Potential Failure of Vancomycin Dosing Using AUC/MIC in a Patient With Purulent Methicillin-Resistant Staphylococcus aureus Pericarditis.

Objective: The objective of this case report is to describe utilization of area under the curve (AUC)/minimum inhibitory concentration (MIC) vancomycin dosing with variable MIC results in a patient with methicillin-resistant Staphylococcus aureus (MRSA) purulent pericarditis. Case: A 57-year-old Caucasian male presented with cardiac tamponade and pulmonary emboli. Echocardiogram showed moderate-large pericardial effusion with signs of early tamponade physiology. Pericardiocentesis removed serosanguinous, straw yellow fluid. Blood and pericardial cultures revealed MRSA. Patient was then initiated on vancomycin with an initial AUC of 415. MIC of repeat blood cultures were inconsistent. After 8 days of persistent bacteremia, patient was transitioned to daptomycin and ceftaroline with blood culture clearance within 48 hours. Discussion/Conclusion: Guidelines recommend AUC/MIC vancomycin dosing in patients with MRSA bacteremia. Literature regarding treatment of MRSA purulent pericarditis is limited to case reports. Evidence shows variation in MIC results dependent on analysis methods. Further studies on obtaining accurate MIC values and use of AUC/MIC dosing for MRSA purulent pericarditis are prudent to provide appropriate therapy in these patients as mortality is high.

Theophylline for Spinal Cord Injury Associated Bradycardia.

Background: Spinal cord injury (SCI) related bradycardia occurs frequently in patients with high cervical spine injuries. In patients with SCI-related symptomatic bradycardia, a variety of agents have been used to improve heart rate and reduce the need for vasopressor therapy. The literature concerning the use of theophylline in this disease state is sparse. Objective: The primary objective of this study was to evaluate and describe the use of theophylline for SCI-related symptomatic bradycardia. Methods: This was a retrospective case series of patients with SCI-related symptomatic bradycardia who were treated with theophylline. Patients were evaluated based on clinical response to theophylline. Patients were classified as a responder if vasopressors were discontinued or the number of bradycardia episodes decreased following the initiation of theophylline. Results: A total of twenty-six patients were included in the study. 17 (65.4%) patients were classified as responders, 5 (19.2%) patients were classified as non-responders, and 4 (15.4%) of patients were classified as undetermined. 11 patients (43.31%) were discharged on theophylline with 7 of these patients (41.2%) classified as responders. There were no significant differences between those classified as responders and those who were not. Conclusion and Relevance: This case series suggest that theophylline could be used as adjunctive therapy in patients with bradycardia secondary to acute SCI who achieve an adequate response to theophylline.

Current pharmacotherapy management of children and adults with pericarditis: Prospectus for improved outcomes.

Pericarditis is the most common inflammatory pericardial disease in both children and adults. Since the 2015 European Society of Cardiology Guidelines for the diagnosis and management of pericardial disease were published, there have been significant updates to management. Pharmacotherapy has been historically reserved for idiopathic pericarditis (IP). However, there has been increasing use of pharmacotherapies, such as anti-inflammatory therapies, colchicine, and immunotherapies for other causes of pericarditis, such as post-cardiac injury syndromes (PCIS). Nevertheless, the quality of data varies depending on PCIS or idiopathic etiologies, as well as the adult and pediatric population. High-dose anti-inflammatory therapies should be used to manage symptoms associated with either etiology of pericarditis in both adults and children, but do not ameliorate the inflammatory disease process. Choice of anti-inflammatory should be guided by drug-drug/disease interactions, cost, tolerability, patient age, and should be tapered accordingly over several weeks to months. Colchicine should be added as adjuvant therapy to anti-inflammatory therapies in adults and children with IP, as it has been shown to lower the risk of recurrence, reduce pericarditis symptoms, and improve morbidity. Colchicine is also reasonable to add to adults and children with pericarditis secondary to PCIS. Systemic glucocorticoids increase risk of recurrence in adults and children with IP and are reserved for second-line treatment in acute and recurrent IP; they are generally avoided in PCIS. Immunotherapies are regarded as third-line for recurrent IP in adults and children. Limited evidence exists to support their use in patients with pericarditis from PCIS. Pharmacovigilance strategies, such as C-reactive protein and adverse drug event monitoring, are also important toward balancing efficacy and safety of the various strategies used to manage pericarditis in adults and children.