Tigecycline
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Severe hypoglycaemic episodes: case report A 45-year-old man developed severe hypoglycaemic episodes during treatment with tigecycline for Klebsiella pneumonia and Enterobacter infection. The man was hospitalised in India with a provisional diagnosis of cellulitis of left leg due to snake bite, sepsis, acute kidney injury and disseminated intravascular coagulation. He was initiated on piperacillin/tazobactam and clindamycin. Magnesium-sulfate [magnesium sulphate] dressing was done twice a day at the site of swelling. Six units of random donor platelets were transfused. He was put on continuous renal replacement therapy the following day. Other medications included metoclopramide, calcium polystyrene sulfonate, glucose, insulin, pantoprazole, vitamin K and magnesium sulfate. Conjugated estrogen was also added due to uremic bleeding. Over the next couple of days, his condition worsened, with no signs of reduction in the swelling. On hospital day 8, the results of transtracheal aspirate culture showed infection with Klebsiella pneumoniae sensitive to tetracycline, minocycline and tigecycline. Therefore, on the same day, piperacillin/tazobactam and clindamycin were switched to IV tigecycline, which was administered at a loading dose of 100mg followed by 50mg every 12 hours. His condition improved over the next few days, with reduction in the size of swelling and sharp fall in the serum procalcitonin level, and his body temperature returned to normal. On hospital day 10, he developed hypoglycaemic episode (glucose level 47 mg/dL) immediately after administration of the morning dose of tigecycline. The hypoglycaemic episodes were manifested as severe palpitations, tremors and sweating. He received treatment with glucose [dextrose], after which palpitations, tremors and sweating resolved promptly and his blood glucose increased to 83 mg/dL. Another hypoglycaemic episode occurred the next day after tigecycline administration (day 11); the blood glucose level was 49 mg/dL and he was hyperventilating with profuse sweating and palpitations. It was managed again with glucose, and the blood glucose level rose to 86 mg/dL. Similar episodes happened later on the same day and on day 13 which were again managed with glucose. The man’s therapy with tigecycline was stopped on day 15 at the treating physician’s discretion because the course of antibiotic treatment was completed. Meropenem, clindamycin and polymyxin B were added in place of tigecycline, but the other medications remained unchanged. Although there were no further hypoglycaemic episodes, blood glucose levels continued to be either below or on the lower end of the normal range. Starting from day 17, blood glucose levels started rising gradually and were well maintained within and slightly above the normal range. His underlying condition improved rapidly with gradual reduction of the swelling. The continuous renal replacement therapy was stopped on day 19 after serum creatinine and urea levels and electrolyte levels remained consistently in the normal range. However,
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