Necrotizing soft tissue infections reported with nonsteroidal antiinflammatory drugs.

BACKGROUND: Recent reports of necrotizing fasciitis in children with varicella who received a nonsteroidal antiinflammatory drug (NSAID) recall earlier concerns regarding the possibility of relationships between infections and NSAIDs. We searched the Food and Drug Administration's Spontaneous Reporting System (SRS) for necrotizing soft tissue infections reported in conjunction with the use of NSAIDs, to identify common features. METHODS: A computer search of NSAID listings in the adverse event database recovered reports with codes for selected infection and necrosis-related diagnostic categories. From review of individual reports classified under these codes, cases were selected if the terms "necrotizing fasciitis," "necrotic," or "gangrenous" appeared in the adverse drug reaction description. Demographic, drug use, and disease course information were gathered. FINDINGS: Thirty-three cases were identified, of which 10 were fatal. Over two-thirds of the patients were younger than 40 years. Thirty (91%) had a possible portal of entry for infection. Most received NSAIDs for acute conditions including varicella, trauma, and postoperative or postpartum pain; 7 received an NSAID by intramuscular injection. Specific NSAIDs accounting for most reports were also among those likely to be most heavily used in the relevant populations. INTERPRETATION: Common features of these rare case reports of necrotizing soft tissue infections with NSAID use include characteristics such as age, portal of infection entry, indication for NSAID use, route of administration, and individual NSAIDs. The total number of SRS cases does not suggest that necrotizing infection is frequent with NSAIDs or likely without other risk factors. Controlled observational studies would help to define any causal contribution of these factors to the evolution of severe infection.

Prior antimicrobials and staphylococcal bacteremia in HIV-infected patients.

OBJECTIVE: Many drugs used for prophylaxis against opportunistic infections in AIDS also have activity against common bacteria. This study was performed to delineate relationships between prior use of antimicrobials and Staphylococcus aureus bacteremia. DESIGN: To compare prior exposure to selected antimicrobial drugs in patients who had S. aureus bacteremia and in controls who did not, a nested case-control study was conducted within a cohort of HIV-infected persons followed in an outpatient clinic. METHODS: Using a computerized database based on HIV clinic records, 48 cases with S. aureus bacteremia were compared against 188 controls selected from patients with CD4 cell counts < 200 x 10(6)/l. Information on demographic risk factors and antimicrobial drug use was analysed using conditional logistic regression. RESULTS: Injecting drug use was strongly associated with S. aureus bacteremia. Rifabutin use was associated with decreased risk of S. aureus bacteremia [conditional relative risk (RR) 0.308, 95% confidence interval (CI) 0.096-0.991] in univariate analysis, near statistical significance in multivariate analysis (RR 0.314, 95% CI 0.096-1.023). The bacteremias were not significantly associated with use of trimethoprim-sulfamethoxazole, quinolones, newer macrolides (azithromycin and clarithromycin), clindamycin or dapsone. CONCLUSIONS: Rifabutin may be associated with diminished risk of S. aureus bacteremia incidental to use for other purposes in HIV infection. Further study is needed to assess effects on microbial resistance.