which drug-induced pancreatitis associations are based is tenuous. A greater emphasis on exclusion of all non-drug causes of acute pancreatitis and on quality reporting would improve the evidence base. It should be recognized that reviews of case reports, are valuable scoping tools but have limited strength to establish drug-induced pancreatitis associations.

REGISTRATION

CRD42017060473.

Clostridioides difficile associated peritonitis in peritoneal dialysis patients - a case series based review of an under-recognized entity with therapeutic challenges

BACKGROUND

Initial presentation of peritoneal dialysis associated infectious peritonitis can be clinically indistinguishable from Clostridioides difficile infection (CDI) and both may demonstrate a cloudy dialysate. Empiric treatment of the former entails use of 3rd-generation cephalosporins, which could worsen CDI. We present a logical management approach of this clinical scenario providing examples of two cases with CDI associated peritonitis of varying severity where the initial picture was concerning for peritonitis and treatment for CDI resulted in successful cure.

CASE PRESENTATION

A 73-year-old male with ESRD managed with PD presented with fever, abdominal pain, leukocytosis and significant diarrhea. Cell count of the peritoneal dialysis effluent revealed 1050 WBCs/mm3 with 71% neutrophils. C. difficile PCR on the stool was positive. Patient was started on intra-peritoneal (IP) cefepime and vancomycin for treatment of the peritonitis and intravenous (IV) metronidazole and oral vancomycin for treatment of the C. difficile colitis but worsened. PD fluid culture showed no growth. He responded well to IV tigecycline, oral vancomycin and vancomycin enemas. Similarly, a 55-year-old male with ESRD with PD developed acute diarrhea and on the third day noted a cloudy effluent from his dialysis catheter. PD fluid analysis showed 1450 WBCs/mm3 with 49% neutrophils. IP cefepime and vancomycin were initiated. CT of the abdomen showed rectosigmoid colitis. C. difficile PCR on the stool was positive. IP cefepime and vancomycin were promptly discontinued. Treatment with oral vancomycin 125 mg every six hours and IV Tigecycline was initiated. PD fluid culture produced no growth. PD catheter was retained.

CONCLUSIONS

In patients presenting with diarrhea with risk factors for CDI, traditional empiric treatment of PD peritonitis may need to be reexamined as they could have detrimental effects on CDI course and patient outcomes.