Acute treatment of intracranial hemorrhage complicated by hemophilia a and emicizumab therapy.

Among patients with hemophilia A with or without FVIII inhibitors, emicizumab prophylaxis has demonstrated significantly reduced bleeding events. However, emicizumab interferes with clotting-based assays used for monitoring FVIII activity, resulting in falsely elevated FVIII activity. This lack of accurate monitoring can complicate the dosing of intravenous therapeutic FVIII clotting factor concentrates in the treatment of critical bleeding events. This case report aims to inform providers who frequently treat hemophilia-associated hemorrhages about emicizumab's effect on clotting-based assays essential for monitoring factor replacement.

Retropharyngeal hematoma mimicking angioedema after intravenous thrombolysis for acute ischemic stroke.

Tissue plasminogen activator (tPA) is a cornerstone treatment for acute ischemic stroke (AIS). Administration of tPA is not without risk, and can provoke life threatening adverse reactions. Retropharyngeal hematoma (RPH) following tPA administration has only been reported after tenecteplase (TNK) administration for ST elevation myocardial infarction (STEMI). A 78 year old patient received tPA for AIS. Following administration of tPA, this patient developed acute signs and symptoms of what appeared to be a more well-known adverse reaction of tPA administration - angioedema. After CT and laboratory findings, our patient received cryoprecipitate for tPA reversal. Our case highlights a unique case of RPH mimicking angioedema following tPA administration.

Treatment of valproic acid overdose with meropenem in an epileptic patient.

Valproic acid (VPA) and derivatives are effective anticonvulsants that are also used for numerous mood disorders. VPA toxicity can cause central nervous system (CNS) depression, dose related hyperammonemia, and eventually hepatotoxicity. While traditional treatment of VPA toxicity often includes l-carnitine, activated charcoal, and hemodialysis; an interaction with carbapenem class antibiotics has been well established in literature and may offer a different avenue of treatment. This case describes a 38 year-old female with a past medical history of epilepsy effectively treated with meropenem to rapidly and safely lower toxic VPA levels after an acute ingestion. A review of four VPA poisoning case reports and the interaction with carbapenem class antibiotics is also included.

Ventriculoperitoneal Shunt Infection Caused by Enterococcus gallinarum in a Pediatric Patient: A Case Report.

Enterococcus gallinarum is a common colonizer of the gastrointestinal tract that expresses intrinsic vancomycin resistance. This case report describes an E. gallinarum ventriculoperitoneal (VP) shunt infection in a pediatric patient. A 4-year-old female patient presented with cerebrospinal fluid (CSF) cultures from a VP shunt significant for E. gallinarum . The patient received ampicillin and synergistic gentamicin. She completed a total of 16 days of therapy following 2 weeks of negative CSF and blood cultures with full clinical cure of infection. The patient was successfully treated following a 2-week course of antibiotics. Awareness of Enterococcus species with intrinsic vancomycin resistance should be increased.

Impact of a Standardized Beta-Lactam Allergy Questionnaire on Aztreonam Use.

METHODS: This quasi-experimental study compared the aztreonam utilization in patients with self-reported beta-lactam allergies admitted to an inpatient service between two study periods (pre- and post-implementation). Post-implementation followed the initiation of a standardized beta-lactam allergy questionnaire, a student pharmacist-driven performance improvement project for beta-lactam allergy documentation. Interviews clarified the allergy, reaction history, and any previous tolerance of beta-lactams. If receiving aztreonam at the time of the questionnaire, recommendations were made for changes in therapy if deemed appropriate by the pharmacist. RESULTS: A total of 95 patients were included in the pre-implementation group versus 65 patients in the post-implementation group. Baseline characteristics were similar. The average number of aztreonam doses per 1000 patient-days in the post-implementation group was decreased (21.23 vs 9.05, P = .003). The average number of days of therapy per 1000 patient-days in the post-implementation group was decreased (8.79-4.24, P = .016). An increase in the number of aztreonam de-escalations was observed post-implementation (P = .003). A total of 122 questionnaires were completed with 114 allergy documentation updates. There were no reported instances of adverse events. CONCLUSION: Utilization of a standardized beta-lactam allergy questionnaire as a pharmacy education tool resulted in a statistically significant decrease in aztreonam utilization, based on doses, days of therapy, and de-escalations.