Case Studies on "Adverse effects of antimicrobial chemotherapy"

Objectives: By the end of this TBL , the student will be able to: 1. List the side effects of common antimicrobial groups. 2. Discuss how to avoid or minimize the unwanted effects for common antimicrobials. 3. Plan the general and specific precautions and limitations for the common antimicrobials. Background: More than 80 years since the first use of a chemotherapeutic agent; the term was first applied to the use of selective toxicity by synthetic chemicals against invading parasitic disease; either bacterial, viral, fungal or protozoa. Then, it extended to the antibiotic, and then far extended to cancer chemotherapeutic. To a great extend the chemotherapeutic do have selectivity of the targets on which they acts, which may be one of the following: Bacterial and fungal cell wall synthesizing enzymes. Bacterial ribosomes. Enzymes required for nucleotide synthesis and DNA replication. Machinery of viral replication Antimicrobials have major and minor adverse reactions; many of them can be avoided, minimized, treated or tolerated. After studying the eight cases given to you, you can answer the questions following them. Then you can collectively summarizes the most striking side effect (s) to commonest group of antimicrobials beginning from B-lactam antibiotics up to antiviral drugs Case No 1: A 52 years old man presents for the evaluation of diarrhea and abdominal pain, which have been worsening over the past week. He is now having 8-10 watery stools a day and mild cramping pain. He denies illness, fever, ill contacts. His previous history, about 10 days ago reveled that he has completed a course of amoxicillin/clavulanic acid for pneumonia. On examination, his vital signs are normal although his mildly ill appearance. His abdomen is soft with hyperactive bowel sounds and diffuse mild tenderness. A

stool sample is negative for blood but positive for leukocytes. A stool culture is negative, but specific toxin assay is positive 1. What is the most probably etiologic agent? a. Drug allergic reaction. b. Hypersensitivity. c. Viral toxins. d. Bacterial toxins 2. Which is the predisposing condition for such a case? a. Pneumonia infection. b. Clavulanic acid. c. Amoxicillin. d. Dehydration.

Case Number 2: 59-year-old man received one of the makrolide group of antibiotic for cough treatment after suspecting pneumonia infection. He has been taking numerous over-the-counter cold medications without relief and has had to use his ipratropium inhaler more often than usual. after three day therapy the patient suffered from ventricular arrhythmia with prolongation of Q-T interval. 1. What is the suspecting drug for this is : a. Ipratropium (bronchodilator). b. Azithromycin ( A Macrolide antibiotic). c. OTC ( antihistaminic) d. Combination therapy. 2. The arrhythmia Can result due to: a. Catecholamine release. b. Enzyme induction. c. Inherited factors. d. Enzyme inhibition Case Number 3: A 20 -year-old female presented to the outpatient clinic complaining of fever and severe sore throat. The patient condition was diagnosed as acute tonsillitis, and penicillin G injections have been prescribed to her. The patient took the first injection of the antibiotic before leaving the hospital. On the following month, while the nurse was giving the patient the injection, the patient was suddenly collapsed, with fainting, cyanosis and severe pallor. On examination, the radial pulse cannot be felt, and the systolic blood pressure was 40 mmHg while diastolic pressure cannot be traced. A diagnosis of anaphylactic shock was made.

1. Put ( True ) or (False)" a. The immediate phase of this reaction is mediated through vasoactive amine. b. Other form of this reaction may be in the form of skin rashes, bronchial asthma. 2. What is the life saving drug should be administered to this patient:

a. Phenylephrine. b. Adrenaline. c. Corticosteroid d. Anti-histamine. Case Number 4: A woman presented her 5-years old son to the pediatric dental office with a certain heath problem. The physician noticed yellowish discoloration which is non brush able. She mentioned that this color was found since years . 1. What is the antibiotic responsible for this color: a. Co-trimoxazole. b. Tetracyclines c. Chloramohenicol d. Clindamycin. 2. All of the following are other manifestation can presented EXCEPT: a. Hypoplesia of teeth. b. Stunting growth. c. Arthralgia d. Irregularity in bone growth. Case Number 5: A premature baby treated with an antibiotic for severe infection, and then he begins to be cyanosed (Ash skin color), flaccid with poor reflexes, unable to suckle, vomiting, collapses and hypothermia. 1. What is the name of this syndrome? a. Redman syndrome. b. Fanconi syndrome c. Steven Johnson. d. Grey baby syndrome 2. The responsible antibiotic is : a. Vancomycin. b. Terramycin c. Chloramphenicol d. Co-trimoxazol

Case Number 6: A 72-year-old female is transferred to the hospital because of fever and altered mental status. She has advanced Alzheimer disease, is bed bound, and has an indwelling Foley catheter as a consequence of urinary incontinence. A urinalysis reveals too numerous to count white blood cells and bacteria. Blood and urine cultures also grow gram-positive cocci. She was treated with vancomycin and an aminoglycoside 1. If the woman develops manifestations of hearing problems. What is the incriminating drug? a. Vancomycin. b. Aminoglycosides. c. Penicillins. d. Cephalosporins. 2. All are aminoglycosides EXCEPT: a. Gentamycin. b. Streptomycin. c. Neomycin. d. Clindamycin. Case No 7: A 20-year-old woman with leukemia was undergoing chemotherapy with intravenous antineoplastic drugs. During treatment, she developed a systemic infection from an opportunistic pathogen. A white vaginal discharge was observed. After appropriate specimens were obtained for culture, empiric antibiotic therapy was started with gentamicin, nafacillin, and ticarcillin intravenously. The patients condition did not improve significantly. Her throat was sore and white plaques had appeared in her pharynx. On day 4, both the blood and urine culture grew out Candida albicans and no bacterial growth. 1- The best course of action is to: a. b. c. d. 2Continue current antibiotics and start amphotericin B Continue current antibiotics and start flucytocine Continue current antibiotics and start ketoconazole Stop current antibiotics and start amphotericin B

If amphotericin B administered, the patient should be premedicated with: a. Diphenhydramine b. Ibuprofen c. Prednisone d. Any or all of the above

Case No 8: A therapeutic regimen was planned for a female patient diagnosed as having chronic hepatitis C virus infection. The age of the patient is 35 years, body weight of 57 kilograms. Biochemical tests revealed moderate elevation of the liver enzymes; AST and ALT without impairment of liver function.

1- A drug that must be included in the therapeutic regimen of this patient is: a- Interferon alpha b-Lamivudine c-Adefovir d-Entecavir 2- One of the Lab tests that should be done to detect an important side effect of the selected drug is: a- Blood amylase level b-Complete blood picture c-Blood sodium level d-Blood lactic acid level

You can refer to the following book: Lippincott's Illustrated Reviews : Pharmacology : Special Millennium Update Mary J. Mycek (Author), Richard A. Harvey (Author), Pamela C. Champe