Rifampicin-isoniazid induced fatal fulminant hepatitis during treatment of latent tuberculosis: A case report and literature review

Isoniazid-Induced Acute Liver Failure Requiring Liver Transplantation

Tuberculosis (TB) is a contagious disease caused by the bacilli Mycobacterium tuberculosis complex. Currently, about a quarter of the world's population is infected with Mycobacterium tuberculosis. According to the World Health Organization, in 2018, Portugal had a TB incidence rate of about 24 cases per 100,000 inhabitants. It is estimated that 5-15% of individuals with latent TB infection progress to active TB. Isoniazid is one of the most widely used drugs for the treatment of active and latent TB. However, care must be taken with the possible development of toxicity, particularly hepatic. The authors report a case of a 60-year-old woman diagnosed with latent TB who started therapy with isoniazid. Five months later, she developed acute liver failure secondary to the drug, requiring liver transplantation, with a favorable clinical outcome. Thus, we intend to alert to the potential toxicities of isoniazid, establishing follow-up strategies in patients on this therapy.

Implementation of the Surviving Sepsis Campaign guidelines

PURPOSE OF REVIEW

Early identification and appropriate management of sepsis improves outcomes. Despite convincing data showing the benefits of early recognition and treatment of sepsis and septic shock, implementation of such evidence-based therapy is suboptimal. This review describes methods that have been shown to improve bedside application of the evidence-based guidelines.

RECENT FINDINGS

The Surviving Sepsis Campaign (SSC) has developed guidelines for the management of severe sepsis and septic shock. The initial SSC guidelines were published in 2004; as evidence continued to evolve, the guidelines were updated, with the most recent iteration published in 2016. Guidelines by themselves can take years to change clinical practice. To affect more rapid change, the SSC guidelines are filtered into bundles to impact behavior change in a simple and uniform way.

SUMMARY

Implementation of the SSC bundles revolves around practice improvement measures. Hospitals that have successfully implemented these bundles have consistently shown improved outcomes and reductions in healthcare spending. Finally, the Centers for Medicare and Medicaid Services has approved SSC bundle compliance as a core measure, and hospitals in the United States are mandated to collect and report their data regularly to Centers for Medicare and Medicaid Services.

Effect of a Sepsis Educational Intervention on Hospital Stay

OBJECTIVES

To evaluate adherence to the sepsis bundle before and after an educational strategy and its impact on hospital stay.

DESIGN

A prospective, analytic, before-and-after study of children with severe sepsis and septic shock who presented to the emergency department.

SETTING

Carried out from January to December 2014 in the emergency department of a quaternary care hospital.

PATIENTS

Of a total of 19,836 children who presented to the emergency department, 4,383 had an infectious pathology, with 203 of these showing severe sepsis and septic shock (124 pre intervention, and 79 post intervention).

INTERVENTIONS

The healthcare providers caring for the patients in pediatric emergency received an educational intervention and an update on the bundle concepts proposed in 2010 by the Pediatric Advanced Life Support program of the American Heart Association and adapted by this study's investigators.

MEASUREMENTS AND MAIN RESULTS

The main cause of sepsis in both groups was respiratory (59 vs 33; p = 0.72), without differences in the Pediatric Index of Mortality 2 score (7.23 vs 8.1; p = 0.23). The postintervention group showed a reduced hospital stay (11.6 vs 7.9 d; p = 0.01), a shorter time before ordering fluid boluses (247 vs 5 min; p = 0.001), the application of the first dose of antibiotic (343 vs 271 min; p = 0.03), and a decreased need for mechanical ventilation (20.1% vs 7.5%; p = 0.01). Postintervention adherence to the complete bundle was 19.2%, compared with the preintervention group, which was 27.7% (p = 0.17).

CONCLUSIONS

Adherence to a bundle strategy is low following an educational intervention. However, when patients are managed after instruction in guideline recommendations, hospital stay may be significantly reduced.

Evaluation of adverse drug reactions in HIV positive patients in a tertiary care hospital

CONTEXT

The advancement and development of new drugs and treatment strategies increase the risk of unusual Adverse Events (AEs) in HIV patients.

AIMS

The objective of our study was to assess the incidence, types and nature of AEs in HIV positive subjects.

SETTINGS AND DESIGN

Patients with WHO stage IV disease irrespective of the CD4 cell count, or WHO stage III disease with a CD4 cell count <350 cell/cu. Mm, or, WHO stage I or II disease with a CD4 cell count of <200 cells/cu. mm, and on prior anti-retroviral therapy for not more than six months preceding the observation date, were included in the study. After initiation of therapy, the patients were examined for the occurrence any adverse events including the type and severity, or any other abnormal laboratory findings. Causality assessment of the adverse events was done using the Naranjo's scale.

RESULTS

Out of 327 patients studied prospectively, 43 patients developed AEs. Out of these, 23 (53.5%) were males and 20 (46.5%) were females. A total of 53 (16.21%) AEs were reported. Antitubercular drugs caused the maximum AEs (28.3%) followed by zidovudine (20.7%), nevirapine (15.0%) and efavirenz (5.6%). Stavudine, ethambutol, sulfamethoxazole and trimethoprim, and atazanavir were also responsible for 3.7% of AEs individually. Causality assessment done according to the Naranjo's scale revealed that 66.04% AEs were 'probable' and 33.96% were 'possible'.

CONCLUSIONS

Anemia, hepatitis and dermatological adverse effects are the most common AEs. Antitubercular drugs contributed significantly for the incidence of AEs in these patients. Frequency of AEs was slightly more in males compared to females.

Isoniazid-induced acute liver failure during preventive therapy for latent tuberculosis infection

Treating latent tuberculosis infection is a strategy for eliminating tuberculosis, and isoniazid is recommended as preventive therapy. However, concerns have been raised regarding the application of isoniazid due to its toxicity, particularly hepatotoxicity; however, biochemical monitoring is not routinely performed during treatment. We herein present a case of fatal isoniazid-induced acute liver failure. The patient's liver function was not periodically examined and isoniazid therapy was continued for 10 days despite the onset of symptoms associated with hepatitis. The patient died four months after hospitalization. It is essential to consider the potential toxicities of isoniazid and establish strategies to prevent acute liver failure.

ATT- A Double Edged Sword?

Antitubercular therapy (ATT) induced hepatotoxicity, although well known to clinicians, is often over looked and underrated. Given the low threshold of starting ATT, especially empirically, the adverse manifestations can take a considerable toll. A variety of associated risk factors compound the morbidity. We throw light on one such a case where ATT was detrimental to the patient and review the literature and possible preventive strategies.