Rickettsialpox is an acute, self-limited, febrile illness caused by Rickettsia akari and transmitted by Liponyssoides sanguineus, a mite that infests the common house mouse, Mus musculus. Liver involvement in rickettsialpox has received little attention, although hepatitis has been reported in several other rickettsial infections. In this report, we describe two patients with rickettsialpox who had acute hepatitis that resolved completely. In the appropriate clinical setting, rickettsialpox should be considered in the differential diagnosis of hepatitis.
What is known and objective Vancomycin, an antibiotic commonly used to treat MRSA infections, can be nephrotoxic. Administering vancomycin requires close monitoring of serum vancomycin levels and appropriate dosing based on patients’ renal function, underlying infection type and serum concentration levels. This article discusses the results and implications of a pharmacist‐driven vancomycin monitoring initiative, which was implemented at Mercy Catholic Medical Center's Philadelphia Campus (MPC) in July 2016. Methods MPC pharmacists were trained on how to give appropriate vancomycin dosing recommendations based on patients’ vancomycin trough levels, renal function and underlying infection. This retrospective observational study consisted of patients who presented to MPC and were administered vancomycin over a 3‐month period in 2015 for pre‐implementation cohort and over a 3‐month period in 2018 for post‐implementation cohort. Patients with age ≥18 and receiving vancomycin for a minimum of 48 hours were included, whereas ESRD patients were excluded. Primary goal evaluated whether the incidence of AKI decreased with the pharmacist‐driven initiative. Secondary goal assessed whether vancomycin level monitoring and achievement of goal serum levels improved with the initiative. Results and discussion A total of 214 patients were included in the final data analysis, with 110 patients in the pre‐implementation cohort and 104 patients in the post‐implementation cohort. Although not statistically significant, a higher incidence of AKI was observed in the post‐implementation cohort. However, compared to pre‐implementation cohort, post‐implementation group had higher percentage of patients with underlying comorbidities (such as CKD), higher number of cases of severe sepsis and septic shock, and greater number of patients with concomitant exposure to CT contrast and piperacillin‐tazobactam—all of which were confounding factors that likely increased the AKI incidence in post‐implementation cohort. With the initiative, there was a significant increase in the number of patients with appropriate vancomycin trough level monitoring (27.3% vs 55.8%, p value < 0.001) in the post‐implementation cohort and a decrease in the number of patients with no trough level monitoring (30% vs. 7.6%, p value < 0.001). What is new and conclusion Pharmacist‐driven vancomycin monitoring significantly improved the monitoring compliance of vancomycin trough levels. In patients who developed AKI during their hospital course, pharmacist interventions improved the total percentage of patients attaining desired trough goals and helped reduce further renal insult from supratherapeutic vancomycin level. Incorporation of AUC‐guided dosing and monitoring has the potential to further optimize vancomycin efficacy and safety.
Abstract. Strongyloides stercoralis is well known to cause hyperinfection syndrome during the period of immunosuppression; but dissemination, worsening hyperinfection, and development of multiorgan dysfunction syndrome after initiation of ivermectin has not been reported in the past. Herein, we describe the case of a 62-year-old man with chronic strongyloidiasis and human T-cell lymphotropic virus-1 coinfection, who developed significant clinical worsening after 24-48 hours of initiation of treatment with ivermectin (200 μg/kg daily). Oral albendazole (600 mg every 12 hours) was added to the regimen due to clinical deterioration. Notably, after a protracted clinical course with multiple complications, which included respiratory failure from gram-negative pneumonia and pulmonary alveolar hemorrhage, Klebsiella meningitis, Clostridium difficile colitis, and herpes labialis, the patient eventually recovered. Health-care providers should be aware that during the early days of antihelminthic treatment initiation, significant dissemination of S. stercoralis and worsening of the clinical scenario can occur.
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