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F Fantin et al.
associated with rivastigmine,1 and there are three previous cases of complete atrioventricular block associated with rivastigmine.2,3 Autonomic dysfunction is a common feature of Parkinson’s disease and DLB, although Ballard et al. found that rivastigmine has a favorable profile of cardiac safety in such patients.5 The present patient had DLB, and sinus arrest occurred only after sputum inspiration, which might have induced a vagal reflex. Thus, other factors influencing autonomic function might also be related to rivastigmine-induced sinus arrest.
Disclosure statement None.
References 1 Paulison B, Léos CL. Potential cardiotoxic reaction involving rivastigmine and beta-blockers: a case report and review of the literature. Cardiovasc Toxicol 2010; 10: 306–310. 2 Kayrak M, Yazici M, Ayhan SS, Koc F, Ulgen MS. Complete atrioventricular block associated with rivastigmine therapy. Am J Health Syst Pharm 2008; 65: 1051–1053. 3 Knudtzen FC, Christophersen TB. Third degree atrioventricular block associated with treatment with rivastigmine transdermal patch. J Geriatr Cardiol. 2013;10:113–5. Ann Pharmacother 2007; 41: 1632–1637. 4 Morganroth J, Graham S, Hartman R, Anand R. Electrocardiographic effects of rivastigmine. J Clin Pharmacol 2002; 42: 558–568. 5 Ballard C, Lane R, Barone P, Ferrara R, Tekin S. Cardiac safety of rivastigmine in Lewy body and Parkinson’s disease dementias. Int J Clin Pract 2006; 60: 639–645.
Shigenori Muto,1,2 Hiroaki Kawano,1 Daisuke Nakatomi,2 Toshihiko Yamasa2 and Koji Maemura1 1 Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki and 2Department of Cardiology, Nagasaki Rosai Hospital, Sasebo, Japan
Use of tigecycline difficile infection
in
elderly
Dear Editor, An 89-year-old man entered the Geriatric Unit of Verona Hospital, Verona, Italy, with fever, dyspnea and leukocytosis. The patient was affected by chronic obstructive pulmonary disease, chronic kidney disease, hypertension and coronary heart disease, and was first admitted to the Orthopedic Department 1 month earlier because of a left femur trochanteric fracture. During the following days, he was administered meropenem to counter a urinary tract multiresistant (cephalosporin, aztreonam, penicillin) Proteus mirabilis infection, and levofloxacin for bronchopneumonia. After a general worsening of the inflammation indices and clinical condition, the patient was treated with ciprofloxacin for approximately 1 month. Immediately after hospitalization in our department, several diarrhea episodes occurred that were associated with increased white cells up to 79 390/uL, C-reactive protein 225 mg/L and procalcitonin 4.2 ug/L. Microbial analysis resulted in a positive identification of Clostridium difficile, for which metronidazole and vancomycin therapy was started. 230 |
doi: 10.1111/ggi.12336
patients
for
Clostridium
Physical examination showed a tense and meteoristic abdomen, absent peristalsis and painful left iliac fossa. Abdominal ultrasonography showed diffuse edematous thickening of the colon walls, indicating colitis. Furthermore, a rectosigmoidoscopy was carried out, showing pseudomembranes with normal (where visible) colon mucosa and no signs of ischemia (Fig. 1). Given the septic shock, intravenous tigecycline was added to therapy combined with dopamine infusion. The new antibiotic therapy led to normalization of abdominal physical examination and phlogosis indices, and a coproculture carried out after 8 days confirmed the absence of C. difficile. Proctoscopy showed an improving endoscopic situation, accompanied by resolution of a consistent thrombocytopenia that occurred during sepsis and lowering creatinine levels. Infection with toxin-producing strains of C. difficile might be asymptomatic, as well as presenting a range of clinical manifestations, from mild diarrhea episodes to sudden and severe pseudomembranous colitis. Common symptoms, although found in less than half of © 2015 Japan Geriatrics Society
Letters to the Editor
penetration. As such, it is particularly suited to treat intestinal infections. This case report, as shown by other observations, suggests tigecycline as an option for severe and complicated disease in critically ill elderly patients when there are few alternative therapeutic options.8–10
Disclosure statement The authors declare no conflict of interest.
Figure 1 Grossly abnormal mucosa with pseudomembranes observed during rectosigmoidoscopy.
patients, include fever, cramping, abdominal discomfort and peripheral leukocytosis.1 Severe infection could lead to colonic ileus or toxic dilatation, abdominal pain associated with distension, but lacking diarrhea.1 Complications commonly reported are dehydration, electrolyte disturbances, elevated lactatate level, hypoalbuminemia, toxic megacolon, bowel perforation, hypotension, renal failure, systemic inflammatory response syndrome, and finally, sepsis and death.2,3 C. difficile infection (CDI) appears to be related to previous antimicrobials treatment. As reported by Olson et al., 96% of patients with symptomatic infection had received antimicrobials within the previous 3 months.4,5 To date, the antibiotic drugs most commonly used for treating CDI have been metronidazole and vancomycin per os. The former has been the first choice for mild CDI, whereas the latter is recommended for severe outbreaks. In the case of severe CDI with complications, such as shock, ileus and megacolon, oral or rectal vancomycin has been used in combination with intravenous metronidazole.3 As the options for treatment of patients at high risk for increased morbidity and mortality are limited, considering new possibilities is mandatory. Tigecycline, which showed in vitro activity against numerous Gram-positive bacteria, including C. difficile,6 and Gram-negative bacteria as well as many anaerobic organisms6,7 is a promising candidate. Furthermore, tigecycline is primarily excreted as an unchanged drug through biliary excretion, and shows good fecal
© 2015 Japan Geriatrics Society
Francesco Fantin,1 Angela Manica,1 Fabio Soldani,2 Luisa Bissoli,1 Alessandra Zivelonghi1 and Mauro Zamboni1 1 Department of Medicine, Section of Geriatrics, University of Verona, and 2Department of Pathology and Diagnostics, Section of Infectious Diseases, Azienda Ospedaliera Universitaria Integrata, Policlinico “G. B. Rossi”, Verona, Italy
References 1 Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med 2002; 346: 334–349. 2 Kuijper EJ, Wilcox MH. Decreased effectiveness of metronidazole for the treatment of Clostridium difficile infection? Clin Infect Dis 2008; 47: 63–65. 3 Cohen SH, Gerding DN, Johnson S et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31: 431– 455. 4 (Olson MM, Shanholtzer CJ, Lee JT Jr et al. Ten years of prospective Clostridium difficile–associated disease surveillance and treatment at the Minneapolis VA Medical Center, 1982–1991. Infect Control Hosp Epidemiol 1994; 15: 371–381. 5 Alfa M, Harding G, Ronald A et al. Diarrhea recurrence in patients with Clostridium difficile-associated diarrhea: role of concurrent antibiotics. J Infect Dis 1999; 10: 287–294. 6 Product information. Tygacil (tigecycline). Philadelphia, PA: Wyeth Pharmaceuticals Inc., July 2010. 7 Hawser SP. Activity of tigecycline against recent European clinical isolates of Clostridium difficile. Int J Antimicrob Agents 2010; 35: 97–98. 8 Herpers BL, Vlaminckx B, Burkhardt O et al. Intravenous tigecycline as adjunctive or alternative therapy for severe refractory Clostridium difficile infection. Clin Infect Dis 2009; 48 (12): 1732–1735. 9 Larson KC, Belliveau PP, Spooner LM. Tigecycline for the Treatment of Severe Clostridium difficile Infection. Ann Pharmacother 2011; 45: 1005–1010. 10 Venugopal AA, Johnson S. Current state of Clostridium difficile treatment options. Clin Infect Dis 2012; 55 (Suppl 2): S71–S76.
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F Fantin et al.
associated with rivastigmine,1 and there are three previous cases of complete atrioventricular block associated with rivastigmine.2,3 Autonomic dysfunction is a common feature of Parkinson’s disease and DLB, although Ballard et al. found that rivastigmine has a favorable profile of cardiac safety in such patients.5 The present patient had DLB, and sinus arrest occurred only after sputum inspiration, which might have induced a vagal reflex. Thus, other factors influencing autonomic function might also be related to rivastigmine-induced sinus arrest.
Disclosure statement None.
References 1 Paulison B, Léos CL. Potential cardiotoxic reaction involving rivastigmine and beta-blockers: a case report and review of the literature. Cardiovasc Toxicol 2010; 10: 306–310. 2 Kayrak M, Yazici M, Ayhan SS, Koc F, Ulgen MS. Complete atrioventricular block associated with rivastigmine therapy. Am J Health Syst Pharm 2008; 65: 1051–1053. 3 Knudtzen FC, Christophersen TB. Third degree atrioventricular block associated with treatment with rivastigmine transdermal patch. J Geriatr Cardiol. 2013;10:113–5. Ann Pharmacother 2007; 41: 1632–1637. 4 Morganroth J, Graham S, Hartman R, Anand R. Electrocardiographic effects of rivastigmine. J Clin Pharmacol 2002; 42: 558–568. 5 Ballard C, Lane R, Barone P, Ferrara R, Tekin S. Cardiac safety of rivastigmine in Lewy body and Parkinson’s disease dementias. Int J Clin Pract 2006; 60: 639–645.
Shigenori Muto,1,2 Hiroaki Kawano,1 Daisuke Nakatomi,2 Toshihiko Yamasa2 and Koji Maemura1 1 Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki and 2Department of Cardiology, Nagasaki Rosai Hospital, Sasebo, Japan
Use of tigecycline difficile infection
in
elderly
Dear Editor, An 89-year-old man entered the Geriatric Unit of Verona Hospital, Verona, Italy, with fever, dyspnea and leukocytosis. The patient was affected by chronic obstructive pulmonary disease, chronic kidney disease, hypertension and coronary heart disease, and was first admitted to the Orthopedic Department 1 month earlier because of a left femur trochanteric fracture. During the following days, he was administered meropenem to counter a urinary tract multiresistant (cephalosporin, aztreonam, penicillin) Proteus mirabilis infection, and levofloxacin for bronchopneumonia. After a general worsening of the inflammation indices and clinical condition, the patient was treated with ciprofloxacin for approximately 1 month. Immediately after hospitalization in our department, several diarrhea episodes occurred that were associated with increased white cells up to 79 390/uL, C-reactive protein 225 mg/L and procalcitonin 4.2 ug/L. Microbial analysis resulted in a positive identification of Clostridium difficile, for which metronidazole and vancomycin therapy was started. 230 |
doi: 10.1111/ggi.12336
patients
for
Clostridium
Physical examination showed a tense and meteoristic abdomen, absent peristalsis and painful left iliac fossa. Abdominal ultrasonography showed diffuse edematous thickening of the colon walls, indicating colitis. Furthermore, a rectosigmoidoscopy was carried out, showing pseudomembranes with normal (where visible) colon mucosa and no signs of ischemia (Fig. 1). Given the septic shock, intravenous tigecycline was added to therapy combined with dopamine infusion. The new antibiotic therapy led to normalization of abdominal physical examination and phlogosis indices, and a coproculture carried out after 8 days confirmed the absence of C. difficile. Proctoscopy showed an improving endoscopic situation, accompanied by resolution of a consistent thrombocytopenia that occurred during sepsis and lowering creatinine levels. Infection with toxin-producing strains of C. difficile might be asymptomatic, as well as presenting a range of clinical manifestations, from mild diarrhea episodes to sudden and severe pseudomembranous colitis. Common symptoms, although found in less than half of © 2015 Japan Geriatrics Society
Letters to the Editor
penetration. As such, it is particularly suited to treat intestinal infections. This case report, as shown by other observations, suggests tigecycline as an option for severe and complicated disease in critically ill elderly patients when there are few alternative therapeutic options.8–10
Disclosure statement The authors declare no conflict of interest.
Figure 1 Grossly abnormal mucosa with pseudomembranes observed during rectosigmoidoscopy.
patients, include fever, cramping, abdominal discomfort and peripheral leukocytosis.1 Severe infection could lead to colonic ileus or toxic dilatation, abdominal pain associated with distension, but lacking diarrhea.1 Complications commonly reported are dehydration, electrolyte disturbances, elevated lactatate level, hypoalbuminemia, toxic megacolon, bowel perforation, hypotension, renal failure, systemic inflammatory response syndrome, and finally, sepsis and death.2,3 C. difficile infection (CDI) appears to be related to previous antimicrobials treatment. As reported by Olson et al., 96% of patients with symptomatic infection had received antimicrobials within the previous 3 months.4,5 To date, the antibiotic drugs most commonly used for treating CDI have been metronidazole and vancomycin per os. The former has been the first choice for mild CDI, whereas the latter is recommended for severe outbreaks. In the case of severe CDI with complications, such as shock, ileus and megacolon, oral or rectal vancomycin has been used in combination with intravenous metronidazole.3 As the options for treatment of patients at high risk for increased morbidity and mortality are limited, considering new possibilities is mandatory. Tigecycline, which showed in vitro activity against numerous Gram-positive bacteria, including C. difficile,6 and Gram-negative bacteria as well as many anaerobic organisms6,7 is a promising candidate. Furthermore, tigecycline is primarily excreted as an unchanged drug through biliary excretion, and shows good fecal
© 2015 Japan Geriatrics Society
Francesco Fantin,1 Angela Manica,1 Fabio Soldani,2 Luisa Bissoli,1 Alessandra Zivelonghi1 and Mauro Zamboni1 1 Department of Medicine, Section of Geriatrics, University of Verona, and 2Department of Pathology and Diagnostics, Section of Infectious Diseases, Azienda Ospedaliera Universitaria Integrata, Policlinico “G. B. Rossi”, Verona, Italy
References 1 Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med 2002; 346: 334–349. 2 Kuijper EJ, Wilcox MH. Decreased effectiveness of metronidazole for the treatment of Clostridium difficile infection? Clin Infect Dis 2008; 47: 63–65. 3 Cohen SH, Gerding DN, Johnson S et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31: 431– 455. 4 (Olson MM, Shanholtzer CJ, Lee JT Jr et al. Ten years of prospective Clostridium difficile–associated disease surveillance and treatment at the Minneapolis VA Medical Center, 1982–1991. Infect Control Hosp Epidemiol 1994; 15: 371–381. 5 Alfa M, Harding G, Ronald A et al. Diarrhea recurrence in patients with Clostridium difficile-associated diarrhea: role of concurrent antibiotics. J Infect Dis 1999; 10: 287–294. 6 Product information. Tygacil (tigecycline). Philadelphia, PA: Wyeth Pharmaceuticals Inc., July 2010. 7 Hawser SP. Activity of tigecycline against recent European clinical isolates of Clostridium difficile. Int J Antimicrob Agents 2010; 35: 97–98. 8 Herpers BL, Vlaminckx B, Burkhardt O et al. Intravenous tigecycline as adjunctive or alternative therapy for severe refractory Clostridium difficile infection. Clin Infect Dis 2009; 48 (12): 1732–1735. 9 Larson KC, Belliveau PP, Spooner LM. Tigecycline for the Treatment of Severe Clostridium difficile Infection. Ann Pharmacother 2011; 45: 1005–1010. 10 Venugopal AA, Johnson S. Current state of Clostridium difficile treatment options. Clin Infect Dis 2012; 55 (Suppl 2): S71–S76.
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