Antibacterials
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Lack of efficacy: case report An 84-year-old woman exhibited lack of efficacy with cefepime, ceftriaxone, daptomycin, gentamicin, nafcillin, rifampicin and tigecycline while being treated for sepsis caused by methicillin-susceptible Staphylococcus aureus infection [not all dosages and routes stated]. The woman, who had undergone right total knee replacement, was hospitalised due to mental status changes and a suspected urinary tract infection. Urine cultures showed no growth. Physical examination revealed discharge from incision of her recent knee surgery; hence, culture was obtained. She was referred for a neurology consultation because of progressive obtundation. At admission, her regular medications included morphine [morphine sulfate], dextrose, enalaprilat and digoxin, which were ruled out as the cause of her mental status changes. Her mental status changes were considered as early signs of sepsis based on fever, tachycardia, leucocytosis, hypertension and tachypnoea. She was treated with IV ceftriaxone 1g every 24h. She was subsequently intubated, shifted to the ICU on day 3 of admission. A diagnosis of sepsis was made. In the ICU, she had fever, tachypnoea and tachycardia with WBC count 15 000 /mm3 and BP 161/81mm Hg. Her right knee wound cultures yielded methicillin-susceptible Staphylococcus aureus on day 3. She was treated with cefepime, ceftriaxone, daptomycin, gentamicin, nafcillin, rifampicin and tigecycline during the hospital days 1–13; however, no improvement was noted. Her clinical status aggravated continuously with APACHE-II score of 27 on hospital day 7. She also developed acute renal failure, and had cyanotic limbs with a partially compensated metabolic acidosis. Initially, she was treated with crystalloid fluids and colloid for managing hypotension. She also had coagulopathy. Following fluid therapy, she was treated with continuous infusion of activated drotrecogin-α 24 µg/kg/h over 96h. The initial bag of drotrecogin-α 15mg was intended to be infused over 7.5h but instead it was infused over 1h period due to which 184 µg/kg of drotrecogin-α was inadvertently infused. Drotrecogin-α was interrupted for 9h, and then re-initiated as a continuous infusion of 24 µg/kg/h for 95h. Overall improvement in her condition was noted on drotrecogin-α therapy. She was evaluated for adverse effects of drotrecogin-α; however, the evaluation was unremarkable. Microcytic anaemia was noted, which was considered secondary to iron deficiency. On hospital day 17, she was extubated. Her condition continued to improve, and stabilised but the acute kidney failure remained. She was subsequently discharged to the hospice care. Urban TM, et al. Clinical response to unintentionally rapid infusion of drotrecogin alfa (activated). American Journal of Health-System Pharmacy 67: 1174-1177, No. 14, 15 803449038 Jul 2010. Available from: URL: http://doi.org/10.2146/ajhp090399
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Reactions 25 Jan 2020 No. 1788
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