Liver abscess

There is this Indian uncle who had admitted to my ward complaining of fever for 3 days and worsening abdominal pain for 1 week. Patient is an alcoholic. Initially he was suspected to have acute calculus cholecystitis and meliodosis. However, CT scan showed that he actually had liver abscess. (a pus filled cavity in the liver).

His blood culture and sensitivity taken on admission showed present of Enterobacter Sakazakii. As there is multiple loculi, and the size of each of the loculus was small, there is no indication for surgical drainage of the abscess. Therefore the surgeons plan to start on conservative management, which is starting antbiotics treatment. So, for how long should we give the antibiotics???

There are 3 types of liver abscess, namely pyogenic, amebic and also fungal liver abscess. In this article, lets discuss pyogenic and amebic liver abscess. Pyogenic abscess is usually present as multiple loculi on the CT scan and commonly cause by gram negative enteric organism such as Klebsiella pneumonia, Enterobacteriacae, enterococcus, anaerobics. On the other hand, amebic liver abscess is usually present as single loculus caused by parasite Entamoeba histolytica. The antibiotics required for this 2 types are different.

Patient in this case received antibiotics (IV cefoperazone 1g BD and IV metronidazole) for 5 days and later discharge with Tab cefuroxime 250mg BD and Tab metronidazole 400mg TDS for 6 weeks. The careless houseman in charge only prescribed 1 week antibiotics for him. Luckily the error was later amended after being informed by us. (this HO did not even show a slight appreciation!!!!! OMG, seriously beh tahan with her "DO I CARE" face. Can't she just say THANK YOU???)

Come back to the case, the national antibiotics guidline in Malaysia back in 2008 is not clear... The guideline only mentioned that patient should be treated until clinical improvement achieved. In pyogenic liver abscess, the choice of IV antibiotics include:
IV Ampicilin + IV Metronidazole + IV Gentamicin, x 2 weeks (Effective but resistant toward ampicilin increased and Gentamicin may cause nephrotoxicitiy)
or
IV Ampicillin/sulbactam alone x 2 weeks. (metronidazole may be added if cant rule out amebic)

Then, the alternative agents include:
IV 3rd gen cephalosporin + IV Metronidazole x 2 weeks or
IV ciprofloxacin + IV Metronidazole x 2 weeks.

For amoebic liver abscess, IV metronidzole 500mg TDS may be started for 10 days and Tab Tinidzole 2g OD for 3-5 days.

Then from Sanford guideline, pyogenic liver abscess may be treated with:
IV metronidazole + (IV ceftriazone or IV ciprofloxacin or IV Pip/Tazo or IV Amp/Sulbactam)
and amebic liver abscess with metronidazole, however the duration was not mentioned.

A search on the total duration of antibiotics patient should received is unclear and inconclusive. The suggested duration include IV antibiotics for 2 to 3 weeks followed by oral anitbiotics for 3 to 12 weeks. The common practice in Hospital Selayang as informed by one of the doctor is IV antibiotics for 2 weeks followed by 6 weeks oral antibiotics.

In the Malaysia ICU antibiotic guideline, pyogenic liver abscess required 6 weeks of oral antibiotics while amebic liver abscess only require 7 to 10 days of therapy followed by a luminal agent for gut colonisation. Suggested regimen for those who is hemodynamically unstable are:
IV Pip/Tazo + IV metronidazole  ---- prefered
IV Cefepime + IV metronidazole ---- prefered
IV Meropenem + IV metronidazole ---- alternative
IV Imipenem/Cilastatin + IV metronidazole ---- alternative

Then for those who is hemodynamically stable are:
IV Ceftriaxone + IV metronidazole
IV Pip/Tazo + IV metronidazole

The SD number for patient is SD330816 for future reference.

Onychomycosis (Nail infection)

My doctor asked me regarding the choice of drug in onychomycosis (nail fungal infection) today. She informed that patient's condition was severe and topical antifungal did not help and oral antifungal may be needed in this patient.

Itraconazole can be use in this kind of patient. The dose and duration for this infection is very unique and it worth to be keep in mind.

1. For onychomycosis which involve fingernail only:
200mg BD x 1 week, then off for 3 weeks, followed by 200mg BD for another week.

2. For onychomycosis which involve toenail (Trichophyton rubrum or T. mentagrophytes):
200mg BD x 12 consecutive weeks

3. For onycomycosis (toenails with or without fingernail involvement):
200mg OD x 12 weeks OR 200mg BD x 1 week, repeat 1 week course twice with 3 week off time between each course.

Myasthenia gravis

Today we had pharmacist round in the medical ward. We had reviewed 2 patients in the medical ward. The first patient is a 78 years old Malay female who was admited for myasthenia gravis (MG) and later progress to myasthenia crisis. Patient was presented with dysphagia, ptosis, diplopia and fatigue. She was also diagnosed with new onset of atrial fibrillation, with existing hypertension and hyperlipidemia.

 

Patient was treated with tab pyridostigmine 30mg TDS for MG. and later the dose was increased to 60mg TDS. At the same time she was also given IVIG infusion 20g OD for 5 days. (0.4g/kg/day). Patient responded to the treatment. However, she still has dysphagia upon review. After IVIG infusion was completed, Tab prednisolone 50mg OD (1mg/kg) was later started for MG and there is plan to initiate immunosuppressant such as Azathioprine or cyclosporine in this patient. These medications are usually required for lifelong unless the culprit organ of secreting antibody has been removed. In the ward, patient's hypertension was also treated with tab amlodipine 10mg OD and her lipid profile showed that total cholesterol was 6 and the LDL was 5.01, as a result, tab simvastatin 20mg was later increased to 40mg ON.

 

Important point of myasthenia gravis include this is an autoimmune disease. Usually affecting voluntary muscle and may cause severe fatigue and respiratory distress. The common cause influde hyperactive thymus. Thymus is an organ that we used during childhood to produce T-lymphocytes, but the organ became dormant in adulthood. However in MG, the thymus gland is hyperactive and this required removal of thymus if the condition was severe.

 

Questions raised during the round included why treatment was not initiated for atrial fibrillation. Suggestions was made to score the patient according to CHA2DS2-VASc score and assess the bleeding risk according to HAS-BLED. I score the patient myself. Total CHA2DS2-VASc score: 4, patient is a candidate for anticoagulation and should be counselled on starting warfarin.

 

C-Chronic heart failure history - 0/1

H-Hypertension history - 1/1

A-Age>75 - 2/2

D-Diabetes mellitus - 0/1

S-Stroke history - 0/2

V-Vascular disease history - 0/1

A-Age 65 to 74 - 0/1

Sex-Female - 1

 

H-Hypertension history

A-Age>65, alcohol usage history

S-Stroke history

B-Prior major bleeding history

L-Labile INR

E-Medication usage predispose to bleeding.

D-Renal / liver disease

 

HAS-BLED score was 2: hypertension and age. The risk is low. If AF is confirmed, suggestion should be made to start warfarin.

 

Questions raised also include should the simvastatin be discontinued as simvastatin may cause muscle weakness and further worsen patient's condition. I suggested that simvastatin may be continued for short period of time and to monitor her condition and only discontinued when patient showed symptoms of muscle weakness again.

 

A list of drugs which should be used cautiously in patient with MG as these medications may worsen patient's symptoms upon using was also mentioned. This include phenytoin, beta blocker, loperamide, aminoglycoside, tetracycline, sulfonamide, fluoroquinolone, colistin, Quinidine, CCB. Further list can refer to

 

http://www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&ved=0CCoQFjAA&url=http%3A%2F%2Fwww.myasthenia.org%2FLinkClick.aspx%3Ffileticket%3DJuFvZPPq2vg%253D&ei=ErWxUs-NC8eHrQfolIDwDA&usg=AFQjCNF---Bkimg54LK4kCXHNP9yf40qRg&sig2=MtfZTA5OkgTD4AEn_aNGEQ

 

 

 

We then proceed to the next patient in the ward next door.