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A typical case of Napoleonic fever
Abstracts
e41
TEICOPLANIN USE AND THERAPEUTIC DRUG MONITORING IN BONE INFECTION Matthews PC 1, Taylor A 2, Byren I 1, Atkins BL
1
1
Bone Infection Unit, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD 2 Oxford City Primary Care Trust, Isis Business Park, Oxford OX4 2RD Background: Teicoplanin is widely used as a once-daily intravenous (iv) treatment regime in the treatment of serious gram positive infection, particularly in patients receiving parenteral antibiotics at home. It is suggested that a trough level of 20mg/L is required for successful treatment of staphylococcal endocarditis and septic arthritis. Monitoring of trough (pre-dose) levels is advocated to ensure that therapeutic concentrations are reached. Methods: We prospectively recorded data over 17 months (commencing April 2005) on consecutive adult patients receiving treatment with iv teicoplanin under the care of Oxford’s Home IV Team. Teicoplanin levels were performed by the regional Antimicrobial Reference Lab (North Bristol NHS Trust). Common dose regimes used were either 400mg iv or 600mg iv daily, with an additional loading dose at 12 hours in both cases. Most patients received a total of 6 weeks of glycopeptide therapy. Results: 149 patient episodes are described (103 male, 46 female), age range 16-89, of whom 96% had musculoskeletal infection. The commonest pathogens being treated were coagulase negative staphylococci and Staphylococcus aureus. 3 patients received treatment with teicoplanin 200mg, 104 patients with 400mg, and 42 patients with 600mg. Teicoplanin levels were available for 118 treatment episodes, at a mode of 5-9 days into treatment. Mean trough levels were 23.5mg/L (range 8.6-89.9). A level of 20mg/L was more likely to be achieved with a dose of 600mg than with lower doses (p ¼ 0.003). There was no relationship between trough level and age, body weight, gender or serum creatinine. Conclusions: Therapeutic teicoplanin levels for severe infections are more likely to be achieved with a daily dose of 600mg than with lower doses. We suggest that dose does not need to be modified according to other patient characteristics. Prospective studies are needed to ascertain whether higher pre-dose levels correlate with improved outcome in musculoskeletal infection, and whether adverse effects increase with higher doses.
Clinical Lessons A TYPICAL CASE OF NAPOLEONIC FEVER Jenkins NE 1, Ferguson DJ 2, Harrison TG 3, Alp NJ 4, Bowler ICJW 1 1
Dept of Micobiology, John Radcliffe Hospital, Oxford Nuffield Dept of Pathology, John Radcliffe Hospital, Oxford 3 Respiratory and Systemic Infection Laboratory, HPA Centre for Infections, London 4 Dept of Cardiovascular Medicine, John Radcliffe Hospital, Oxford 2
A 35 year old Ukrainian itinerant builder with poor dentition presented with breathlessness for two months. He was afebrile and inflammatory markers were only slightly raised. A transthoracic echocardiogram revealed aortic valve vegetation with severe valve dysfunction. Multiple blood cultures did not yield an organism and there were few ongoing features of infection. While on broad spectrum antibiotics, he suffered a sudden deterioration requiring emergency aortic valve replacement. Histology of the valve revealed features of chronic inflammation only. Culture of the valve did not reveal a pathogen. Both Bartonella and Chlamydia antibody titres were markedly raised. Cross reactivity between these two tests is well documented and the case allows a brief review of this area. We were able to obtain electron microscopy of the valve revealing intracellular cocco-bacilliary organisms. PCR performed on valve tissue found Bartonella quintana. Our patients’ lifestyle, involving alcohol abuse and self neglect, is likely to have brought him into contact with the human body louse (Pediculus humanus humanus), the usual vector for this diease. This case is typical of B. quintana endocarditis, a torpid infection clinically apparent only as the valve is destroyed and haemodynamic compromise ensues. A requirement for urgent valve replacement is therefore a common feature. There is new and interesting data on its epidemiology and various opinions on appropriate treatment. The epidemic form of the disease -Trench Fever, was first described during WWI where it was the most prevalent disease in Allied troops. It re-emerged on the Eastern Front in WW2. More recently a sporadic form of the disease has been described - Urban Trench Fever. This affects inner-city dwellers, alcohol abusers, and displaced persons. Seroprevalence studies in these populations suggest that exposure is common in some locations and many infections are subclinical. Endocarditis cases represent the tip of the clinical iceberg.
A CHINESE SAILOR: ALL AT SEE Sloan DJ 1, Taegtmeyer M 1, Hart IJ 2, Pearce I.A. Darroch J 3,4, Beeching NJ 1, Miller ARO 1 1
Dept of Infectious Diseases, Royal Liverpool University Hospital, Liverpool L7 8XP 2 Virology, Royal Liverpool University Hospital, Liverpool L7 8XP 3 Ophthalmology, Royal Liverpool University Hospital, Liverpool L7 8XP 4 Immunology, Royal Liverpool University Hospital, Liverpool L7 8XP Case A 69-year-old retired, diabetic Chinese sailor presented with progressive visual deterioration whilst on long-term inhaled bronchodilators and low dose prednisolone for post-TB bronchiectasis and asthma. Ophthalmology examination revealed Acute Retinal Necrosis (photo). The polymerase Chain Reaction (PCR) for cytomegalovirus(CMV) was positive in the aqueous humour. Plasma CMV PCR was negative. Serology was IgG positive (avidity index: 72%) and IgM negative. Intravenous ganciclovir treatment, followed by oral valganciclovir for six months, was successful.
e41
TEICOPLANIN USE AND THERAPEUTIC DRUG MONITORING IN BONE INFECTION Matthews PC 1, Taylor A 2, Byren I 1, Atkins BL
1
1
Bone Infection Unit, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD 2 Oxford City Primary Care Trust, Isis Business Park, Oxford OX4 2RD Background: Teicoplanin is widely used as a once-daily intravenous (iv) treatment regime in the treatment of serious gram positive infection, particularly in patients receiving parenteral antibiotics at home. It is suggested that a trough level of 20mg/L is required for successful treatment of staphylococcal endocarditis and septic arthritis. Monitoring of trough (pre-dose) levels is advocated to ensure that therapeutic concentrations are reached. Methods: We prospectively recorded data over 17 months (commencing April 2005) on consecutive adult patients receiving treatment with iv teicoplanin under the care of Oxford’s Home IV Team. Teicoplanin levels were performed by the regional Antimicrobial Reference Lab (North Bristol NHS Trust). Common dose regimes used were either 400mg iv or 600mg iv daily, with an additional loading dose at 12 hours in both cases. Most patients received a total of 6 weeks of glycopeptide therapy. Results: 149 patient episodes are described (103 male, 46 female), age range 16-89, of whom 96% had musculoskeletal infection. The commonest pathogens being treated were coagulase negative staphylococci and Staphylococcus aureus. 3 patients received treatment with teicoplanin 200mg, 104 patients with 400mg, and 42 patients with 600mg. Teicoplanin levels were available for 118 treatment episodes, at a mode of 5-9 days into treatment. Mean trough levels were 23.5mg/L (range 8.6-89.9). A level of 20mg/L was more likely to be achieved with a dose of 600mg than with lower doses (p ¼ 0.003). There was no relationship between trough level and age, body weight, gender or serum creatinine. Conclusions: Therapeutic teicoplanin levels for severe infections are more likely to be achieved with a daily dose of 600mg than with lower doses. We suggest that dose does not need to be modified according to other patient characteristics. Prospective studies are needed to ascertain whether higher pre-dose levels correlate with improved outcome in musculoskeletal infection, and whether adverse effects increase with higher doses.
Clinical Lessons A TYPICAL CASE OF NAPOLEONIC FEVER Jenkins NE 1, Ferguson DJ 2, Harrison TG 3, Alp NJ 4, Bowler ICJW 1 1
Dept of Micobiology, John Radcliffe Hospital, Oxford Nuffield Dept of Pathology, John Radcliffe Hospital, Oxford 3 Respiratory and Systemic Infection Laboratory, HPA Centre for Infections, London 4 Dept of Cardiovascular Medicine, John Radcliffe Hospital, Oxford 2
A 35 year old Ukrainian itinerant builder with poor dentition presented with breathlessness for two months. He was afebrile and inflammatory markers were only slightly raised. A transthoracic echocardiogram revealed aortic valve vegetation with severe valve dysfunction. Multiple blood cultures did not yield an organism and there were few ongoing features of infection. While on broad spectrum antibiotics, he suffered a sudden deterioration requiring emergency aortic valve replacement. Histology of the valve revealed features of chronic inflammation only. Culture of the valve did not reveal a pathogen. Both Bartonella and Chlamydia antibody titres were markedly raised. Cross reactivity between these two tests is well documented and the case allows a brief review of this area. We were able to obtain electron microscopy of the valve revealing intracellular cocco-bacilliary organisms. PCR performed on valve tissue found Bartonella quintana. Our patients’ lifestyle, involving alcohol abuse and self neglect, is likely to have brought him into contact with the human body louse (Pediculus humanus humanus), the usual vector for this diease. This case is typical of B. quintana endocarditis, a torpid infection clinically apparent only as the valve is destroyed and haemodynamic compromise ensues. A requirement for urgent valve replacement is therefore a common feature. There is new and interesting data on its epidemiology and various opinions on appropriate treatment. The epidemic form of the disease -Trench Fever, was first described during WWI where it was the most prevalent disease in Allied troops. It re-emerged on the Eastern Front in WW2. More recently a sporadic form of the disease has been described - Urban Trench Fever. This affects inner-city dwellers, alcohol abusers, and displaced persons. Seroprevalence studies in these populations suggest that exposure is common in some locations and many infections are subclinical. Endocarditis cases represent the tip of the clinical iceberg.
A CHINESE SAILOR: ALL AT SEE Sloan DJ 1, Taegtmeyer M 1, Hart IJ 2, Pearce I.A. Darroch J 3,4, Beeching NJ 1, Miller ARO 1 1
Dept of Infectious Diseases, Royal Liverpool University Hospital, Liverpool L7 8XP 2 Virology, Royal Liverpool University Hospital, Liverpool L7 8XP 3 Ophthalmology, Royal Liverpool University Hospital, Liverpool L7 8XP 4 Immunology, Royal Liverpool University Hospital, Liverpool L7 8XP Case A 69-year-old retired, diabetic Chinese sailor presented with progressive visual deterioration whilst on long-term inhaled bronchodilators and low dose prednisolone for post-TB bronchiectasis and asthma. Ophthalmology examination revealed Acute Retinal Necrosis (photo). The polymerase Chain Reaction (PCR) for cytomegalovirus(CMV) was positive in the aqueous humour. Plasma CMV PCR was negative. Serology was IgG positive (avidity index: 72%) and IgM negative. Intravenous ganciclovir treatment, followed by oral valganciclovir for six months, was successful.