Differentiating probable nitrofurantoin-induced drug fever from antipsychotic-induced hyperthermia in a patient receiving clozapine.

Nitrofurantoin (NIT) is a commonly utilized antibiotic for the treatment of UTIs. Although well tolerated, NIT is not without potential adverse reactions. This case report details the observation of probable NIT-induced drug fever in a patient receiving clozapine. A 61-year-old female with treatment-refractory schizoaffective disorder was admitted to a psychiatric unit with paranoia and auditory hallucinations, prompting clozapine initiation during day 1 of hospitalization. Due to worsening hallucinations and anxiety, antibiotic therapy with NIT for a presumed UTI was initiated 8 days after admission. Febrile episodes were observed beginning on hospital day (HD) 9, leading to concern for possible neuroleptic malignant syndrome (NMS), which led to clozapine discontinuation. The patient received a total of 3 doses of NIT with continued fever until discontinuation on HD 10. No further complications were encountered, and clozapine was safely resumed on HD 13. Although sparsely described in the medical literature, occurrences of drug fever attributable to NIT are previously reported. A review of the medical literature identified only 5 previously published articles specific to NIT-induced drug fever, none of which specified interruptions of psychotropic therapy for a patient with acute psychiatric decompensation. This case highlights the differential diagnosis of fever related to NIT in a patient receiving clozapine when NMS was initially suspected.

Incorporating Pharmacist Interns Into a Study of Fall-Risks.

INTRODUCTION: Inpatient falls continue to have detrimental effects on patient care and recovery. Because controllable and uncontrollable factors impact fall rates, predicting which patients are at the greatest risk can be challenging. One method includes the incorporation of student learners to help identify which patients are at the greatest risk for falls.
OBJECTIVE: To generate a scoring metric and investigate its reliability for appropriately identifying geriatric and medical psychiatric patients at risk for falling while hospitalized.
METHODS: In this single-center, quasi-experimental study, pharmacist-interns led a fall-prevention initiative at a community hospital within two behavioral health units.
RESULTS: A total of 96 patients were analyzed over the study period, revealing no notable trends for either geriatric or medical psychiatric patients. There was no significant change in the odds of falling for each fall score point increase for either the geriatric-psychiatric unit (odds ratio [OR] = 0.95; 95% confidence interval [CI] 0.83-1.08) or the medical-psychiatric unit (OR = 1.11; 95% CI 0.91-1.36).
CONCLUSION: This pharmacist-intern-led falls-prevention initiative did not provide a statistically significant reduction in falls. While the scoring metric was helpful in reviewing charts to make recommendations for interventions, the assigned score did not correlate as expected to incidents of falls.

Early detection of an atypical presentation of neuroleptic malignant syndrome: A case report.

Neuroleptic malignant syndrome (NMS), which is considered a neurologic emergency, is believed to be caused by exposure to dopamine antagonist or withdrawal from a dopamine agonist. This article reports a case of suspected atypical NMS in a patient following rapid conversion of ziprasidone to risperidone without titration. While the initial presentation did not fully meet the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, diagnostic features, a sequential treatment strategy was initiated and the patient appropriately responded to antipsychotic cessation in addition to combination therapy with dantrolene and bromocriptine. Neuroleptic malignant syndrome diagnostic criteria, treatment, and prognosis are discussed.

Successful Use of Ceftolozane-Tazobactam to Treat a Pulmonary Exacerbation of Cystic Fibrosis Caused by Multidrug-Resistant Pseudomonas aeruginosa.

Ceftolozane-tazobactam, a novel ß-lactam/ß-lactamase inhibitor, was recently approved for the treatment of complicated urinary tract and intraabdominal infections, as monotherapy and in combination with metronidazole, respectively. Ceftolozane-tazobactam exhibits a wide spectrum of activity against both gram-positive bacteria, gram-negative bacteria including multidrug-resistant (MDR) Pseudomonas aeruginosa, and some anaerobic bacteria. Although not currently approved for any pulmonary indication, studies have demonstrated excellent distribution to epithelial lining fluid, indicating that it may be an alternative agent to use in the treatment of respiratory tract infections caused by MDRP. aeruginosa. Unfortunately, data are lacking regarding the use of ceftolozane-tazobactam in the treatment of respiratory tract infections including patients with cystic fibrosis (CF). We describe the first case report, to our knowledge, of a 25-year-old white man successfully treated with ceftolozane-tazobactam for a pulmonary exacerbation of his CF caused by MDRP. aeruginosa. He was admitted for his fourth hospitalization in 7 months for a pulmonary exacerbation of his CF. After blood and sputum were cultured, prednisone, cefepime, inhaled tobramycin, and intravenous ciprofloxacin were started. On day 4, after no signs of clinical improvement, respiratory cultures revealed nonmucoid MDRP. aeruginosa, susceptible only to colistin. ß-Lactam therapy was subsequently changed to ceftolozane-tazobactam 3 g intravenously every 8 hours while continuing ciprofloxacin and inhaled tobramycin. Ceftolozane-tazobactam susceptibility was determined by the Etest method (minimum inhibitory concentration 1.5 µg/ml). By day 3 of therapy, the patient showed signs of clinical improvement and was discharged after completion of a 12-day course of antibiotics. Until additional research is available, we hope this evidence will provide consideration of ceftolozane-tazobactam for this novel off-label indication.

Boceprevir: a novel NS3/4 protease inhibitor for the treatment of hepatitis C.

Hepatitis C virus (HCV) infection affects over 170 million people worldwide and is the most common blood-borne infection in the United States. Standard treatment with peginterferon alfa-ribavirin results in low sustained virologic response (SVR) rates in many patients, especially those who are African-American, are coinfected with human immunodeficiency virus (HIV), or have liver cirrhosis. Because of suboptimal SVR rates, new direct-acting antiviral agents that target HCV viral replication steps are in development. Boceprevir is one of the novel NS3/4A protease inhibitors that was recently approved by the U.S. Food and Drug Administration. We evaluated the literature regarding boceprevir by performing a MEDLINE search (January 1996-July 2011) to identify relevant clinical trials. Abstracts and poster and oral presentations from hepatology and HIV conferences were also reviewed. Potent anti-HCV activity was seen in clinical trials with boceprevir when it was studied in HCV genotype 1-infected patients who were naïve to or had experience with HCV therapy. Data with boceprevir in HIV-HCV-coinfected patients are currently lacking; however, initial data on drug-drug interactions between boceprevir and antiretrovirals have become available. Resistance to boceprevir has been evaluated in trials as well, although more data are needed in this area. The most common adverse events with boceprevir included anemia and dysgeusia. Based on available data, boceprevir is one of the promising novel direct-acting antiviral agents that will likely reshape the treatment of patients with HCV infection.

Telaprevir: a novel NS3/4 protease inhibitor for the treatment of hepatitis C.

Hepatitis C virus (HCV) infection affects millions of people worldwide; however, standard therapy with peginterferon and ribavirin has resulted in suboptimal responses. Thus, new anti-HCV drugs with novel mechanisms of action are being studied. In particular, new drugs are being developed that target the NS3/4A protease complex. We evaluated the literature on telaprevir, a new, oral, covalent, reversible NS3/4A HCV protease inhibitor. A MEDLINE search (January 1996-July 2011) was performed to identify relevant clinical trials, and abstracts from hepatology and human immunodeficiency virus (HIV) conferences were reviewed. In large clinical trials, the addition of telaprevir to peginterferon and ribavirin resulted in high sustained virologic response rates in both treatment-naïve and treatment-experienced patients infected with HCV genotype 1. Clinical data with telaprevir in the HIV-HCV coinfected population are emerging, as well as data on potential drug-drug interactions with this agent. Preliminary data describe the resistance profile of telaprevir; however, more information is needed in this evolving area. Telaprevir's most common adverse events included rash, pruritis, and anemia. Based on available data, this new anti-HCV drug will likely be widely used and may revolutionize the treatment of HCV-infected individuals.