Respiratory Muscle Paralysis Associated With Colistin, Polymyxin B, and Muscle Relaxants Drugs

Abstract

Polymyxins B and E (colistin) exert a bactericidal effect on the gram-negative bacterial cell wall, causing permeability changes in the cytoplasmic membrane, leading to cell death. Their use was substantially decreased in clinical practice from the 1970s to 2000s due to their significant nephrotoxicity and neurotoxicity compared to the newly introduced antibiotics. The increasing prevalence of multidrug-resistant gram-negative bacteria infections in this century has led to an upsurge in the use of these “older” drugs. Respiratory paralysis caused by neuromuscular blockage associated with the use of polymyxin B and E was reported mostly in literature published in the 1960s to 1970s with a few reports after 2000. In addition, such a reaction might be enhanced by the presence of other classes of drugs. We report a case of polymyxin B and E–induced apnea in a patient receiving “muscle relaxants.”

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“… 49 , 50 Other dose-dependent reversible adverse effects include ataxia, apnea, paresthesias, delirium, visual disturbances, seizures, vertigo, and neuromuscular defects. 51 …”

Antimicrobial Peptides and Nanotechnology, Recent Advances and Challenges

“…Its mechanism of action is via attachment to acidic phospholipids and lipopolysaccharide bacterial cell membrane, causing the leakage of intracellular components, ending in death ( Brogden, 2005 ; Arnold et al, 2007 ). Polymyxin B is widely used for urinary tract infection, meningitis, mucocitis, otitis, periodontitis and lung, ear, ocular and wound infection treatment ( Arnold et al, 2007 ; Henao and Ghaffari, 2016 ; Myint et al, 2016 ; Rigatto et al, 2016 ). However, adverse side effects have been reported for polymyxin, such as neurotoxicity and nephorotoxicity, as well as a risk of promoting skin pigmentation ( Gallardo-Godoy et al, 2016 ).…”

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“…The mechanism of this adverse event is thought to be secondary to the presynaptic blockade of acetylcholine release and may be exacerbated by administration of other medications with known neurotoxicities. Neurotoxicity associated with polymyxin antibiotics primarily presents as paresthesias and is associated with incidence estimates ranging from 7.3% to 27% . Although rare, the association with the polymyxin antibiotics and respiratory arrest secondary to respiratory muscle paralysis has been previously described, including cases requiring intubation and some progressing to PEA cardiac arrest .…”

“…17 Although rare, the association with the polymyxin antibiotics and respiratory arrest secondary to respiratory muscle paralysis has been previously described, including cases requiring intubation and some progressing to PEA cardiac arrest. [17][18][19][20] With regard to onset of respiratory paralysis associated with polymyxin antibiotics, no specific trends have been observed. 19 Case reports exist with onset occurring during the first dose of polymyxin, with others occurring after 45 days of therapy.…”