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

Increasing the number of adverse drug reactions reporting: the role of clinical pharmacy residents

Detection of adverse drug reactions [ADRs] in hospitals provides an important measure of the burden of drug related morbidity on the healthcare system. Spontaneous reporting of ADRs is scare and several obstacles to such reporting have been identified formerly. This study aimed to determine the role of clinical pharmacy residents in ADR reporting within a hospital setting.Clinical pharmacy residents were trained to report all suspected ADRs through ADR-reporting yellow cards. The incidence, pattern, seriousness, and preventability of the reported ADRs were analyzed. During the period of 12 months, for 8559 patients, 202 ADR reports were received. The most frequently reported reactions were due to anti-infective agents [38.38%]. Rifampin accounted for the highest number of the reported ADRs among anti-infective agents. The gastro-intestinal system was the most frequently affected system [21.56%] of all reactions. Fifty four of the ADRs were reported as serious reactions. Eighteen of the ADRs were classified as preventable. Clinical pharmacy residents' involvement in the ADR reporting program could improve the ADR reporting system

Pharmacokinetic study of mycophenolic acid in Iranian kidney transplant patients

The purpose of this study was to characterize the pharmacokinetic parameters of mycophenolic acid [MPA] in Iranian kidney transplant patients. Plasma MPA concentration of mycophenolate mofetile [MMF] 1 gram two times a day was measured in 21 Iranian kidney transplant recipients receiving treatment. Patients who entered the study had been transplanted for more than 3 months and their drug level was supposed to be at steady state. MMF concentration was measured with High- Performance Liquid Chromatography [HPLC]. The plasma MPA concentration-time curve was characterized by an early sharp peak at about 1 hour postdose. The mean Area Under Curve [AUC], Cmax and Tmax were 47.0 +/- 18.3 microg.h/ml, 18.6 +/- 8.5 microg/ml and 1.0 +/- 0.5 hours respectively. The plasma MPA concentration-time curve pattern of Iranian patients was similar and consistent with previously reported profiles in other populations taking the same dose.

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]

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