Ertapenem-induced neurotoxicity in an end-stage renal disease patient on intermittent haemodialysis: a case report.

BACKGROUND: Carbapenem-induced neurotoxicity is an unusual side effect, with seizure being the most commonly reported symptom. Among the carbapenems, imipenem-cilastin is classically associated with the most severe neurotoxicity side effects. Carbapenem is mainly excreted by the kidney and its half-life is significantly increased in patients with chronic kidney disease (CKD). Therefore, dose adjustment is necessary in such patients. Ertapenem-associated neurotoxicity is increasingly being reported in CKD patients, but rarely seen in patients with recommended dose adjustment. CASE PRESENTATION: We report a case of a 56-year-old male patient with chronic kidney disease 5 on dialysis(CKD 5D). The patient presented with a history of fever, chills and rigours during a session of haemodialysis (HD). He was diagnosed with Enterobacter cloacae catheter-related blood stream infection and was started on ertapenem. After 13 days of ertapenem, he experienced an acute confusional state and progressed to having auditory and visual hallucinations. His blood investigations and imaging results revealed no other alternative diagnosis. Hence a diagnosis of ertapenem-induced neurotoxicity was made. He had complete resolution of symptoms after 10 days' discontinuation of ertapenem. CONCLUSION: Our case draws attention to the risk of potentially serious toxicity of the central nervous system in HD patients who receive the current recommended dose of ertapenem. It also highlights that renal dosing in CKD 5D patients' needs to be clinically studied to ensure antibiotic safety.

Catheter-Related Bloodstream Infections and Catheter Colonization among Haemodialysis Patients: Prevalence, Risk Factors, and Outcomes.

INTRODUCTION: Catheter-related bloodstream infection (CRBSI) and catheter colonization (CC) are two complications among haemodialysis (HD) patients that lead to increased morbidity and mortality. This study aims to evaluate the prevalence of CRBSI and CC among HD patients registered at Universiti Kebangsaan Malaysia Medical Centre and to identify the factors involved by focusing on the demographic profile of the patients as well as their clinical characteristics and outcomes. METHOD: This is a retrospective study of end-stage renal disease patients with suspected CRBSI during the period from 1 January 2016 to 31 December 2018. Data on patients who fulfilled the blood culture criteria for CRBSI and CC diagnosis were further analysed for clinical manifestations, comorbidities, history of dialysis, catheter characteristics, and microbiological culture results. The outcomes of CRBSI and CC were also assessed. Findings. In the 3-year period under study, there were 496 suspected CRBSI cases with a total of 175 events in 119 patients who fulfilled the inclusion criteria. During that time, the percentage of patients who experienced CRBSI and CC was 4.2% and 4.8%, respectively. The majority of the cohort consisted of male (59.4%), Malay ethnicity (75%), and patients on a tunnelled dialysis catheter (83%). Patients who were fistula naïve and had an internal jugular catheter were more common in the CRBSI group than in the CC group. The predominant microorganisms that were isolated were Gram-positive organisms. In terms of clinical presentation and outcome, no differences were found between the CRBSI and CC groups. Patients with Gram-negative bacteraemia, high initial c-reactive protein, and catheter salvation were likely to have poor outcomes. Recurrence of CRBSI occurred in 31% of the cohort. Neither catheter salvation nor antibiotic-lock therapy were associated with the recurrence of CRBSI. On the other hand, the femoral vein catheter site was associated with risk of recurrence. The overall mortality rate was 1.1%. Discussion. From the analysis, it was concluded that clinical assessment and positive culture are crucial in diagnosing CRBSI with or without peripheral culture. This study provides essential information for the local setting which will enable healthcare providers to implement measures for the better management of CRBSI.

Parathyroid Carcinoma: Analysis of Patient Characteristics and Outcomes in a Retrospective Review of Eight Cases seen in a Single Center.

Eight cases of parathyroid carcinoma were identified (8 females; median age 45 years, range 28-72). Half of whom were diagnosed preoperatively. Hypercalcemic symptoms were seen in 87.5% of the patients and the main complication was nephrolithiasis. At presentation, the median calcium was 3.675 mmol/L, median phosphate of 0.68 mmol/L, median intact parathyroid hormone (iPTH) was 211 pmol/L. Five patients had regional nodes metastasis and 1 had distant metastasis to the lungs. Parathyroid gland invasion to adjacent structures was seen in 62.5% of cases while another 62.5% showed capsular or vascular infiltration on histology with median tumour size of 3.2 cm. Recurrent hypercalcemia occurred in 50% of the patients with median time of recurrence of 21 months. In this case series, we found that patients with severe hypercalcemia and high iPTH also exhibited a high index suspicion of PC.