Front-loaded diazepam versus lorazepam for treatment of alcohol withdrawal agitated delirium.

BACKGROUND: Front-loaded diazepam is used to rapidly control agitation in patients with severe alcohol withdrawal syndrome (AWS). Our institution began using front-loaded lorazepam in August 2017 secondary to a nation-wide shortage of intravenous (IV) diazepam. Currently, there are no studies comparing lorazepam to diazepam for frontloading in severe AWS. METHOD: Retrospective cohort study of all adults presenting to the emergency department with a diagnosis of AWS and prescribed the institution's alcohol withdrawal agitated delirium protocol 8 months pre and post shortage of IV diazepam were eligible inclusion for the study. Of these, 106 patients were front-loaded with diazepam and 70 patients were front-loaded with lorazepam. RESULTS: There was no difference in the mean change in Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised scores 24 h pre and post front-loading in the two groups (-13.9 ± -8.08 vs. -13.1 ± -8.91, p = 0.534). Patients who received front-loaded lorazepam had an increased incidence of ICU-delirium (positive for the Confusion Assessment Method in the ICU: 75% with lorazepam vs. 52.6% with diazepam, p = 0.009) and a higher risk of over-sedation, but this did not reach statistical significance (Richmond Agitation-Sedation Scale score < -1: 32.1% with lorazepam vs. 18.2% with diazepam, p = 0.063). CONCLUSION: Front-loaded lorazepam was similar to front-loaded diazepam in controlling AWS symptoms. Lorazepam's delayed onset of action should be considered when determining how quickly repeat doses are administered to avoid the potential for adverse drug events.

Granulicatella Causing Infective Endocarditis and Glomerulonephritis.

Granulicatella is a type of nutritionally variant Streptococcus (NVS) that requires special medium for growth. It has shown to cause infective endocarditis which is associated with higher mortality and complications. We present a case of Granulicatella causing endocarditis and glomerulonephritis. There has only been one such prior case report. An adult male with a remote history of gastric bypass presented with shortness of breath with exertion, lower extremity swelling of 1-month duration. Blood cultures 4/4 bottles grew Granulicatella albicans with infected tooth being the source. Transesophageal echocardiogram revealed a vegetation on the mitral valve. He received intravenous vancomycin. He was found to have acute kidney injury requiring hemodialysis. Kidney biopsy revealed immune complex deposits in the mesangium and along the capillary basement membrane suggestive of post infectious glomerulonephritis. It is crucial to recognize NVS as potential cause for endocarditis in cultures that are slow growing. NVS require a special medium. Though it is rare, NSV can also cause glomerulonephritis. Early recognition is important to help with determining treatment options which may include immunosuppressive therapy along with treatment of underlying infection.