Continuous infusion of cefepime and neurotoxicity: a retrospective cohort study

OBJECTIVES

Neurotoxicity related to cefepime is increasingly reported in the literature but specific data concerning continuous infusion (CI) of the drug are still lacking. Our primary objective was to evaluate the incidence of neurotoxicity related to CI of cefepime and the associated risk factors. Our secondary objectives were to analyse the plasma cefepime concentrations and to define the threshold above which neurotoxicity occurs.

METHODS

In this single-centre retrospective cohort study, all adult patients who underwent at least one cefepime therapeutic drug monitoring (TDM) and were treated with CI of 4 g/day between January 2017 and June 2019 were included. Neurotoxicity was evaluated according to a strict definition and was correlated with steady-state concentration at the time of toxicity presentation.

RESULTS

Ninety-eight patients with 201 cefepime TDM studies were included, with an incidence of neurotoxicity of 14.3% (14/98). Patients with neurotoxicity had more often underlying brain disease (35.7% (5/14) vs 11.9% (10/84), p = 0.030)) and higher steady-state concentrations (mean ± standard deviation 71.8 ± 32.9 mg/L vs 49.6 ± 30.6, p = 0.036) than the others. A receiver operating characteristic curve analysis yielded a cefepime steady-state concentration of 63.2 mg/L as the best cut-off point between patients with or without neurotoxicity. A mean steady-state concentration of 46.4 mg/L was achieved if the dosages of cefepime were adapted to renal function which was under our threshold concentration but above our highest pharmacokinetic/pharmacodynamic target of 32-40 mg/L.

CONCLUSIONS

Our results suggest that 4 g/day of cefepime adapted to renal function and infused over 24 h is a trade-off for the risk/benefit ratio, when used empirically.

[Streptococcus agalactiae infective endocarditis]

Infectious endocarditis is a rare pathology whose mortality is high and whose diagnosis is still difficult by the usual clinical, biological and ultrasound tools. We report the case of a patient, drug addict, suffering from an infectious endocarditis of the aortic valve at Streptococcus agalactiae. This germ is rarely at the origin of cardiac infection but it is responsible for quickly destructive lesion by its pathophysiological mechanisms. In this case, the infection unfortunately caused the death of the patient.

[Emergency department utilization by HIV-positive adults in a Belgian setting]

The use of the emergency department (ED) by human immunodeficiency virus (HIV)-infected adults undergoes an evolution following the introduction of antiretroviral therapy (ART). Improving our knowledge about ED use characteristics will contribute to a correct diagnosis and therapeutic approach in this patient group, at the moment they are discharged from the ED. We conducted a one-year retrospective study on characteristics of ED use involving 1026 patients living with HIV. The majority of them was treated with antiretroviral therapy (95 %) and had a viral load lower than 50 copies (73.6 %). Among them, 117 patients (11.8 %) were admitted at least once to the ED. The most common ED discharge diagnoses were related to trauma (30 %). This study shows that the great majority of diagnoses were not related to infectious diseases (6.3 %, of which half were HIV-related). One hypothesis to explain these results would be that HIV-positive adults in this study had excellent antiretroviral coverage and were well controlled in terms of HIV.

[Infective endocarditis:an emergency well too minimized]

Infective endocarditis is a rare disease that can lead to some diagnostic wandering because of its often nonspecific and polymorphic clinical manifestations. This latency is at the origin of severe cardiac and extra-cardiac complications, yet highly fatal. The clinician should always bear in mind the differential diagnosis of a patient with fever of undetermined origin, with risk factors for valve infection such as foreign material, and history recent invasive procedures (including dental procedures) or recent hospitalization. The current medical tools make it possible to highlight the infection and its complications in a fast and complete manner, so as not to delay the patient's management, particularly with the introduction of urgent empirical antibiotherapy.

[Endocarditis of mitral and aortic prosthetic heart valves caused by Aggregatibacter aphrophilus]

We present the case of an acute endocarditis of mitral and aortic prosthetic heart valves caused by Aggregatibacter aphrophilus (Haemophilus aphrophilus-paraphrophilus). This third report in the literature emphasizes the diagnostic work-up and the role of positron emission tomography combined with computed tomography in this setting. The specificities of endocarditis due to the HACEK group (Haemophilus spp., Aggregatibacter, Cardiobacterium hominis, Eikenella corrodens and Kingella spp.) and the specific microbiological data and therapeutic options pertinent to this germ are discussed.

[Management of chronic osteomyelitis by long-term antibiotic suppression]

Chronic osteomyelitis is a chronic inflammatory disease induced by bone infection. It may be limited to a single portion of bone or involve several areas such as marrow, cortical, periosteum and adjacent soft tissues. Being able to persist for weeks, months or even years, it remains a therapeutic challenge in spite of the important medical and surgical advances, with a prolonged and complex management given the nature of the surgical interventions and the antibiotherapies required. We report a case of chronic osteomyelitis treated by long-term suppressive antibiotic therapy, which may be a reasonable alternative to surgery in inoperable clinical situations, but taking into account the risks associated with it in terms of side effects and selection of resistant organisms, as well as the cost of treatment and the quality of life of the patient.

Quality of documentation on antibiotic therapy in medical records: evaluation of combined interventions in a teaching hospital by repeated point prevalence survey

This study aimed to improve the quality of documentation on antibiotic therapy in the computerized medical records of inpatients. A prospective, uncontrolled, interrupted time series (ITS) study was conducted by repeated point prevalence survey (PPS) to audit the quality of documentation on antibiotic therapy in the medical records before and after a combined intervention strategy (implementation of guidelines, distribution of educational materials, educational outreach visits, group educational interactive sessions) from the antimicrobial stewardship team (AST) in the academic teaching hospital (CHU) of Liège, Belgium. The primary outcome measure was the documentation rate on three quality indicators in the computerized medical records: (1) indication for treatment, (2) antibiotics prescribed, and (3) duration or review date. Segmented regression analysis was used to analyze the ITS. The medical records of 2306 patients receiving antibiotics for an infection (1177 in the pre-intervention period and 1129 in the post-intervention period) were analyzed. A significant increase in mean percentages in the post-intervention period was observed as compared with the pre-intervention period for the three quality indicators (indication documented 83.4 ± 10.4 % vs. 90.3 ± 6.6 %, p = 0.0013; antibiotics documented 87.9 ± 9.0 % vs. 95.6 ± 5.1 %, p < 0.0001; and duration or review date documented 31.9 ± 15.4 % vs. 67.7 ± 15.2 %, p < 0.0001). The study demonstrated the successful implementation of a combined intervention strategy from the AST. This strategy was associated with significant changes in the documentation rate in the computerized medical records for the three quality indicators.

[Hooping cough in adults, think about it!]

We report the case of a 47 year old patient who had been suffering from persistent cough for more than three weeks. Patient coughed predominantly during night time, without fever. The amoxicillin-clavulanic acid initially prescribed was not effective. A series of complementary investigations were performed before serology finally identified Bordetella pertussis infection after two months of symptoms which improved slowly without evident benefit of macrolide treatment. The diagnosis of whooping cough was also established for the wife of the patient with fast resolution of the symptoms after rapid unset of treatment with macrolides.

Drug-induced uveitis in aids patients: two case reports

Patients with acquired immunodeficiency syndrome (AIDS) can develop severe uveitis. Although infectious and autoimmune causes must always be considered, drug induced uveitis is also an important etiology. Herein, we present two case reports illustrating the classical presentation of rifabutin and cidofovir induced uveitis. The first case was a 33 year old woman with AIDS treated with anti-protease and anti-tuberculosis drugs (including rifabutin). She presented with a red painful right eye. There was a strong anterior segment inflammation with fibrinous exudates and a dense vitritis. Rifabutin was stopped and topical steroids and mydriatics were given. Intraocular inflammation and symptoms rapidly resolved. The second patient was a 36 year old woman who presented with a painful decrease of vision in her left eye. She was followed for bilateral CMV retinitis in the setting of AIDS and had recently received 2 systemic injections of cidofovir. Anterior segment inflammation with posterior synechiae in both eyes and folds of Descemet membrane in the left eye were noted. Intraocular pressure was 0 mmHg in the left eye and 10 mmHg in the right eye. Fundus examination disclosed CMV retinitis scars in the right eye and choroidal folds in the macula of the left eye. Cidofovir was discontinued and topical steroids and mydriatics started. Progressively the inflammation decreased and the intraocular pressure returned to normal levels. In conclusion, rifabutin and cidofovir are classical examples of drug induced uveitis with distinct characteristic clinical presentation. Recognition of those entities in AIDS patients can avoid useless and potentially invasive interventions in those fragile people.

[Prophylaxis of infective endocarditis: improved dental care and oral health rather than systematic antibiotic prophylaxis?]

Prophylaxis for infective endocarditis has been recommended on the basis of the supposed pathophysiology of the disease, although no randomised clinical trial has confirmed its efficacy. Bacteraemia resulting from daily activities is much more likely to cause infective endocarditis than bacteraemia associated with invasive medical procedures. As a result, recommendations for antibiotic prophylaxis tend now to be severely restricted.

[Syphilis in 2008: practical aspects and controversies]

Rising incidence rate of syphilis is observed in economically advanced countries, particularly among homosexual men and subpopulation with low socioeconomic status. The various clinical presentations are divided into early and late stages, including neurosyphilis. The latter can occur during any stage of the disease, leading to the question "when to perform lumbar puncture", particularly in HIV positive patients. Penicillin continues to be the first-line therapy for all stages of syphilis. An alternative treatment should be considered as an exemption, after advice from a specialist. All patients require prolonged clinical and serological follow-up after treatment to rule out relapse or re-infection. The diagnosis of syphilis is an opportunity to search and treat other sexually transmitted diseases in patients and their sexual partner(s).

Chronic hepatitis C infection in a patient with bone marrow hypoplasia

Chronic hepatitis C virus (HCV) infection is associated with multifarious extra-hepatic manifestations; the most described and discussed being mixed cryoglobulinemia which is strongly related to B-cell lymphoproliferative disorders (LPDs). We present a case of chronic HCV infection and mixed cryoglobulinemia, with minimal liver involvement. The case is a 53-year-old patient who was diagnosed as having bone marrow hypoplasia at the age of three. She received several blood transfusions to normalize her haemoglobin. At the age of 31, she was diagnosed with rheumatoid arthritis on account of her diffuse joint pain and inflammation, elevated rheumatoid factor (RF) and Raynaud’s phenomenon. Twenty years later, monoclonal gammopathy of IgG Lambda (one year later, changed to IgM Kappa) was detected during a routine examination. A bone marrow biopsy showed hypoplasia, Kappa positive B-lymphocytes and low-grade malignant lymphoma cells. PCR of the bone marrow aspirate was not contributory. No treatment was initiated owing to her poor bone marrow function and she is under regular follow-up.

[Isolated tricuspid valve endocarditis as a cause of fever of unknown origin]

Isolated tricuspid valve endocarditis is the least common endocarditis with an incidence of 5 to 10% in the literature. It is usually described in drug abusers and as a complication of nosocomial infections (catheter, post-surgery...). We present the case of a 70 year-old patient admitted for a fever of unknown origin lasting for 2 months. He had an isolated tricuspid endocarditis with Enterococcus faecalis. We review the diagnostic criterias predisposing factors and treatment of right-sided valvular endocarditis, particularly the endocarditis produced by Enterococcus faecalis, a rare etiopathogenic agent of tricuspid endocarditis.

[New treatments of infectious diseases over the last ten years]

This review focuses on new antibiotics, particularly for gram-positive infections, new antiretroviral drugs, new treatment of fungal infections and indications of miltefosine in the treatment of leishmaniasis.

[New approaches to the treatment of the HIV-infected patient]

HIV infection remains a major problem of public health in Belgium as well as globally. The number of new diagnosies of HIV infection in Belgium remains between two and three daily. Given the dramatic effect of antiretroviral therapy on the mortality due to HIV infection, the number of patients is constantly increasing. The different problems related to HIV care are also changing. Aging of the patients and chronic exposure to antiretroviral medications have induced new complications. We will present in this brief article several new experimental and clinical approaches in which our centre has participated during the last two years.

[A review about nephropathia epidemica]

We propose a review of history, aetiology, physiopathology, clinical features, treatment and prevention of nephropathia epidemica (NE) which represents the only form of Hantavirus infection in Belgium.

[Asymptomatic bacteriuria: which management in patients with diabetes mellitus?]

Most of the research about asymptomatic bacteriuria (ASB) in patients with diabetes mellitus has been performed in female patients, with a prevalence of approximately 7-13 %, about 3 to 4 times higher than that reported for nondiabetic women. Poor metabolic control, as assessed by haemoglobin A1c or glucosuria, is not associated with increased ASB. The latter is associated with an increased risk of symptomatic urinary tract infection among patients with type 2 diabetes, but not type 1 diabetes. These infections tend to be more complicated and caused by more resistant organisms than reported for nondiabetic patients. Despite this, systematic screening for and treating ASB have not been shown to reduce long-term complications, such as accelerated progression to arterial hypertension or renal failure, or symptomatic urinary tract infections (including pyelonephritis) or hospitalization for these infections. Thus, available evidence does not support systematic screening and antimicrobial treatment of ASB among patients with diabetes mellitus.

[Are there criteria for the diagnosis of paraneoplastic fever?]

INTRODUCTION

This study was aimed at reviewing useful criteria for the diagnosis of fever of paraneoplastic origin in patients with cancer.

CURRENT KNOWLEDGE AND KEY POINTS

Apart from episodes of neutropenia, hyperthermia is observed in approximately 60% of patients with cancer. Fever is often due to infection and, as a contraindication, may hamper treatment. The differential diagnosis, i.e., fever of paraneoplastic or infectious origin, may be difficult. Paraneoplastic fever is mostly observed in patients with advanced cancer. It is related to the production of inflammatory cytokines, especially interleukin 6, and is not specific. Neither current markers of inflammation, nor X-ray, nor naproxen confirm diagnosis. The diagnosis of fever of paraneoplastic origin in patients with cancer should rely on a network of arguments to exclude other causes of fever, especially infectious causes.

FUTURE AND PROJECTS

Further evaluation of the specificity of procalcitonin will determine whether or not it is a useful tool for the diagnosis of fever of paraneoplastic or infectious origin.

Splenic infarction: report of three cases of atherosclerotic embolization originating in the aorta and retrospective study of 64 cases

The authors report 3 cases of thromboembolic splenic infarction due to atherosclerosis of the thoracic aorta and the splenic artery. On this occasion, a retrospective analysis of 64 splenic infarcts showed that, in contrast to the literature, the leading aetiology in our series consisted of haematologic disorders (50%), followed by cardiovascular diseases (29%) and by digestive disorders (20%). Mean age was 58 +/- 17 years and 50% of the patients were aged below 60 years. Hospital mortality rate was high (34%) but not directly related to splenic infarction, suggesting that splenic infarction often occurs in the setting of severe underlying diseases. Splenic infarct is part of the differential diagnosis of the left upper quadrant pain and can also mimic renal disorders. Laboratory values may show an inflammatory syndrome and an increase in serum lactate deshydrogenase. Diagnosis is often made by CT scan and can be confirmed by a selective spleen scintigraphy. Transoesophageal echocardiography is essential in the detection of cardiac and thoracic aorta embolic material.