Amoxicillin Induced Fever, Rash, and Catatonia - A Case Study.

INTRODUCTION: Adverse drug reactions (ADR) are defined as any harmful or unpleasant events or injuries resulting from the use of any particular drug. Among those antibiotics that cause adverse reactions, amoxicillin is one of them. Catatonia and vasculitic rash are its rare adverse effects. CASE PRESENTATION: A 23-year-old postpartum female, with a history of taking empirical Amoxiclav (amoxicillin-clavulanic acid 625 mg) injection and oral tablets for episiotomy wound, presented with altered sensorium and fever followed by maculopapular rash. On examination, she had generalized rigidity with waxy flexibility that improved by lorazepam challenge and was diagnosed as catatonia. On evaluation, amoxicillin was found to be precipitating catatonia in this patient. CONCLUSION: Since the diagnosis of catatonia is often missed, any cases with clinical presentation of fever, rash, altered sensorium, and generalized rigidity should also be suspected for druginduced ADR and the precipitating factor should be searched for.

Cryptococcal Meningitis Presenting as Chronic Headache in an Apparently Immunocompetent Patient.

Cryptococcal meningitis, a severe fungal infection, usually afflicts immunocompromised individuals, mainly those with acquired immunodeficiency syndrome (AIDS). However, rarely, immunocompetent individuals can develop the infection too. Here, we present a case of a human immunodeficiency virus (HIV)-seronegative individual without known immunocompromised states. This patient suffered from chronic headaches for five years before presenting to us, with multiple past consultations resulting in misdiagnoses of migraines and tension-type headaches (TTH). The patient had developed new-onset warning signs in the last month after which neuroimaging was done, which showed features of increased intracranial pressure. Cerebrospinal fluid (CSF) analysis revealed Cryptococcus neoformans. The patient received amphotericin B alongside flucytosine, and he underwent three therapeutic lumbar punctures (LP) to relieve symptoms from raised intracranial pressure. Within two weeks, he showed significant improvement in headaches and was discharged in a healthy state. The patient was doing fine two months post discharge. This case emphasizes the necessity of ruling out red flag signs before diagnosing primary headaches. In clinical practice, if any patient shows poor response to medications despite adequate compliance, a thorough evaluation is required to rule out serious causes of headache, with a low threshold for neuroimaging.

Compliance with the 4Ds of antimicrobial stewardship practice in a tertiary care centre.

BACKGROUND: Antimicrobial stewardship describes the practice of promoting the selection of the right drug, dosage, delivery and duration of antimicrobial therapy (the 4Ds) in order to curtail the emergence of resistant organisms. It is important to quantify the inappropriate use of antimicrobials in terms of percentage adherence to each of the 4Ds mentioned. METHODS: We undertook a prospective review of medical records of patients admitted to the medical wards of a tertiary care centre in North India. All patients on antimicrobials were included and their records reviewed for indication, drug, dose, delivery and duration (or by asking the treating physician if not documented). Adherence to the 4Ds was determined by referring to updated literature-based standard treatment guidelines (STGs) for each specific disease. RESULTS: Of 304 patients, drugs were appropriate and matched STGs in 218 (72%) patients, with adherence to the right dose in 210 (69%), route of delivery in 216 (71%) and duration in 197 (65%). Full adherence to the 4Ds was observed in 196 (64.5%). Maximum adherence was observed in treating skin and soft tissue infections (100%), while minimum adherence was observed in administering medical prophylaxis (40%). WHO Access, Watch and Reserve categories comprised 29%, 63% and 8.5% of all prescribed antibiotics, respectively. CONCLUSIONS: The right drug, dose, delivery and duration of therapy are prescribed in 72%, 69%, 71%, and 65% of patients, respectively. In order to increase the adherence to 100%, bedside stewardship practices in the form of prospective audits and feedback must be improved. There is a need to integrate WHO AWaRe classification of antibiotics into treatment guidelines.

Influenza B presenting with bicytopenia in an adult - An unusual presentation and failure of antimicrobial stewardship by a practicing physician.

Influenza is a very common cause of upper respiratory illness, rarely presented with bicytopenia, and is being wrongly treated with antimicrobials many-a-times. We report a case of 36-year-old North-Indian man, physician by profession who presented with a 5-day history of typical upper respiratory tract symptoms (sore throat, irritative cough, hoarseness of voice, coryza) and high-grade fever for which he took antibiotics (initially levofloxacin for 2-days, followed by azithromycin) after self-prescription. He developed hematological involvement (leukopenia and thrombocytopenia) for which he was admitted. Throat swab tested positive for Influenza B by RT-PCR. This case highlights a rare presentation of influenza as bicytopenia which rapidly improved with oseltamivir given for 5-days. This is also a classic case of lack of antimicrobial stewardship practice by a physician while self-treating viral pharyngitis. There is a pressing need to create more awareness regarding appropriate use of antimicrobial resources among doctors, only then will others follow.