Infective endocarditis; report from a main referral teaching hospital in Iran

Background/Objective: The aim of the present preliminary study was to assess the demographic, clinical, paraclinical, microbiological, echocardiographic, and therapeutic profile as well as in-hospital outcome of patients with infective endocarditis at a referral center for various infectious diseases in Iran

Methods: Required demographic, clinical, plausible complications and paraclinical data were collected from patients' medical charts. Echocardiographic findings were obtained by performing transthoracic and/or transesophageal echocardiography as clinically indicated. In addition, details of management modalities and in-hospital outcome of patients were recorded

Results: During a 3-year period, 55 patients with definite or possible diagnosis of Infective endocarditis were admitted to the ward. Twenty one [38.2%] patients were injection drug users. Staphylococcus aureus and S.epidermidis were the most commonly isolated microorganisms. Management modalities of Infective endocarditis included antimicrobial therapy alone [48 cases] and the combination of antimicrobial therapy and surgery [7 cases]

Conclusion: The rate of negative blood culture in our cohort is high. S. aureus and S.epidermidis were the most commonly isolated microorganisms from positive blood cultures. Congestive heart failure was the most frequent infective endocarditis complication as well as indication for surgery. In-hospital mortality rate of patients was unexpectedly low

Clinical, paraclinical, and antimicrobial resistance features of community-acquired acute bacterial meningitis at a large infectious diseases ward in Tehran, Iran

In this study demographic, clinical, paraclinical, microbiological, and therapeutic features of patients with community-acquired acute bacterial meningitis admitted to a referral center for infectious diseases in Iran, have been evaluated. Medical records of adult [> 18 years] individuals with confirmed diagnosis of community-acquired bacterial meningitis during a 4-year period were retrospectively reviewed. All required data were obtained from patients' medical charts. Available findings about antimicrobial susceptibility of isolated bacteria from CSF and/or blood were also collected. Kirby-Bauer disc diffusion method was used to determine their antimicrobial susceptibility profile. Details of medical management including antibiotic regimen, duration, patients' outcome, and possible sequelae of meningitis were recorded. The most commonly isolated microorganism from CSF or blood of patients was Streptococcus pneumonia [33.33%] followed by Neisseria meningitidis [27.78%] and Haemophilus influenza [16.67%]. The most common antimicrobial regimen was ceftriaxone plus vancomycin [69.44%] followed by ceftriaxone plus vancomycin plus ampicillin [11.11%]. Neurological sequelae of meningitis including cranial nerve palsy, deafness, and hemiparesis were identified in 4 [11.11%], 2 [5.56%], and 1 [2.78%] subjects, respectively. Regarding mortality, only 3 [8.33%] patients died from bacterial meningitis and the remaining 33 individuals discharged from the hospital. In conclusion, findings of the current study demonstrated that the mean incidence of acute bacterial meningitis in a referral infectious diseases ward in Iran was 9 episodes per year. The majority cases of community-acquired acute bacterial meningitis admitted to our center had negative CSF culture and classic triad of meningitis was absent in them

Approach to anemia in hospitalized patients with infectious diseases; is it appropriate?

Anemia of chronic diseases [ACD] is a common problem in patients with infectious diseases and can influence the quality of life and patients› survival. Despite the clinical importance of ACD, data are still lacking regarding this problem in the infectious diseases. This study aimed to evaluate the prevalence, related factors, outcome and approaches to anemia in the infectious diseases ward. This retrospective study was performed to review the medical records of patients admitted to the infectious diseases department of Imam Khomeini hospital during a two-year period between 2009 and 2011. A standard protocol was developed to evaluate anemia. Patients' demographic data approaches to manage anemia and routine laboratory tests were recorded and compared with the protocol. Totally, 1,120 medical records were reviewed. ACD was recognized in 705 patients [63%]. Only 5.1% of diagnostic and 8.7% of treatment approaches was based on the protocol. The majority of patients [89.4%] were received inappropriate treatment regarding. Mortality rate of patients with ACD was 3.4%. Moreover, a significant correlation between anemia and mortality was detected [r = 0.131; p = 0.026]. A statistically significant correlation was also identified between patients' Hgb and ESR, CRP, reasons of admission, number of medications, and underlying diseases. In conclusion, results of this study suggested that ACD is a common problem in infectious diseases patients and significantly associated with patients' mortality. Moreover, the majority of studied patients were not received an appropriate diagnostic and treatment approach which arises more concerns regarding the management of ACD in infectious diseases setting

Preventing or attenuating amphotericin B nephrotoxicity with dopamine receptor agonists: a literature review

Nephrotoxicity is generally considered as the most clinically significant and dose-limiting adverse reaction of amphotericin B. Currently, only the clinical effectiveness of salt loading and administering lipid formulations of amphotericin B have been clearly demonstrated to prevent its nephrotoxicity. In this review, we collected the published data related to dopamine receptor agonists in preventing amphotericin B nephrotoxicity. A literature search was conducted by the relevant keywords like [amphotericin B], [nephrotoxicity, and [dopamine] in databases such as Scopus, Medline, Embase and ISI Web of Knowledge. Four relevant articles were considered. Results of all the 3 experimental studies demonstrated that co-administration of dopamine [0.5-10 microg/kg/min] as continuous intravenous infusion, SK and F R-105058 [10 mg/kg twice daily], a prodrug of fenoldopam, orally, or fenoldopam, a relatively selective dopamine receptor type 1 agonist, [0.5 or 1 microg/kg/min] as continuous intravenous infusion can at least significantly mitigate the decrease in creatinine clearance caused by amphotericin B. Furthermore, fenoldopam and SK and F R-105058 can also protect against or delay amphotericin B-induced tubular damages. In contrast, the only clinical trial published until now found that simultaneous continuous intravenous infusion of low dose dopamine [3 microg/kg/min] had no beneficial effects on the incidence, severity, as well as time onset of developing amphotericin B-induced nephrotoxicity in autologous bone marrow transplant and leukemia patients. Considering the lack of beneficial effects in different settings such as acute kidney injury of any cause, negative results of the only clinical trial, and risk of significant adverse reactions, continuous intravenous infusion of low dose dopamine [1-3 microg/kg/min] or selective dopamine receptor type 1 agonists [e.g., fenoldopam] currently appears to have no real clinical role in preventing or attenuating amphotericin B nephrotoxicity

Clinical pharmacokinetics of tacrolimus in iranian liver transplant recipients

Tacrolimus, a cornerstone of immunosuppressive therapy in solid organ transplantation, has a narrow therapeutic range with considerable inter-individual and intra-individual pharmacokinetic variability. To date, there is no information on the pharmacokinetics of tacrolimus in Iranian liver transplant recipients. This study was designed to determine pharmacokinetic properties of orally administered tacrolimus in Iranian adult liver transplant recipients. Tacrolimus doses and steady state whole blood trough concentrations as well as patient demographic and clinical data were obtained retrospectively using the 30 included patients' medical records. Pharmacokinetic parameters were estimated by using a nonlinear mixed effect model program [Monolix version 3.1]. Absorption rate constant was fixed at two hours[-1]. Drug apparent clearance [CL/F], apparent volume of distribution [Vd/F], and elimination half life [t1/2 Beta] were calculated. The administered dose of tacrolimus to the patients ranged from 0.02 to 0.14 mg/Kg/day. Tacrolimus blood trough concentrations varied widely within the range of 1.8 to 30 ng/mL. The mean values of CL/F, Vd/F, and t1/2 Beta were found to be 9.3 +/- 0.96 L/h, 101 +/- 29 L, and 7.5 hours, respectively. The pharmacokinetics of tacrolimus was highly variable among our patients. CL/F, Vd/F, and t«? of tacrolimus in this study were comparable to reported values from Italian heart transplant patients but somewhat different from reported ones from other solid organ transplant populations

Elevated vancomycin trough concentration: increased efficacy and/or toxicity?

Vancomycin susceptibility of methicillin-resistant Staphylococcus aureus has been changed over time and its average minimum inhibitory concentration increased from 1.5 to 1.75 mg/L.A recently published guideline by the American Society of Health Pharmacist recommended a daily dose of 15-20 mg/Kg every 8 to 12 hours of vancomycin to achieve a trough concentration between 15-20 mg/L for treatment of severe infections. Medical records of 69 patients from infectious ward of Imam Khomeini hospital, with suspected or confirmed gram-positive infection who had at least one trough level of vancomycin, were evaluated regarding vancomycin therapeutic goal; efficacy and renal safety. Most of patients [60.6%] with severe infections did not achieve the recommended vancomycin trough level during treatment course. Time to normalization of the signs and symptoms of infection did not correlate with the patients' serum vancomycin trough levels. At the end of treatment course, there was no significant correlation between patients' creatinine clearance and vancomycin trough levels [P=0.32]. However, patients'cratinine clearance showed a negatively significant correlation with trough level of vancomycin [P=0.01]. Vancomycin induced nephrotoxicity was detected in 4.3% of the patients. These data showed that vancomycin trough level may not necessarily assure treatment success, and also it would not essentially predict the risk of vancomycin induced nephrotoxicity. However, more well designed studies with larger sample size needed for better clinical and practical judgment

Bacterial contamination of single- and multiple-dose vials after multiple use and intravenous admixtures in three different hospitals in Iran

There is possibility of microbial contamination of any single-dose vials [SDVs], multiple-dose vials [MDVs] and admixtures [ADXs] during the preparation and injection to the patients that could be resulted in bloodstream infection. The goal of this study was to investigate the microbial contamination of MDVs and SDVs after multiple use and ADXs prepared by nursing staff in the treatment room versus those prepared by the hospital pharmacist in the clean room. The sterility of 43 opened MDVs and SDVs, 92 prepared ADXs in treatment room and 17 prepared ADXs in clean room were studied by membrane filtration method. Only one of 92 ADXs prepared in treatment room was contaminated with Bacillus subtilis [%1.1] and none of the ADXs prepared in clean room, MDVs and SDVs had microbial contamination. Although good sanitization practices and training of nurses could reduce the risk of microbial contamination in traditional units, using clean room for preparation of parenteral products could be the best strategy

Antibiotics induced acute kidney injury: incidence risk factors, onset time and outcome

Drug induced acute kidney injury [AKI] has been implicated in 8% to 60% of all cases of in-hospital AKI and as such is a recognized source of significant morbidity and mortality. Evaluation of incidence, risk factors, onset time, and outcome of antibiotics' associated acute kidney injury. During one-year period, all patients who developed acute kidney injury during their hospital stay in the infectious diseases ward of Imam Khomeini hospital were included in the study prospectively. Patients' demographic data, baseline diseases, cause of current hospital admission, history of past and current medications and hemodynamic parameters were collected and monitored closely. Drug induced acute kidney injury was defined based on acute kidney injury network criteria. From 424 admitted patients, 76 [17.9%] developed acute kidney injury. Aminoglycosides [gentamicin and amikacin], amphotericin B, vancomycin, beta-lactam antibiotics [cefazolin and ceftriaxone] in monotherapy and combination therapy were the causes of acute kidney injury in most of the patients. From the co-morbid diseases in patients with acute kidney injury, diabetes mellitus [26.3%] and hypertension [5.5%], were the most frequent ones. Presence of diabetes mellitus as comorbidity [OR=2.6; CI=1.3-5.7, P=0.01], dehydration of patients upon admission [OR=3.4; CI=1.9-6.4, P<0.001], and administration of nephrotoxic combinations [OR=2.1; CI=1.2-4.1, P=0.04] were independent risk factors for antibiotic induced nephrotoxicity in our study. About 18% of the patients developed acute kidney injury during their hospitalization period in the infectious diseases ward. Aminoglycosides, amphotericin B, vancomycin and beta-lactam antibiotics were responsible agents for acute kidney injury in this study

The role of clinical pharmacy services in achieving treatment targets in Iranian haemodialysis patients

<p><b>INTRODUCTION</b>The number of patients suffering from chronic kidney disease (CKD) is increasing worldwide. Hyperphosphataemia and high serum calcium (Ca) and phosphorus (P) product contribute to the substantial increase in cardiovascular events in CKD patients. Although reports of CKD complications in Iranian haemodialysis (HD) patients are comparable to data from other developed countries, management of these complications has failed to meet generally accepted targets. This study evaluated the impact of clinical pharmacy services in the management of complications in HD patients.</p><p><b>METHODS</b>During a six-month prospective study, clinical pharmacists conducted medical visits in the HD ward and adjusted the patients' medications according to their laboratory findings.</p><p><b>RESULTS</b>Serum Ca concentration was increased in hypocalcaemia patients and decreased in hypercalcaemia patients until it reached the optimal range in both groups. A decline in serum P level was noted in hyperphosphataemia patients, although it did not reach the target range. The Ca × P product decreased in patients with Ca × P > 55 mg2/dL2. Although it did not reach the goal, there was an increase and decrease in serum intact parathyroid hormone (iPTH) concentration in suboptimal and supraoptimal range patients, respectively. Serum Ca, P and iPTH levels did not change in patients with optimal values at the initiation of the study. Haemoglobin concentration increased in anaemic patients and serum ferritin reached target values in all patients. Total cholesterol, low-density lipoprotein cholesterol and triglycerides decreased to near-optimal values in dyslipidaemia patients.</p><p><b>CONCLUSION</b>This study showed that clinical pharmacy services at the HD centre can improve the management of complications in CKD patients.</p>

Changes in 4-year antimicrobial resistance pattern of gram-positive bacteria at the main referral teaching hospital, Tehran, Iran

Infectious diseases are one of the most common causes of morbidity and mortality and the spread of resistant microorganisms is playing a significant role in this regard. The purpose of this study was to assess the trend in antimicrobial resistance of gram-positive bacteria at the main referral teaching hospital in Tehran during a 4-year period. All patients' biological isolates such as blood, urine, wound drainage, synovial fluid, sputum, and cerebrospinal fluid sent to the central laboratory of the hospital from 2007 to 2010 for identification and subsequently, antimicrobial susceptibility testing by Kirby-Bauer disc diffusion method were considered. All isolates [100%] of S. aureus were sensitive to vancomycin and linezolid and resistant to amoxicillin. The rate of S. aureus resistance to oxacillin increased from 60.78% in 2007 to 72% in 2010. All isolates of Streptococci in 2007 and 2008 were sensitive to vancomycin; while, 3.33% and 4.76% of Streptococci isolates were reported to be vancomycin-resistant in 2009 and 2010, respectively. Enterococci isolated from the entire specimens were identified to be sensitive to teicoplanin and linezolid and resistant to cloxacillin and oxacillin. The rates of Enterococci sensitivity to vancomycin were 90.91%, 81.25%, 86.67%, and 93.3% in 2007, 2008, 2009, and 2010, respectively. Changes of antibiotics sensitivity against g positive pathogens were significant during four years in this study. To minimize the spread of resistant gram positive pathogens, periodic and regular surveillance of antimicrobial resistance pattern is highly recommended.

[Pharmacological treatment of neuropathic pain]

Neuropathic pain results from injury to or dysfunction of the central or peripheral nervous system. Diabetic peripheral neuropathy, post-herpetic neuralgia, and trigeminal neuralgia are among the most common types of neuropathic pain. Patients with these types of pain usually suffer from localized symptoms such as constant or intermittent paresthesia, tingling, burning sensation or spontaneous pain. Neuropathic pain is an unpleasant sensation and experience that could adversely affect the quality of life of patients. They often responds to treatment with difficulty and based on the current treatments, only 40 to 60% of patients with neuropathic pain achieve partial relief. Antidepressants [tricyclics and serotonin-norepinephrine reuptake inhibitors], ligand of calcium channel alpha 2-delta subunits]gabapentin and pregabalin] and topical lidocaine have been considered as the first-line therapy for neuropathic pain. Oipoid analgrsics and tramadol are generally recommended as the second-line therapy. Other agents such as antiepileptics [e.g. carbamazepine], antagonists of N-Methyl-D-aspartate receptor [e.g. memantine, dextromethorpham], and topical capsaicin have been mainly classified as the third-line treatment for neuropathic pain. Due to the importance of neuropathic pain, reviewing its novel non-pharmacological and pharmacological modalities seems necessary

Adherence to empiric antibiotic therapy guideline in a referral teaching hospital, Tehran, Iran

Antibiotic guidelines have proven to be a simple and effective intervention to guide the choice of appropriate empiric antibiotic regimens. The goals of this study were to evaluate adherence to guidelines and streamlining of antibiotics. Hospital records of hospitalized patients in infectious diseases ward Imam Khomeini Hospital, Tehran, Iran, from May 2008 to September 2009 were reviewed. Adherence to guideline was defined as the use of empiric antibiotic in accordance with the clinical diagnosis and local guideline recommendations. In this study, 528 patients with a confirmed infectious disease diagnosis were considered for analysis. The four most frequent diagnoses were skin and soft tissue infections, tuberculosis, respiratory tract infections, and HIV associated opportunistic infections. The most frequent prescribed antibiotic was ceftriaxone. Overall adherence to guideline was 70.8% and the adherence for the most frequent diagnosis was 68%. Frequency of compatibility with the guidelines for were administrated regimes on the basis of drug selection, dosage form and drug dosing were 86.2%, 97% and 84.7%, respectively. The mean lag time between patients' hospital admission and starting empiric therapy was 1.69 +/- 4.9 days. In general, physicians' adherence with guidelines for empiric antibiotic therapy was high in infectious disease ward with a justified delay. Larger studies are required to establish these conclusions

Reliability of disk diffusion test results for the antimicrobial susceptibility testing of nosocomial gram-positive microorganisms: is e-test method better?

Disk diffusion test is the usual applicable method for assessing the antimicrobial susceptibility pattern in most institutions and hospitals. The aim of this study was to determine the reliability of resistant-reported results of disk diffusion test for 6 routinely used antibiotics against Gram-positive microorganisms of nosocomial origin, using E-test method. Over a 1-year period, clinical specimens [e.g. blood, tracheal secretions, wound secretions, urine, etc.] were obtained from hospitalized patients with defined nosocomial infection and were cultured. Isolated Gram-positive bacteria underwent disk diffusion test for cephalothin, oxacillin, clindamycin, ciprofloxacin, vancomycin, teicoplanin [only for Enterococci], and meropenem antibiotics. E-test method was performed for all isolates resistant or intermediately sensitive to the disks of any mentioned antibiotics. Data showed compatible results of disk diffusion test with the results of E-test method for cephalothin, oxacillin, ciprofloxacin, vancomycin, and teicoplanin. None of ciprofloxacin- and vancomycin-resistant isolates in disk diffusion test showed sensitivity in E-test method. Significant differences between the results of disk diffusion and E-test methods were observed for clindamycin and meropenem against S.aureus [p = 0.01 and 0.04, respectively] and Enterococcus spp [p = 0.03 and 0.02, respectively]. In order to increase the reliability of antimicrobial susceptibility results, it is recommended to perform E-test for nosocomial Gram-positive microorganisms that show antibiotic resistance by disk diffusion test and it is more important for clindamycin and meropenem

Drug fever

Drugs have been estimated to the cause of 10-15% of adverse events in hospitalized patients. Drug fever as the only manifestation or the most prominent clinical characteristics of an adverse reaction occurs in 3-5% of patients. Considering drugs as a cause of fever of unknown origin is important from clinical viewpoint. Drug fever is a febrile response coinciding temporally with the administration of a drug, subsides once the causative drug is disvontinued, and other probable causes of fever such as infection, malignancy, thromboembolic disease, cerebrovascular accidents, collagen vascular diseases, acute gout, surgery, and trauma have been ruled out by physical examinations and paraclinical investigations. A wide range of agents could induce fever by different mechanisms. Antibiotics have been considered as the most common offending agents among different drug classes causing fever. Antibiotics are associated with about one-third of drug-related fever episodes. Among antibiotics, drug fever has been mostly reported with beta-lactams, sulfonamides, and nitrofurantion. The sole effective approach to manage drug fever is to discontinue the offending agents[S]

comparative study of bolus administration and continuous infusion of ranitidine on gastric PH with intragastric PH-probe

The high mortality rate associated with significant bleeding from stress ulceration has promoted efforts to prevent this complication in critically ill patients. Gastric pH is a key factor in the pathogenesis of stress ulceration and maintaining a pH of 4 or greater reduces the risk for development of the gastric ulceration. Our aim was to compare effects of intravenous bolus administration and continuous intravenous infusion of ranitidine on gastric pH in critically ill patients at the intensive care unit [ICU]. Twenty patients who met the inclusion criteria were entered this prospective, randomized, cross over study. A total of 1500 gastric pH measurement was obtained for each phase of the study. Continuous infusion of ranitidine maintained a gastric pH greater than 4 over a longer period than that of bolus administration [22.1 hrs vs. 14.2 hrs, respectively; P<0.001]. The pH-monitoring device which was made locally, was comparable to a standard international device. This study showed that continuous infusion of ranitidine was more effective than administration of an equivalent dose of the drug by bolus in maintaining the appropriate gastric pH required for the prevention of stress ulceration