Amphotericin B/antibacterials/polyethylene glycols
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Oesophageal and intestinal obstructions (first report with amphotericin B, tobramycin, polymixin B and polyethylene glycols) following SDD: 3 case reports Three patients developed oesophageal obstruction (patients 1 and 3) and intestinal obstruction (patient 2) during selective decontamination of the digestive tract (SDD) with amphotericin B, polymixin B and tobramycin. Patient 2 also received polyethylene glycol [dosage not stated]. Patient 1, an 80-year-old man, was hospitalised with respiratory insufficiency due to congestive heart failure accompanying myocardial infarction. On arrival at an ICU, enteral feeding was started along with SDD with topical polymixin B, amphotericin B and tobramycin, applied to his buccal cavity and through the gastric tube four times a day [doses not stated]; the antibacterial paste also contained mineral oil (liquid paraffin) and hypromellose. After 18 days, bronchoscopy revealed an incomplete longitudinal tracheal compression. Due to persistent respiratory and haemodynamic problems, treatment was discontinued but, shortly afterwards, he died. An autopsy revealed a complete oesophageal obstruction with a solid mass, which resembled clotted antibacterial paste. Tobramycin and amphotericin B were later identified in the solid mass. Patient 2, a 70-year-old man, was admitted to an ICU following a gastrectomy. Fluid resuscitation was started along with SDD with topical polymixin B, amphotericin B and tobramycin, applied to his buccal cavity and through the gastric tube four times a day [doses not stated]; the antibacterial paste also contained mineral oil (liquid paraffin) and Orabase (gelatin, pectin and carmellose). Laparotomy was then performed and a Foley catheter was placed in his duodenum. He received a polyethylene glycol (macrogol [dosage not stated; specific drug not clearly stated]) as a hyperosmotic laxative and, on ICU day 2, enteral feeding was started. On day 5, a laparotomy, performed due to discolouration of the Foley catheter, revealed an obstruction in his jejunum due to a bezoar. The bezoar was removed and was found to contain amphotericin B and macrogol. [Patient outcome not stated.] Patient 3, a 62-year-old patient [sex not stated], was admitted to an ICU due to respiratory insufficiency. SDD was started with topical polymixin B, amphotericin B and tobramycin, applied to the buccal cavity and through the gastric tube four times a day [doses not stated]; the antibacterial paste also contained mineral oil (liquid paraffin) and Orabase (gelatin, pectin and carmellose). After several days, oesophageal obstruction was diagnosed [time to reaction onset not clearly stated]. The mass, which was removed by rigid scope, macroscopically resembled clotted paste used for SDD. [Patient outcome not stated.] Author comment: "Most probably the clotted SDD mass is a result of accumulation of residual buccally applied SDD paste in the esophagus (cases 1 and 3). The clotted mass in the jejunum (case 2) might be the result of residual SDD paste and/or SDD suspension." Smit MJ, et
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