Antibiotics
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Anaphylactoid reaction and lack of efficacy: case report A 56-year old man developed an anaphylactoid reaction during treatment with colistin for Acinetobacter baumannii ventriculitis. Additionally, he exhibited lack of response during treatment with meropenem, cotrimoxazole and tigecycline for the infection. The man presented to the emergency department due to headache and vomiting. His glasgow coma scale was 13/15. He was found to have hydrocephalus, intraventricular haemorrhage (IVH) and an intracerebral haemorrhage in the right basal ganglia. He was shifted to the operation theatre for external ventricular drain (EVD) placement, after which he was transferred to the ICU. He experienced breathing difficulties. X-ray revealed pulmonary oedema, while ECG demonstrated diastolic dysfunction. Hence, he was intubated and mechanically ventilated. On day 4 of hospitalisation, his condition improved; hence, he was extubated. However, he became highly febrile on day 8; hence, he started receiving IV meropenem 2g every 8 hours alongside vancomycin as empirical therapy. CSF culture revealed growth of multidrug-resistant Acinetobacter baumannii, sensitive to colistin and cotrimoxazole [trimethoprim-sulfamethoxazole], with intermediate sensitivity to tigecycline. He was prescribed IV colistin 9 × 106 units stat followed by 3 × 106 units every 8 hours. However, he developed an anaphylactoid reaction after the stat dose, which manifested as restlessness, shivering, hypotension, tachycardia and wheezing. The man’s treatment with colistin was discontinued, and he started receiving epinephrine [adrenaline], hydrocortisone and diphenhydramine, followed by cetirizine. The medical team advised discontinuation of vancomycin and recommended high-dose IV tigecycline 200mg (stat dose) followed by 100mg twice daily. However, on day 13, his consciousness decreased, and he was intubated again. He started receiving IV cotrimoxazole 1920mg every 6 hours. A brain CT scan revealed a mild decrease in the haemorrhagic parenchymal blood in the right basal ganglia and a decrease in the fresh blood inside the left lateral ventricle. Blood tests revealed neutrophilic pleocytosis. On day 14, repeat CSF culture revealed the growth of multidrug-resistant Acinetobacter baumannii with an antimicrobial susceptibility pattern that was identical to the first report. His condition did not improve with meropenem, cotrimoxazole and IV tigecycline. Therefore, he was prescribed intraventricular (IVT) tigecycline. After each dose of IVT tigecycline, the CSF drain was temporarily closed for 4 hours. Eight hours after receiving the first dose of IVT tigecycline, he developed a myoclonic seizure lasting for 4 minutes. The uncontrolled ventriculitis was believed to be the precipitating factor. He was treated with midazolam and phenytoin. A brain CT scan revealed a mild reduction in IVH. He started receiving levetiracetam and phenytoin. ECG was consistent with mild-to-moderate encephalopathy; however, no epileptiform discharges were seen. He continued receiving me
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