“I go after Streptococcus pneumoniae and many other bacteria causing community-acquired pneumonia with vengeance but lately I have had a hard time keeping up with many gram-negatives, including some E. coli. Who am I?”

Additional hint: “The latest FDA warning against the use of my class of drugs has to do with increased risk of ruptures or tears in the aorta in certain patients, including the elderly and those with hypertension, aortic aneurysm or peripheral vascular disease.” 

Editor’s note: This post is part of the P4P “Talking Therapeutics” series designed to make learning about antibiotics fun. Individual antibiotics give a short description of themselves and you are asked to guess their names. Antimicrobial spectrum, common uses and potential adverse effects follow. Enjoy!

And the answer is…… HERE

Selected antimicrobial spectrum

                Gram-positives: Streptococcus pneumoniae, Staphylococcus aureus                         (some resistance even in MSSA), Enterococcus spp (urine;some resistance)

                Gram-negatives: Enterics (eg, E. coli, Klebsiella spp), Pseudomonas spp,                                 Stenotrophomonas maltophilia, H. influenzae, some ESBLs.

                 AVOID: MRSA, anaerobes

Common clinical uses: community-acquired pneumonia (CAP), healthcare-associated pneumonia (HAP), urinary tract infections (UTIs), legionnaire’s disease, abdominal infection (plus anaerobic coverage)

WATCH OUT! QT prolongation, C. difficile, central nervous system toxicity, seizures, myasthenia gravis, peripheral neuropathy, tendinopathy, drug interactions (eg. warfarin), and most recently aortic aneurysm diagnosis/dissection!

Remember the key features of levofloxacin before you prescribe it!

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Selected references

  1. FDA. FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients.  https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-increased-risk-ruptures-or-tears-aorta-blood-vessel-fluoroquinolone-antibiotics. Accessed Nov 26, 2020,.
  2. Marangon FB, Miller D, Muallem MS, et al. Ciprofloxacin and levofloxacin resistance among methicillin-sensitive Staphylococcus aureus isolates from keratitis and conjunctivitis. Am J Ophthal 2004;137:453-58. https://www.ajo.com/article/S0002-9394(03)01287-X/pdf
  3. Yasufuku T, Shigemura K, Shirakawa T, et al. Mechanisms of and risk factors for fluoroquinolone resistance in clinical Enterococcus faecalis from patients with urinary tract infections. J Clin Microbiol 2011;49:3912-16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3209098/
  4.  Rawla P, Helou MLE, Vellipuram AR. Fluoroquinolones and the risk of aortic aneurysm or aortic dissection: A systematic review and meta-analysis. Cardiovasc Hematol Agents Med Chem 2019;17:3-10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6865049/

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

“I go after Streptococcus pneumoniae and many other bacteria causing community-acquired pneumonia with vengeance but lately I have had a hard time keeping up with many gram-negatives, including some E. coli. Who am I?”

Which patients outside of ICU setting should be placed on telemetry monitoring in the hospital?

Telemetry monitoring should be used in patients at increased risk of arrhythmias during hospitalization (1). While the American Heart Association provides expert opinion on telemetry for a variety of cardiac conditions (1), a more recent review (2) makes suggestions for common cardiac and non-cardiac diagnoses based on arrhythmia risk.

Telemetry is recommended for patients admitted for implantable cardioverter- defibrillator firing, second or third degree AV block, prolonged QT interval with ventricular arrhythmia, acute heart failure, acute cerebrovascular event,  acute coronary syndrome and massive blood transfusion.

Telemetry may be beneficial in syncope with arrhythmia as a suspected cause, gastrointestinal hemorrhage after endoscopy, atrial arrhythmias on rate or rhythm control therapy, electrolyte imbalance and subacute congestive heart failure.

Telemetry is not generally indicated in chest pain with normal EKG and cardiac markers, COPD exacerbation, PE if the patient is stable and on anticoagulation, and cases requiring minor blood transfusion. 

Contributed by Joome Suh, MD, Boston, MA

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References 

(1) Drew BJ, Califf RM, Funk M, et al. Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. Circulation 2004;110:2721–46. 

(2) Chen EH and Hollander JE. When do patients need admission to a telemetry bed? The Journal of Emergency Medicine 2007:33(1):53-60.

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers, Mass General Hospital, Harvard Medical School or its affiliated institutions. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Which patients outside of ICU setting should be placed on telemetry monitoring in the hospital?

Is the QTc interval an accurate reflection of myocardial repolarization time in ventricular conduction defects associated with a widened QRS complex?

Ventricular conduction defects associated with a widened QRS complex—specifically, complete and incomplete bundle branch blocks—may artificially elongate the QT interval without reflecting an actual increase in myocardial repolarization time (1).

In complete bundle branch block, the widened QRS complex may elongate the QTc interval by as much as 16% while having no effect on the JT index, defined as JT interval x (heart rate+ 100)/518), where an index >112ms is considered to be prolonged (2).

Calculation of the JT index has been suggested for patients with incomplete bundle branch block, as well (2).

Put simply, in patients with ventricular conduction defects associated with a widened QRS complex, the JT index appears to be superior to the QTc interval for assessment of repolarization time.

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 References

 

1. Salik J, Muskin P. Consideration of the JT interval rather than the QT interval. Psychosomatics 2013; 54(5): 502. https://www.ncbi.nlm.nih.gov/pubmed/24034531

2. Zhou SH, Wong S, Rautaharju PM, et al. Should the JT rather than the QT be used to detect prolongation of ventricular repolarization? An assessment in normal conduction and in ventricular conduction defects. J Electrocardiology 1992; 25 (Suppl): 131-6. https://www.ncbi.nlm.nih.gov/pubmed/1297679

Contributed by Jonathan Salik, MD, Mass General Hospital, Boston, MA

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Is the QTc interval an accurate reflection of myocardial repolarization time in ventricular conduction defects associated with a widened QRS complex?