Azithromycin Treatment for Acne Vulgaris: A Case Report on the Risk of Clostridioides difficile Infection.

BACKGROUND Clostridium difficile (C. difficile) is a gram-positive, anaerobic, spore-forming bacillus. It can lead to pseudomembranous colitis characterized by electrolyte disturbances, toxic megacolon, and septic shock. The risk of C. difficile infection is higher with use of certain classes of antibiotics, or when an antibiotic used for a long time. Azithromycin is a macrolide antibiotic known to be safe, with few adverse effects such as diarrhea, stomach pain, and constipation. Azithromycin is currently used for the treatment of acne, with different dosing regimens for patients who cannot receive traditional treatment based on practice guidelines. CASE REPORT A 41-year-old woman was treated with a course of azithromycin 500 mg by mouth 3 times weekly for 6 weeks for acne vulgaris. This was her second antibiotic course of acne treatment within 10 months. A few days after completion of the second azithromycin course, she presented to the clinic with worsening abdominal pain and frequent soft bloody stool. A complete blood count test, C. difficile toxin test, stool culture, and colonoscopy were ordered. She was diagnosed with C. difficile infection confirmed by C. difficile toxin and symptoms. CONCLUSIONS Despite the safety profile of azithromycin, our patient was predisposed to a non-severe case of C. difficile-associated diarrhea, most likely due to the repeated course of the azithromycin regimen that was used to treat her acne vulgaris. This report highlights the importance of managing patients with acne vulgaris according to current practice guidelines, and to report a link between the use of azithromycin as an acne treatment and the occurrence of C. difficile colitis.

Evaluation of Physicians' Compliance With Secondary Prevention Among Ischemic Stroke Patients: A Retrospective Study.

Background: Stroke is a leading cause of disability and death worldwide. Globally, stroke affects 13.7 million individuals every year. Several studies have shown an increase in the rehospitalization rate among stroke patients caused by non-adherence to secondary prevention as recommended by the American Heart Association/American Stroke Association (AHA/ASA) guideline. The aim of this study was to evaluate physicians' compliance with secondary prevention of stroke upon patients' discharge. Methods: A retrospective chart review study was conducted at King Fahad Medical City. The primary outcome of this study was the number of patients discharged with the recommended medications for the secondary prevention of ischemic stroke (IS). The data were collected from the patient's medical record files and analyzed using the Statistical Package for the Social Sciences (SPSS). Results: Of the 675 patients who were screened for eligibility, 507 were included and 168 were excluded. The mean age of the patients was 59.5 (± 15.6) years. Of the 507 patients, 181 (35.7%) had a history of previous stroke. Overall, 376 (74%) stroke patients were discharged with appropriate secondary prevention recommendation per AHA/ASA guideline. Conclusions: This study stresses the importance of compliance with the AHA/ASA guideline for secondary stroke prevention and highlights the role of pharmacists in the stroke unit in which it is necessary to ensure that all stroke patients are discharged with the recommended medications to reduce recurrent stroke.

Severe Neutropenia and Hepatotoxicity After Carbimazole Drug Therapy for Hyperthyroidism in a Pediatric Patient: A Case Report.

BACKGROUND Hyperthyroidism is an overproduction of thyroid hormones. Carbimazole is an anti-thyroid medication used to treat hyperthyroidism in adults and children. It is a thionamide associated with rare adverse effects such as neutropenia, leukopenia, agranulocytosis, and hepatotoxicity. Severe neutropenia is a life-threatening event characterized by a sharp drop in absolute neutrophil count. Severe neutropenia can be treated by discontinuation of the precipitating medication. Administration of granulocyte colony-stimulating factor provides longer protection against neutropenia. Elevated liver enzymes indicate hepatotoxicity, which usually normalize after discontinuation of the offending medication. CASE REPORT A 17-year-old girl was treated with carbimazole since the age of 15 for hyperthyroidism secondary to Graves' disease. She initially received 10 mg of carbimazole orally twice daily. After 3 months, the patient's thyroid function reflected residual hyperthyroidism and was then up-titrated to 15 mg orally in the morning and 10 mg orally in the evening. She presented to the emergency department reporting fever, body aches, headache, nausea, and abdominal pain for 3 days. She was diagnosed with severe neutropenia and hepatotoxicity induced by carbimazole after 18 months of dose modification. CONCLUSIONS In hyperthyroidism, it is important to maintain patients in a euthyroid state for a long period to minimize the autoimmunity and hyperthyroid relapse, which often requires long-term use of carbimazole. However, severe neutropenia and hepatotoxicity are rare and serious adverse effects of carbimazole. Clinicians should be aware of the importance to discontinuation of carbimazole, administration of granulocyte colony-stimulating factors, and supportive treatment to reverse the consequences.