This paper describes a case of lung injury attributed to the use of Nitrofurantoin and a review of the relevant literature. An 88-year-old woman was admitted to the floor for the evaluation of recent symptoms of dyspnea, fatigue and productive cough. She was initiated on nitrofurantoin 300 mg per day for the treatment of a urinary tract infection 3 days earlier. Upon examination, chest auscultation revealed bilateral inspiratory crackles. Chest radiograph showed bilateral airspace and interstitial infiltrates. Laboratory studies revealed an elevated white blood cell count of 13,500/μL (reference range = 5200-12,400/μL) and blood eosinophilia (10%, reference range: 0-7%). Using clinical judgment and the algorithm of Naranjo, it was determined that nitrofurantoin use was the probable cause of the patient's lung injury. Symptomatic improvement was observed shortly after the drug was discontinued. A review of information from several European and North American pharmacovigilance databases (through June 2014) identified several reports of suspected nitrofurantoin-induced toxicity, including reports of acute toxicity reactions, which were related in many ways to the case we are reporting here.

Objective The purpose of this study is to evaluate antibiotic-prescribing practices and adherence to IDSA guidelines for the treatment of uncomplicated urinary tract infections in Lebanon. Methods This observational prospective study was conducted in 15 community pharmacies in Lebanon over 1 year in adult females. A regimen of nitrofurantoin 100 mg bid for 5 days or fosfomycin 3 grams single dose were considered appropriate. For the bivariate analysis, the chi-square test was used. Results A total of 376 patients were included in this study. The prescribed antibiotic was appropriate in 35 percent of the patients. Age (more than 50 years) did not significantly affect the appropriateness of the prescribed antibiotic (p=0.508). The frequency of attacks per year (more than 3) negatively affected the choice of antibiotic (p=0.025). The dose and duration of the prescribed antibiotic was appropriate in 73 and 58 percent of the patients, respectively, with a significant inappropriate dose and duration with fluoroquinolones as compared to nitrofurantoin and fosfomycin (p < 0.001 for the dose and p=0.014 for the duration of therapy). Conclusions In an era of increasing bacterial resistance, interventions that improve physicians' prescribing practices for uncomplicated urinary tract infections are needed.

BackgroundThe aim of the study was to evaluate the simplicity, safety, patients’ preference, and convenience of the administration of insulin using the pen device versus the conventional vial/syringe in patients with diabetes.MethodsThis observational study was conducted in multiple community pharmacies in Lebanon. The investigators interviewed patients with diabetes using an insulin pen or conventional vial/syringe. A total of 74 questionnaires were filled over a period of 6 months. Answers were entered into the Statistical Package for Social Sciences (SPSS) software and Excel spreadsheet. t-test, logistic regression analysis, and correlation analysis were used in order to analyze the results.ResultsA higher percentage of patients from the insulin pen users group (95.2%) found the method easy to use as compared to only 46.7% of the insulin conventional users group (P 0.001, relative risk [RR]: 2.041, 95% confidence interval [CI]: 1.178–3.535). Moreover, 61.9% and 26.7% of pen users and conventional users, respectively, could read the scale easily (P 0.037, RR 2.321, 95% CI: 0.940–5.731), while 85.7% of pen users found it more convenient shifting to pen and 86.7% of the conventional users would want to shift to pen if it had the same cost. Pain perception was statistically different between the groups. A much higher percentage (76.2%) of pen users showed no pain during injection compared to only 26.7% of conventional users (P 0.003, RR 2.857, 95% CI: 1.194–6.838).ConclusionThe insulin pen was significantly much easier to use and less painful than the conventional vial/syringe. Proper education on the methods of administration/storage and disposal of needles/syringes is needed in both groups.

Simple and cost-effective methods are needed to extract DNA in order to use it in large-scale studies. Blood is an excellent DNA source; however, it is costly and invasive thus an alternative is needed. Several kits and chemical protocols using buccal cells have been proposed for DNA extraction. The objective of the study is to evaluate buccal NaOH chemical protocol and Nucleospin Tissue Kit (BD Biosciences, Macery-Nagel, Germany) for DNA extraction. DNA swab samples were collected from 300 voluntary participants. DNA yields and purity were measured by NaOH and Nucleospin Tissue Kit techniques; the cost and time consumption for DNA extraction per sample were assessed as well. Results have shown that DNA amount and purity extracted by NaOH procedure was compared to that of the kit (p = 0.164; p = 0.249, respectively). NaOH method was considered cheaper and less time consuming (0.06 versus 3.80 USD, and 1.33 versus 3.59 minutes per sample, p < 0.001). Buccal cell derived DNA extracted by NaOH protocol can be considered a feasible substitute for more expensive and time-consuming kits.

A 68-year-old man diagnosed with a diabetic foot infection caused by R. ornithinolytica was successfully treated with amoxicillin-clavulanate and ciprofloxacin.

BackgroundThe purpose of this study was to review the current literature and information on the combination product Juvisync™ (sitagliptin + simvastatin), which was approved by the US Food and Drug Administration in October 2011.MethodsPubMed (2001–2014) was searched for primary and review articles on sitagliptin, simvastatin, or the combination product. Drug manufacturing data and product labeling were also used. Studies of simvastatin, sitagliptin, or the combination were screened and analyzed to include relevant and recent papers. Selected English language trials were limited to those with human subjects and included both safety and efficacy outcomes.ResultsWhen compared with glipizide as add-on therapy to metformin, sitagliptin was noninferior but had lower rates of hypoglycemia and weight gain. In addition, when compared with insulin glargine, sitagliptin was less effective in decreasing glycosylated hemoglobin, but was associated with significantly lower rates of hypoglycemia. Further, trials have shown a beneficial effect of using statins in patients with diabetes mellitus with regard to decreasing cardiovascular risk, regardless of baseline lipid levels or the presence of a cardiac disease. Both medications have also demonstrated an acceptable side effect profile. However, caution is needed when coadministering with any drug that may increase simvastatin levels to reduce the risk of myopathy and rhabdomyolysis.ConclusionJuvisync should be used in patients requiring both sitagliptin and simvastatin. Both agents have shown good efficacy and acceptable safety profiles. Sitagliptin is a good option for diabetic patients to improve glycemic control with a lower risk of hypoglycemia and weight gain.

This paper describes a case of an acute and fatal isoniazid-induced hepatotoxicity and provides a review of the literature. A 65-year-old female diagnosed with latent Mycobacterium tuberculosis infection was receiving oral isoniazid 300 mg daily. She was admitted to the hospital for epigastric and right sided flank pain of one-week duration. Laboratory results and imaging confirmed hepatitis. After ruling out all other possible causes, she was diagnosed with isoniazid-induced acute hepatitis (probable association by the Naranjo scale). After discharge, the patient was readmitted and suffered from severe coagulopathy, metabolic acidosis, acute kidney injury, hepatic encephalopathy, and cardiorespiratory arrest necessitating two rounds of cardiopulmonary resuscitation. Despite maximal hemodynamic support, the patient did not survive. A review of the literature, from several European countries and the United States of America, revealed a low incidence of mortality due to isoniazid-induced hepatotoxicity when used as a single agent for latent Mycobacterium tuberculosis infection. As for the management, the first step consists of withdrawing isoniazid and rechallenge is usually discouraged. Few treatment modalities have been proposed; however there is no robust evidence to support any of them. Routine monitoring for hepatotoxicity in patients receiving isoniazid is warranted to prevent morbidity and mortality.

This paper reviews the current literature and information on the combination drug Complera(™) (rilpivirine/emtricitabine/tenofovir disoproxil fumarate) that was approved by the Food and Drug Administration (FDA) in August 2011. PubMed, Cochrane and Embase (2001-2014) were searched for primary and review articles on rilpivirine, emtricitabine, and tenofovir disoproxil fumarate, individually or in combination. Data from drug manufacturer and product label was also used. Clinical trial reports were selected, extracted and analyzed to include relevant and recent ones. Selected English-language trials were limited to those with human subjects and included both safety and efficacy outcomes. Results from two phase 3 randomized double blind trials (ECHO and THRIVE) showed that rilpivirine is non-inferior to efavirenz in suppressing viral load below 50 copies/mL in anti-retroviral therapy (ART) naïve human immunodeficiency virus (HIV) infected patients. In addition, psychiatric disturbances, rash and increase in lipid levels occurred less frequently with rilpivirine when compared to efavirenz. However, virological failure and drug resistance were higher with rilpivirine in patients with baseline viral load >100,000 copies/mL. Rilpivirine showed cross resistance to efavirenz and etravirine. Efavirenz, on the other hand, did not demonstrate cross resistance to rilpivirine and etravirine, leaving the latter drugs as options for use in case of virological failure with efavirenz. Complera(™) remains an acceptable alternative treatment to Atripla(™) in ART naïve patients who have a pre-ART plasma HIV RNA <100,000 copies/mL and CD4 count >200 cells/mm(3) with non-inferior efficacy and better safety and tolerability.